pondering on this case

A 57 year old male presented in December 2013 to a general clinic complaining of abdominal and diarrhea that was intermittently bloody, the patient maintains he did not have insurance and did not undergo an abdominal cat scan.   By march 2014, he has lost weight and went to Juarez Mexico to be evaluated, There, an abdominal cat scan was also not completed.   Finally 2 weeks ago, he was admitted with leg swelling and shortness of breath, the rectal bleed continued....This time not only he was found with bilateral Deep vein thrombosis (DVT),  a Pulmonary Embolus, A CT revealed a a 7 cm liver Metastatic lesion, the mass in the distal transvers Colon had a "controlled" perforation and an abces like formation was observed through the wall of the Colon at the Ulcerated bleeding mass.  The bleeding was important, in 2 weeks of the evaluation, he received 8 units of PRBC, and anticoagulation could not be performed.  An IVC filter was placed.
A surgical consult was reportedly obtained and somehow decision not to proceed with palliative resection was not immediately made, and the patient was referred to CRBCM for an oncologic opinion and need assessment for Neo-adjuvant chemotherapy.

While an eager Oncologist would certainly Obtain an MRI of the brain, preparing for use of Avastin, place a port catheter for a Folfox infusion, One needs to set back and look at certain aspects of this case.
Treating with chemotherapy
1.May open wide the perforation in light of a shrinking tumor, leading to a frank peritonitis
2.The mass is bleeding, an indication for palliative surgery
3.The "Abces" could also spark a significant abdominal infection/peritonitis when marrow suppression is induced by chemotherapy.
4.The anticoagulation that is contre-indicated by the bleeding mass, could be further exacerbated by chemotherapy which on its own has been linked to DVT.  The thing is removal of this colon lesion would allow easy anticoagulation and diminishing post-phlebitic consequences!
5.We will not dwell on consequential Microangiopathy which will come into play when liver lesion resection will be due!
6.To make this matter interesting genetically, the CEA was below 4 and drastically  so!  0.7 as a matter of fact.
7. And the KRAS not requested by early observers!

This case has touched so many aspect of problems encountered in the management of Colon Cancer that capture our attention....

By the way, we have recommended the palliative removal  of the culprit Colon lesion, the patient does not have insurance and the surgeons are not very eager to proceed...such is life in the real world and there is nothing you and I can do other than advocating for our patients!   Quite frankly, chemotherapy drug makers have been responding to us so far in helping patients but obtaining a service from specialty physicians has been the hardest to achieve!  No one wants to help for free especially institutions which receives millions in public funds!

Our (CRBCM and Greater East Cancer center) work continues though...will see it through...because our fight is just!