1. Case

2. Kreem is 53 year old man who is quite healthy with no previous illness. He has noticed changes in his bowel habits for the last few months, with prolonged periods of constipation. He has good appetite. There is no vomiting or abdominal pain. There is no weight loss. Kareem is quite worried about his illness because he has a brother with colon cancer.

3. Colon cancer. –What is cancer? –What is colon cancer? –Family history of cancer!

4. Kareem is referred to a gastroenterologist who examines him and suggests screening for colon cancer by stool occult blood. Kareem is very anxious about this test and asked: –What is screening? –What doest it mean if the test is positive? In fact Kareem has a positive stool occult blood test, and he is booked for colonoscopy (endoscopy).

5. Kareem has the colonoscopy done. It showed 3 polyps of the colon, one in the rectum and two in the sigmoid colon. The polyps are removed and the pathology result is tubular adenoma of the colon. The doctor told Kareem that this is a benign tumor of the colon and he does not have cancer. However he needs to continue the follow up to prevent cancer.

7. What is polyp? What is the role of pathology in diagnosis of cancer? What is benign tumor, What is malignant tumor? What is adenoma?

8. Kareem is lost from the follow up for 5 years. 5 years later, Kareem presents to this doctor with mild to moderate vague lower abdominal pain. He lost about 10 Kg in the last 4 months. He is not eating well and feels weak. There is no vomiting. Kareem has another colonoscopy done and showes a large mass in the sigmoid colon measuring 5 cm in maximum dimension.

10. What is the cause of the mass? Why is there loss of weight? What is the cause of abdominal pain?

11. Kareem has a surgical resection of the sigmoid colon. The pathology shows: –Adenocarcinoma of the colon –Well differentiated (Grading) –Tumor invades the wall of the colon and the mesenteric fat (Staging) –2 of 10 lymph nodes are positive for metastatic adenocarcinoma –Surgical margins are clear of tumor

13. What is adenocarcinoma? What is grading? What is staging? What is the meaning of metastasis? Why is there tumor in the lymph nodes?

14. 6 months later, Kareem presented with deterioration in his condition, with generalized weakness, fatigue and severe weight loss. He is found to have high level of liver enzymes ALT, AST and jaundice. He has high level of CEA in the serum. He has CT scan done and showed multiple nodules in the liver, consistent with metastases. He also has multiple nodules in the lungs bilaterally. Kareem received chemotherapy but dies few months later.

15. Why and how does the tumor progress? Why is there metastasis to the liver and the lungs?