A 40-year-old otherwise healthy Sri Lankan man presented with abdominal pain and reduced stool frequency of one month's duration. He gave a strong family history of bowel cancer. Two first degree and 6 second degree relatives had colonic cancer. His father and elder brother were diagnosed with colon cancer at the age of 54 and 42 years respectively. His father had 10 siblings and of them, 5 had colorectal cancers. The patient's grandfather was also diagnosed with colon cancer. His medical, drug and psychosocial history were unremarkable.
Colonoscopy and biopsy confirmed a moderately differentiated adenocarcinoma of the proximal transverse colon. Contrast enhanced computed tomography (CT) scan showed a mass in the proximal transverse colon without any evidence of locoregional spread or distant metastasis and the carcinoembryonic antigen (CEA) level was 2.6 ng/ml. After counseling, he opted for an extended right hemicolectomy with colonoscopic surveillance than a total colectomy. The final histology confirmed a moderately differentiated adenocarcinoma without any lymphovascular or perineural invasion and no metastasis to lymphnodes (T2N0Mx). Incidentally, multiple, caeseating epithelioid-type granulomas were found in the sub mucosa and mesenteric lymph nodes. He did not have clinical, biochemical (normal ESR, mantoux and interferon gamma) or radiological evidence (Chest X-ray and CT scan) of tuberculosis. He did not receive adjuvant chemotherapy but was commenced on a 9-month course of anti-tuberculosis treatment postoperatively with an intensive phase of 2 months (Rifampin, Isoniazid, Pyrazinamide, and Ethambutol) and continuation phase of 7 months (Rifampin and Isoniazid).
Two months following the hemicolectomy, he developed a rapidly enlarging lump over the chin (Fig. 1). This was mistakenly identified as a sebaceous cyst and excised in another unit. Biopsy revealed a well differentiated squamous cell carcinoma with an involved deep margin. There was no clinical or ultrasound evidence of cervical lymphadenopathy. A wide local excision of the tumor bed with a radial forearm free flap reconstruction was done (Figs. 2 and 3) without sentinel lymph node dissection. A month later he developed a similar nodular lesion in the occipital region which was excised and proved also to be a well differentiated squamous cell carcinomas with tumor free resection margins.
He was followed up with six monthly CEA, annual colonoscopy, annual CT scans and was disease free for more than 2 years after surgery.