Adult Intussusception Caused by Descending Colon Cancer during Chemotherapy of Stomach Cancer Recurrence.

Abstract

Intussusception in adults is uncommon, and it is rare in the descending colon because of its fixation to the retroperitoneum. We herein describe a case of intussusception caused by descending colon cancer. A 74-year-old man was admitted to our hospital for treatment of vomiting and abdominal pain. He had undergone chemotherapy for lymph node recurrence of stomach cancer for about 4 years. Computed tomography revealed a 'target mass' with a tumor in the descending colon. We diagnosed his illness as intussusception of a descending colon tumor and performed emergency laparotomy. Conservative resection was performed following anastomosis after reduction of the intussusception. The tumor was pathologically diagnosed as poorly differentiated adenocarcinoma with neuroendocrine features. To the best of our knowledge, this is the first report of an intussusception caused by descending colon cancer incidentally diagnosed during chemotherapy for stomach cancer recurrence.

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Page 1

Case Rep Gastroenterol 2012;6:88–93
DOI: 10.1159/000336601
Published online:
January 31, 2012
© 2012 S. Karger AG, Basel
ISSN 1662–0631
www.karger.com/crg
This is an Open Access article licensed under the terms of the Creative Commons
Attribution-NonCommercial-NoDerivs 3.0 License (www.karger.com/OA-license), applicable
to the online version of the article only. Distribution for non-commercial purposes only.



Minoru Fukuchi, MD




Department of Surgery, Social Insurance Gunma Chuo General Hospital
1-7-13, Kouun-cho, Maebashi, Gunma, 371-0025 (Japan)
Tel. +81 27 221 8165, E-Mail mfukuchi @ med.gunma-u.ac.jp

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Adult Intussusception Caused
by Descending Colon Cancer
during Chemotherapy of
Stomach Cancer Recurrence
Minoru Fukuchia Ritsuko Tsukagoshia Shinji Sakuraib
Masaki Suzukia Hiroshi Naitoha Hayato Yamauchia
Yuichi Tabea Takaharu Fukasawaa Shinsuke Kiriyamaa
Hiroyuki Kuwanoc
Departments of aSurgery and bDiagnostic Pathology, Social Insurance Gunma
Chuo General Hospital, and cDepartment of General Surgical Science, Gunma
University Graduate School of Medicine, Maebashi, Japan


Key Words
Intussusception · Descending colon cancer · Stomach cancer recurrence ·
Chemotherapy


Abstract
Intussusception in adults is uncommon, and it is rare in the descending colon because of
its fixation to the retroperitoneum. We herein describe a case of intussusception caused
by descending colon cancer. A 74-year-old man was admitted to our hospital for treatment
of vomiting and abdominal pain. He had undergone chemotherapy for lymph node
recurrence of stomach cancer for about 4 years. Computed tomography revealed a ‘target
mass’ with a tumor in the descending colon. We diagnosed his illness as intussusception of a
descending colon tumor and performed emergency laparotomy. Conservative resection was
performed following anastomosis after reduction of the intussusception. The tumor was
pathologically diagnosed as poorly differentiated adenocarcinoma with neuroendocrine
features. To the best of our knowledge, this is the first report of an intussusception caused
by descending colon cancer incidentally diagnosed during chemotherapy for stomach cancer
recurrence.

Page 2

Case Rep Gastroenterol 2012;6:88–93
DOI: 10.1159/000336601
Published online:
January 31, 2012
© 2012 S. Karger AG, Basel
ISSN 1662–0631
www.karger.com/crg



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Introduction
Intussusception is most commonly encountered in infants and children, although
approximately 5% of cases occur in adults. In fact, it accounts for an estimated 1% of
all cases of bowel obstruction in adults. Adult intussusception of the colon is rare and
often originates from neoplasia [1]. This condition generally does not present with
any specific symptoms. The diagnosis can be in emergency situations, with the aid of
integrated examinations. The association of readily available diagnostic means, such as
radiological and ultrasonographic studies, may yield reliable findings [2, 3]. These help
in formulating a diagnosis of the nature and site of occlusion. However, this condition is
often subsequently confirmed intraoperatively. Preoperative diagnosis of this condition
can be difficult in emergency cases.
We herein describe a case of adult intussusception of the descending colon
caused by a malignant tumor. Intussusception of the descending colon generally
does not readily occur because the descending colon is anatomically fixed to the
retroperitoneum [4]. Moreover, this patient had undergone chemotherapy for lymph
node recurrence of stomach cancer for about 4 years, which could not prevent colon
cancer. The progression of this patient’s condition seemed to indirectly suggest a
difference in biological malignancy between stomach cancer and colon cancer.
Case Report
A 74-year-old Japanese man was admitted to our hospital for treatment of vomiting and abdominal
pain on June 15, 2011. Physical examination revealed a temperature of 36.9°C, blood pressure of
175/105 mm Hg and a pulse rate of 65 beats/min. His abdominal pain continued intermittently for
approximately 12 h in the night. Clinical examination revealed a distended abdomen with provocative
pain in the left upper quadrant and a palpable, fist-sized mass. Blood tests showed a slightly elevated
C-reactive protein level of 1.15 mg/dl, although other tests, including tumor markers, were within
normal limits.
The patient had a past history of distal gastrectomy for stomach cancer in December 2003 and
was visiting our hospital for chemotherapy for lymph node recurrence around the aorta approved
since March 2007. This patient underwent 12 courses of irinotecan (100 mg/m2 weekly for 3 weeks
followed by 2 weeks of rest) followed by 14 courses of S-1 (80 mg/m2 weekly for 4 weeks followed by
2 weeks of rest) and 5 courses of paclitaxel (100 mg/m2 weekly for 3 weeks followed by 1 week of
rest). Computed tomography (CT) indicated that the lymph node recurrence had disappeared on
June 1, 2011, resulting in a complete response.
At his visit to our hospital, CT revealed a ‘target mass’ in the descending colon, suggesting the
existence of a tumor in the head of the intussusception (fig. 1), whereas colonoscopic examination
had revealed normal results in June 2008. We diagnosed his illness as intussusception of a colon
tumor and performed emergency laparotomy. At surgery, the descending colon was intussuscepted
into itself by the tumor. The intussusceptum was easily isolated because the fixation between the
descending colon and the retroperitoneum was relatively weak. Reduction of the intussusception was
performed before the resection following anastomosis because of the shortness and tension in the
neighboring colon. The left colon, including the ischemic area and tumor, and regional lymph nodes
were removed. An end-to-end anastomosis was primarily fashioned between the transverse colon and
sigmoid colon. The postoperative course was uneventful, and the patient was discharged 14 days after
surgery.
Macroscopically, the surgical specimen contained a 5.3 × 3.5 cm protuberant tumor at the
proximal edge of the 16-cm-long ischemic area in the descending colon (fig. 2). Microscopic
examination revealed poorly differentiated adenocarcinoma with invasion into the subserosa and
ischemic wall on the anal side of the tumor by hematoxylin-eosin staining (fig. 3a). The regional

