Annals of Advanced Sciences www.aascience.com Volume 2, Issue 1, February 2018
Case Report
Colon Cancer In A Patient Undergoing Dialysis For End-Stage Renal Disease: A Case Report Ehsan Zaboli1, Ali Mirabi2, Mohammad Zahedi3, Amir Shamshirian3, Seyyed Abbas Hashemi*4 1. 2. 3.
Department of Hematology-Oncology, Imam Khomeini hospital, Mazandaran university of medical sciences, Sari, Iran.
Medical Student, Student Research committee, Mazandaran university of Medical Sciences, Sari, Iran. Department of Laboratory Sciences, School of Allied Medical Science, Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran. 4. Department of Internal Medicine, Faculty of Medicine, Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran. Corresponding Author: Seyyed Abbas Hashemi Email of Corresponding Author:
[email protected]
Abstract End-stage renal disease (ESRD) is a renal failure with irreversible renal function. The number of patients with ESRD is increasing worldwide. ESRD and cancer are both common in older patients; whether ESRD increases the risk for cancer are not well documented. Chronic kidney disease may conversely be a risk factor for cancer, and both may be associated with each other because of sharing common risk factors. We would like to report on a case of a 63-year-old man, known case of ESRD and hypertension, who referred with only a slight pain on the right side of his abdomen and finally diagnosed as an adenocarcinoma of ascending colon. Keywords: Chronic Kidney Disease, End Stage Renal Disease, Colon Cancer, Iran Citation to This Article: Zaboli E, Mirabi A, Zahedi M, Shamshirian A, Hashemi SA. Colon Cancer in a Patient Undergoing Dialysis for End-Stage Renal Disease: a case report. Annals of advanced sciences, February 2018; 2 (1): 8-13.
1. INTRODUCTION Chronic kidney disease is a major public health problem and is characterized by persisting kidney damage and loss of renal function. End-stage renal disease (ESRD) is a complete renal failure with irreversible renal function. The number of patients with ESRD is increasing worldwide at an estimated annual rate of 7%. In ESRD, the glomerular filtration rate is less than 15 mL/min, and these patients need renal replacement therapy including hemodialysis or peritoneal dialysis, which can increase the risk of hepatitis and liver cancers (1-5). Advanced age, hypertension, diabetes mellitus, obesity, a history of renal disease and social history of smoking or opium addiction are risk factors for ESRD. It can lead to fluid retention, anemia, disturbances of bone and mineral metabolism, and increased risk of cardiovascular disease (6, 7). ESRD and cancer are both common in older patients; whether ESRD increases the risk for cancer are not well documented (8, 9). Renal failure, persistent metabolic changes and other related complications following ESRD may predispose the patient to cancer (9). Chronic kidney disease (CKD) and cancer are connected to each other either directly or indirectly. CKD may conversely be a risk factor for cancer, and both may be associated with each other because of sharing common risk factors (10). Cancers most strongly associated with dialysis include Kaposi sarcoma and tumors of the oral cavity, kidney, bladder, stomach, liver, lung, cervix and thyroid (10, 11). Here we would like to report a case of colon cancer in a patient on dialysis for end-stage renal disease. 2. CASE PRESENTATION A 63-year-old man, known case of end-stage renal disease (ESRD) and hypertension, referred with chief complain of pain in the right side of the abdomen for two months. The abdominal pain was not positional and did not radiate to anywhere. The pain did not appear to be associated with his eating behavior. The patient had not any underlying symptoms including fever, chills, weight loss, decreased appetite, nausea, vomiting, diarrhea, constipation or urinary tract symptoms. He was not cigarette smoker or opium-addicted. The patient had a history of ESRD for four years and was undergoing dialysis twice a week. The patient had not any cancer-related morbidity or mortality in his family history. The vital signs were in stable condition at the time of admission. In physical examination, palpebral conjunctiva Page | 18
