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  Table of Contents  
LETTER TO THE EDITOR
Year : 2015  |  Volume : 52  |  Issue : 4  |  Page : 502-504
 

Microsatellite stable adenocarcinoma in a pediatric patient presenting as a dual mass in the colon and cecum: A rare presentation


Department of Pathology, S. R. T. R. Government Medical College, Ambajogai, District Beed, Maharashtra, India

Date of Web Publication10-Mar-2016

Correspondence Address:
S Y Sunil
Department of Pathology, S. R. T. R. Government Medical College, Ambajogai, District Beed, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.178375

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How to cite this article:
Sunil S Y, Rasika G U, Grace D F. Microsatellite stable adenocarcinoma in a pediatric patient presenting as a dual mass in the colon and cecum: A rare presentation. Indian J Cancer 2015;52:502-4

How to cite this URL:
Sunil S Y, Rasika G U, Grace D F. Microsatellite stable adenocarcinoma in a pediatric patient presenting as a dual mass in the colon and cecum: A rare presentation. Indian J Cancer [serial online] 2015 [cited 2019 Dec 5];52:502-4. Available from: http://www.indianjcancer.com/text.asp?2015/52/4/502/178375


Sir,

Colorectal carcinoma is rare in the pediatric age group with incidence of 1.3-2 cases/million children and is much lower in India.[1] Microsatellite instability (MSI) is present in approximately 15% of colorectal cancers (CRC), which are mostly non-familial (sporadic) and caused by hypermethylation of the mutL homolog 1 (MLH1) promoter.[2]

A 10-year-old male child presented with a swelling in the right iliac fossa, gradually increasing in size since 6 months and with pain since 1 month. General and hematological examinations were insignificant.

Systemic examination showed a palpable mass of size 3 cm × 4 cm × 2 cm in the right lower quadrant of the abdomen. The clinical diagnosis was Koch's abdomen with differential diagnosis of lymphoma. Fine-needle aspiration cytology [Figure 1] was suggestive of round cell malignancy suggestive of non-Hodgkin's lymphoma (NHL). Computed tomography abdomen showed a hypodense mass occupying the caecum and part of the ascending colon with iliac lymphadenopathy. Intraoperative findings revealed two tumors in the cecum and ascending colon of size 6 cm × 6 cm and 4 cm × 4 cm respectively.
Figure 1: Fine-needle aspiration cytology suggestive of malignant pleomorphic tumor? Non-Hodgkin's lymphoma (Pap, ×10)

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On gross [Figure 2], a segment of intestine of length 40 cm was received. Two masses, one in the cecum and the other in the ascending colon were seen on cut section. The cecal mass [Figure 3] was an endophytic growth of size 6 cm × 5 cm × 2 cm size with infiltrative margins. The ascending colon mass [Figure 4] was well-circumscribed, 4 cm × 3 cm × 2 cm in size with cut surface grayish white and gelatinous.
Figure 2: Gross: Intestine of 40 cm length

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Figure 3: Endophytic growth of 6 cm × 5 cm × 2 cm in the caecum with infiltrative margins

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Figure 4: Well-circumscribed, grayish white and gelatinous tumor of 4 cm × 3 cm × 2 cm size

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The cecal tumor with endophytic growth [Figure 5] showed diffusely scattered round to oval cells with hyperchromatic nuclei and anisonucleosis, separated by thin fibrous septa. Areas of necrosis and calcification were also seen. The ascending colon tumor with a glistening surface [Figure 6] showed sheets and groups of cells with hyperchromatic nuclei, prominent nucleoli, admixed with mucin pools. The tumor was infiltrating all the layers of the large intestine.
Figure 5: Diffusely scattered round to oval tumor cells separated by thin fibrous septa (H and E, ×10)

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Figure 6: Groups of tumor cells admixed with mucin pools (H and E, ×10)

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Lymph node [Figure 7] showed metastatic deposits of tumor cells.
Figure 7: Lymph node showing metastatic deposits (H and E, ×10)

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A diagnosis of adenocarcinoma of the colon with NHL was made.

Immunohistochemistry revealed [Figure 8] a diffuse positivity for pan cytokeratin (CK) and [Figure 9] epithelial membrane antigen, focal positivity for CK20 [Figure 10] and vimentin [Figure 11] and negativity for CK7, CD99, CD45 (leukocyte common antigen) [Figure 12], synaptophysin and chromogranin, indicating that the tumor was an adenocarcinoma.
Figure 8: Pan cytokeratin: Diffuse positivity

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Figure 9: Epithelial membrane antigen: Diffuse positivity

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Figure 10: Cytokeratin 20: Focal positivity

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Figure 11: Vimentin: Focal positivity

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Figure 12: Leukocyte common antigen: Negative in tumor cells

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Further investigations like microsatellite markers were done and showed nuclear positivity for MutS homolog 2 [MSH2], MSH6, MLH1 and Postmeiotic segregation increased 2 [PMS2].

Immunoprofile showed mismatch repair protein proficient tumor, which is compatible with microsatellite stable tumor type.

The final diagnosis was given as invasive adenocarcinoma of colon (poorly differentiated and with microsatellite stable tumor type). Patient was lost for further follow-up.


  Discussion Top


The incidence of colorectal carcinoma in individuals younger than 20 years of age is less than0.1 cases per million.[3] Delayed diagnosis, advanced stage of disease at presentation and most importantly mucinous type of histology are the major determinants of poor outcome in childhood colorectal carcinoma.[4]

microsatellite instability-high is present in more than 90% of hereditary non-polyposis CRC, compared to only 15-20% of sporadic carcinoma.[5]


  Inference Top


MSI tumors have a good prognosis and reduced likelihood of metastasis compared with microsatellite stable tumors, which highlights the value of MSI as a prognostic marker in CRC.[2]

 
  References Top

1.
Devendra K, Carachi R. Colorectal cancer in children. Pediatric Oncology. 1st ed.: Jaypee Brothers; 2007. p. 457-8.  Back to cited text no. 1
    
2.
Vilar E, Gruber SB. Microsatellite instability in colorectal cancer-the stable evidence. Nat Rev Clin Oncol 2010;7:153-62.  Back to cited text no. 2
    
3.
Walker WA. Clinical manifestations and management. The intestine. Paediatric Gastrointestinal Disease. Pathophysiology and Diagnosis. Hamilton: B.C. Decker; 2004. p. 989.  Back to cited text no. 3
    
4.
Ibrahim K, Arbay O, Ciftci, Mehmet E, Nebil B. Colorectal carcinoma in children. J Pediatr Surg 1999;34:1499-504.  Back to cited text no. 4
    
5.
Koch TR. Genetic testing for colon cancer. Colonic Diseases. New Jersey: Human Press; 2003. p. 200.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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