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Case Rep Gastroenterol 2012;6:88–93
DOI: 10.1159/000336601
Published online:
January 31, 2012
© 2012 S. Karger AG, Basel
ISSN 1662–0631
www.karger.com/crg


lymph nodes did not have metastasis. The tumor was partially positive for chromogranin A, KIT, and
CD56 by immunohistological staining, resulting in an adenocarcinoma with neuroendocrine features
(fig. 3b–d).

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Discussion
Most colon intussusceptions in adults are caused by malignant tumors, although
other causes and idiopathic forms of intussusception have been reported [1–3]. These
intussusceptions are frequently located in the flexible portions of the colon, for
example the sigmoid colon or cecum [5, 6]. Intussusception of the descending colon is
rarer because the descending colon is anatomically fixed to the retroperitoneum [4].
Incomplete fixation between the retroperitoneum and descending colon might result in
the presently described condition.
Few general surgeons encounter more than one or two patients with colon
intussusception during their careers, and most cases are undiagnosed before surgery.
Previous papers reported that CT is the most accurate imaging modality for diagnosing
intussusception [1, 2]. The characteristic CT findings of intussusception include an
early target mass with enveloped, eccentrically located areas of low density [7].
Reduction of intussusceptions with suspected malignancy is not generally
advisable because it may cause bowel perforation and tumor cell dissemination [8].
However, reduction may be advisable to accurately determine the range of resection
for minimally invasive surgery [6]. In our case, conservative resection was performed
following anastomosis after reduction of the intussusception. If the intussusception had
been operatively reduced, it would have been difficult to anastomose primarily because
of the shortness and tension in the neighboring colon.
It was thought that colon cancer in this case occurred during the past 3 years,
because colonoscopic examination had revealed a normal study in 2008. On the
other hand, our patient had received several kinds of chemotherapy for lymph node
recurrence of stomach cancer for about 4 years and had obtained a complete response.
Thus chemotherapy seems to be generally effective for both gastric cancer and colon
cancer, but could not prevent colon adenocarcinoma in our case. One reason could be
the mixture of neuroendocrine features, because neuroendocrine carcinomas often
show resistance to chemotherapy [9].
Colon intussusception in adults is generally rare. To the best of our knowledge, this
is the first report of an intussusception caused by descending colon cancer incidentally
diagnosed during chemotherapy for stomach cancer recurrence. The progression of this
patient’s condition also suggested a difference in the biological malignancy between
stomach cancer and colon cancer.
Disclosure Statement
The authors have no conflicts of interest.

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Case Rep Gastroenterol 2012;6:88–93
DOI: 10.1159/000336601
Published online:
January 31, 2012
© 2012 S. Karger AG, Basel
ISSN 1662–0631
www.karger.com/crg



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Fig. 1. Abdominal CT indicated enlargement of the descending colon wall within the intussusception
(arrows), suggesting the existence of a tumor in the head. a Transverse slice. b Sagittal slice.

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Case Rep Gastroenterol 2012;6:88–93
DOI: 10.1159/000336601
Published online:
January 31, 2012
© 2012 S. Karger AG, Basel
ISSN 1662–0631
www.karger.com/crg



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Fig. 2. The surgical specimen contained a 5.3 × 3.5 cm protuberant tumor that was thought to be the
lead point of the intussusception. The ischemic area of the wall was 16 cm along the anal side of the
tumor.



Fig. 3. Microscopic examination. a The tumor was a poorly differentiated adenocarcinoma with
invasion into the subserosa (hematoxylin-eosin staining, ×100). b–d The tumor was partially positive
for chromogranin A, KIT, and CD56 by immunohistological staining (×100).