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was pale and there was a tenderness on the right side of the abdomen especially with more tenderness in periumbilical region. Other physical examinations were normal. On the laboratory tests, the patient just had low hemoglobin level (Hb: 9.3 gr/dl), high blood urine nitrogen (BNU) and creatinine (Cr) (BUN: 113 mg/dl and Cr: 4.6 mg/dl). In ultrasonography imaging, solid and cystic mass did not appear in liver parenchyma. Increased parenchymal echogenicity and decreased corticomedullary differentiation of the right kidney was seen. The longitudinal diameter of the right and left kidney were 72 mm and 82 mm respectively. Two cysts in the size of 13 and 19 mm were found in the right kidney. Approximately two ccs free fluid was present in the right paracolic region. The increased wall thickness of one of the intestinal lobes for about 10 mm was observed. A hypo-echoic mass of about 38 × 25 mm seemed to have originated from the thick lobe below the patient's complaint on the right side of the abdomen. Totally, the above findings in ultrasonography suggested the masses with the origin of the ascending colon wall. Therefore, abdominal and pelvic computed tomography (CT) scan with oral contrast was suggested for closer investigation of the lesion. In CT interpretation, an increased in the wall thickness of ascending colon was seen in about 14 mm, which caused a degree of colon stenosis but no obstruction was observed. The kidneys were smaller than normal with reduced renal parenchymal thickness. Colonoscopy and biopsy were recommended, because of abnormal findings in CT scan. There was a large fragile circumferential tumor in ascending colon and internal hemorrhoid in the anus (figure 1). Biopsies were taken in order to figure out the type of colonic tumor. The microscopic study showed nests, sheets, and glands of neoplastic cells with hyper-chromic pleomorphic large nuclei with high nuclear-cytoplasmic (N/C) ratio. Extensive foci of tumor necrosis and many mucosal secretions were noted. Overall, the diagnosis of adenocarcinoma in the ascending colon was confirmed. Total Colectomy was done for the patient (figure 2)
Figure 1. Colonoscopy. Large fragile circumferential tumor in ascending colon and internal hemorrhoid in anus
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Figure 2. Total colectomy after the diagnosis of adenocarcinoma in ascending colon
3. DISCUSSION CKD is associated with significant morbidity and mortality (12). ESRD incidence is rapidly increasing. These patients possess risk for neurologic complications, cardiopulmonary pathology, infection, and access site complications. Advanced renal pathology and the systemic effects of reduced kidney function, including some impairment of immunity following ESRD can increase the risk of cancer (13, 14). Patients on renal replacement therapy for end-stage chronic kidney disease are at high risk for cancer. Understanding the relationship between CKD and other chronic diseases is important to develop a public health policy to improve outcomes. Variety of cancers can occur in patients with CKD after renal replacement therapies. Kidney transplant recipients are at very high risk of cancers, most, but not all. Patients on dialysis with CKD also experience, but to a lower extent, an excess risk for a number of tumors (15, 16). The pattern of cancer incidence risk differs according to renal replacement therapy modality, overall the risk of cancer is higher after renal transplantation due to an excess of virus-associated cancers (17). Only a few analyses of cancer risk in patients on long-term dialysis have been done, and these have had conflicting results (9, 18). To the best of our knowledge, there is no documented case in the literature in which colonic adenocarcinoma represent the following dialysis in a patient with ESRD. In our patient, the first presentation after four years dialysis was just a slight pain in his abdomen in physical examination, and anemia, high serum BUN and Cr level in laboratory tests. This case illustrates that these presentations in patients with the late stage of chronic kidney disease might be related to a clinically occult cancer.
4 CONCLUSION Controlling the underlying diseases such as hypertension and diabetes mellitus can reduce kidney damages. As all patients on renal replacement therapy should be under close medical surveillance, organ imaging modalities from time to time and some screening for asymptomatic cancer will have resulted in earlier diagnosis and treatment. Physicians and health authorities should consider evaluating the strategies for cancer screening in people at high risk for chronic kidney diseases especially ESRD patients. Conflict of interest Authors declare no conflict of interest. 5. REFERENCES 1. Abbasi MA, Chertow GM, Hall YN. End-stage renal disease. BMJ clinical evidence. 2010;2010. 2. Long B, Koyfman A, Lee CM. Emergency medicine evaluation and management of the end stage renal disease patient. The American journal of emergency medicine. 2017;35(12):1946-55.
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