EP269 - Signet Ring Cell Colon Carcinoma in the Young

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Purpose/Background: Colorectal cancer is the 3rd most frequently seen cancer worldwide and ranked third among men. Primary signet ring cell carcinoma of of the colon and rectum (PSRCCR) is a rare histologic subtype, accounting for approximately 0.6–2.7% of all adenocarcinomas of the colon. A few literatures reported this on adult patients but none of young patients locally. The tumor is characterized by abundant intracellular mucin with peripherally displaced nuclei comprises of more than 50% of the lesion. SRCC has been shown to be a poor prognostic factor in several studies and the AJCC Guidelines qualified it to be an independent prognostic factor.

Methods/Interventions: This is the case report of a 19-year old male who initially presented as a case of incarcerated indirect inguinal hernia, right. No history of bowel habit change, significant weight loss nor hematochezia or melena. Family, past medical as well as surgical history were all unremarkable. However, there was eventual spontaneous reduction of the inguinal mass and resolution of incarceration and patient was admitted for elective hernia repair. During admission, patient was noted to have abdominal distention with absence of bowel movement. Upon repeat abdominal examination, patient noted to have distended abdomen, normoactive bowel sounds, dull to tympanitic on all quadrants, without associated tenderness or guarding. Bowel decompression was done through insertion of nasogastric tube and foley catheter. Broad spectrum antibiotics was started and fluid resuscitation was initiated. Improved signs and symptoms were appreciated and diet progression resumed. However, upon diet progression, noted again with abdominal distention, now with vomiting episodes. Patient was placed back again on bowel decompression and imaging was requested. On whole abdominal CT scan, noted with circumferential irregular wall thickening at the hepatic flexure area causing dilatation of proximal small and large bowels. Due to persistent signs and symptoms, patient was scheduled for emergency exploratory laparotomy, right hemicolectomy.

Results/Outcomes: Dilated small and large bowels were noted intraoperatively and no notable liver mass was appreciated. A 3x4cm constricting mass at the hepatic flexure with multiple paracolic, intermediate and central lymph nodes. No carcinomatosis was also noted. Due to these findings, an extended right hemicolectomy, complete mesocolic excision with central vascular ligation was done. Also, a hand-sewn end-to-end anastomosis was done for the reconstruction. Operation was done within 3 hours with only minimal blood loss and patient tolerated the whole procedure well. On microscopic evaluation, it revealed sheets and nests of neoplastic cells exhibiting intracellular mucin displacing the nucleus to the periphery.

Conclusion/Discussion: Signet ring cell carcinoma is a rare poor prognostic histopathologic subtype of colon and rectal cancers that is more prevalent in young adults. In this case, it has unusual clinical presentation and an unconventional localization in the colon, however presented in our case as an incidental finding during admission. Our patient is thought to have a benign pathology and revealed as a blessing in disguise for it actually led for the diagnosis of a rare and aggressive tumor. We also conclude that additional work-up for molecular characteristics further improves the therapeutic modalities of this disease that can result from a worse status to a good and manageable prognosis.