Adenosquamous Carcinoma of the Cecum with Metastatic Disease, a Case Report.

N Noorbakhshsabet¹, R Malayeri*

*Correspondence to:  R Malayeri, Imam Khomeini Hospital, Tehran University of Medical Sciences

 Copyright.

© 2024 Dr. R Malayeri. This is an open access article distributed under the Creative Commons Attribution   License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 19 October 2024

Published: 01 November 2024

DOI: https://doi.org/10.5281/zenodo.14159995

Abstract

This report presents a rare case of adenosquamous carcinoma (ASC) of the cecum in a 71-year-old woman who had been diagnosed with breast cancer 15 years earlier. The patient arrived with abdominal pain. At presentation, she had a bowel obstruction and an ileocolic mass, prompting surgery. A right hemicolectomy was performed. Post-surgical results revealed advanced metastatic disease, underscoring the aggressive nature of adenosquamous carcinoma of the cecum. Very soon after her operation, the patient died.

Introduction

Adenosquamous carcinoma (ASC) of the colon is an uncommon form of colorectal cancer, defined by both glandular (adenocarcinoma) and squamous cell carcinoma features (1). It is typically linked to a poor prognosis due to its aggressive progression and frequent detection in a later-stage (2).

Adenosquamous carcinoma is extremely rare, making up only about 0.1% to 1% of colorectal cancers. The prognosis for ASC is much worse compared to adenocarcinoma:

• Overall Survival (OS): The median OS for colon adenosquamous cancer patients is considerably shorter than for those with adenocarcinoma.

• Five-Year OS Rates: The five-year survival rate for adenosquamous cancer patients is around 38.9%, and 60% or higher for adenocarcinoma, of course it depends on the stage at diagnosis.

These statistics define the aggressive nature of adenosquamous carcinoma and its poor outcomes in comparison to more common forms of colorectal cancer like adenocarcinoma.

This report explores the clinical presentation, surgical outcomes, and treatment complexities associated in this case of metastatic adenosquamous cancer of the cecum.

A 71-year-old woman with a history of breast cancer which was diagnosed and treated with a mastectomy and hormonal treatment 15 years ago, came in with abdominal pain and symptoms of bowel obstruction.

Preoperative CT scans showed a huge ileocolic mass and widespread metastatic disease, including:

• Multiple liver metastases

• Peritoneal spread

• Significant lymph node enlargement in the porta hepatis and porta caval areas

• Lung metastasis

Due to the high risk of tumor perforation, a right hemicolectomy was performed. During the operation, a 8.4 x 2.7 cm mass was discovered in the cecum. Histopathological analysis confirmed adenosquamous carcinoma with key characteristics including:

• Infiltration into pericolonic fat

• Lymphovadenosquamous cancerular invasion

• Perineural invasion

Out of 18 lymph nodes analyzed, 10 tested positive for metastasis. The tumor was classified as

pT3 pN2b according to the AJCC staging system. The cancer had also spread into the subserosal

fat of the appendix, indicating extensive local disease.

Elevated bilirubin levels (8 mg/dL) pointed to liver dysfunction, which worsened after surgery, restricting further treatment options.

Tumor Markers

The patient had elevated levels of the following tumor markers:

• Carcinoembryonic antigen (CEA): 12 ng/mL

• Cancer antigen 125 (CA125): 5.89 U/mL

• Cancer antigen 19-9 (CA19-9): 89.49 U/mL

• Cancer antigen 15-3 (CA15-3): 62.7 U/mL

Discussion

Adenosquamous carcinoma of the colon is a rare and highly aggressive cancer, often diagnosed in advanced stages with metastases. The presence of both adenocarcinoma and squamous cell carcinoma components tends to become aggressive and lead to early metastases. The outlook for patients is typically poor, with limited treatment options, especially in cases like ours, where metastases are already widespread at diagnosis.

In this patient’s case, her prognosis was poor and despite removing the primary tumor through surgery, the extent of her metastatic disease and her ECOG Performance status of 3 didn’t allow any kind of systemic treatment such as chemotherapy. The case was discussed by our multidisciplinary team and palliative care was suggested. Her general condition deteriorated quickly and her liver function declined further, after her operation. Unfortunately, the patient died six weeks after surgery, largely due to liver failure and her declining general condition.

This case emphasizes the significance of recognizing adenosquamous carcinoma as a rare but highly aggressive form of colorectal cancer. The presence of both glandular and squamous cell components generates a particularly challenging clinical course, especially when metastases are present at the time of diagnosis. This case stresses the importance of comprehensive management strategies and early detection of this uncommon cancer subtype.

References

1.  Hwang, J.H., et al. "Adenosquamous Carcinoma of the Colon: A Case Report." Journal of Gastrointestinal Oncology, vol. 11, no. 3, 2020, pp. 631-635.

2. Kim, S.H., et al. "Clinical Characteristics and Treatment Outcomes of Adenosquamous Carcinoma of the Colon." Cancer Medicine, vol. 9, no. 5, 2020, pp. 1756-1764.

3. Wang, Y., et al. "Adenosquamous Carcinoma of the Colon: A Review." World Journal of Gastroenterology, vol. 26, no. 30, 2020, pp. 4426-4436.

4. Cagir, A., et al. "Primary Adenosquamous Carcinoma of the Colon." BMC Gastroenterology, vol. 23, no. 1, 2023.

5. Zhang, X., et al. "Clinicopathological Characteristics of Colorectal Adenosquamous Carcinoma." Journal of Gastrointestinal Oncology, vol. 14, no. 2, 2023.