Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 66, Num. 4, 2004, pp. 236-238

Indian Journal of Surgery, Vol. 66, No. 4, July-August, 2004, pp. 236-238

Case Report

Mucinous carcinoma of rectum in an 11 year old child

Sarda DineshK, Kamble AshokT, Mungate GayatriS, Gosavi Amol

Department of Surgery, Indira Gandhi Medical College, Nagpur

Correspondence Address:C/o Dr. Gayatri S. Mungate, Plot No. 12, Telecom Nagar, Nagpur
sardadinesh@rediffmail.com

Code Number: is04056

ABSTRACT

KEY WORDS:Gastrointestinal haemorrhage, intestinal obstruction, colorectal malignancies.

INTRODUCTION

Carcinoma of the colon and rectum is a relatively uncommon malignancy in India as compared to the western world. The age-standardized rates of colorectal cancer in India have been estimated to be 4.2 and 3.2/1,00,000 for males and females, respectively as compared to 60.8 and 42.3 respectively in the USA.[1] Considering such a low incidence in adults it would be rare to find colorectal carcinoma in the pediatric age group. A literature search could not reveal much more information on colorectal cancer in the Indian pediatric population. Primary gastrointestinal malignancies constitute only 1% of pediatric neoplasms and therefore, remain unsuspected in children, often presenting late with symptoms of intestinal obstruction.[2]

CASE REPORT

An 11-year-old boy was admitted to our unit with complaints of bleeding per rectum, constipation and mucus in stools since one month. This was accompanied by persistent lower abdominal pain. On examination, the lower abdomen was tender. Digital rectal examination revealed anal stenosis and a large circumferential constricting growth with palpable induration. It was approximately 2 cm from anal verge and upper extent was about 8 to 10 cm. CT Scan showed an eccentric thickening of wall of rectum and anal canal with lobulated soft tissue mass in presacral space of size 6x3x2 cm. Fat planes between rectum and lateral pelvic wall were infiltrated [Figure - 1]. On exploratory laparotomy the mass was seen arising from the rectum and was stuck to the lateral and posterior pelvic walls. It was inoperable. There were no intra-abdominal secondaries. Only sigmoid colostomy was done to relieve the obstruction. Histology of biopsy material was suggestive of poorly differentiated mucinous adenocarcinoma [Figure - 2]. Patient was advised palliative radiotherapy.

DISCUSSION

Colorectal malignancies are extremely rare in pediatric age group and the youngest recorded case is a 9-month-old child. The reported incidence is 1.3 per million children.[2] In general, these malignancies in children have a very poor prognosis and are usually beyond the scope of operative correction. The main reasons attributed for this are delay in the diagnosis, advanced stage of the disease at presentation and poor histological differentiation of the malignancy.

The differences in duration of symptoms, primary site, pathological findings, stage and prognosis between adults and children are striking. [Table - 1]

The existence of predisposing conditions, which increase the risk of colorectal carcinoma developing, is well recognised. These include familial polyposis coli, Gardner′s syndrome, Turcot′s syndrome, Peutz-Jeghar′s syndrome, juvenile polyposis of colon, ulcerative colitis, and family cancer syndrome.[2]

In children, there is a higher incidence of involvement of the right and transverse colon (53%) compared with adults (33%) and a far lower rate of involvement of rectum (10%). In pediatric age group, there are far more common causes of abdominal pain than rectal carcinoma. Symptomatology like altered bowel habit with abdominal pain in this age group is often attributed to more common inflammatory conditions of bowel rather than a colorectal malignancy.

Resection even palliative is always preferable to bypass, because it effectively relieves the obstruction and also decreases the tumour load. Surgery should be the first modality of treatment as the disease in children responds poorly to chemotherapy as well to radiotherapy. The value of chemotherapy as a means of palliation has been controversial and responses have been less than optimal. In rectal cancers, preoperative radiotherapy has been utilized extensively to convert unresectable lesions to resectable ones.[6]

The predominant histological type in children and adolescents is the poorly differentiated mucinous adenocarcinoma.[2] The prognosis with a mucinous carcinoma is very poor. The mucin absorbs water, swells and invades local tissues, thereby promoting spread of malignant cells. It also interferes with the immune recognition of carcinoma cells due to mucopolysaccharide coating. This histopathology is known to be more aggressive with predisposition to early metastasis.

CONCLUSION

The overall prognosis of the carcinoma of the colon and rectum in children will only improve with increased awareness leading to early diagnosis of the condition. A high level of suspicion coupled with a simple digital rectal examination followed by sigmoidoscopy and/or colonoscopy if required, can result in early diagnosis which will go a long way in providing effective therapy.[5]

REFERENCES

Copyright 2004 - Indian Journal of Surgery

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