Patient demographics

A 34-year-old man, previously well, with no family history of colorectal cancer, no inflammatory bowel disease, and no genetic syndrome identified. Non-smoker, occasional alcohol, sedentary office worker. The case is presented with patient consent and all identifying details have been changed.

Presenting symptoms

The patient presented to the outpatient clinic with a three-month history of:

  • Altered bowel habit, alternating between loose motion and mild constipation
  • Intermittent right-sided lower abdominal discomfort, dull, non-radiating
  • Unintentional weight loss of about 4 kg over three months
  • Fatigue and reduced exercise tolerance
  • One episode of dark stool, attributed at the time to dietary iron

He had seen a primary care physician and had been treated for presumed irritable bowel syndrome for six weeks before being referred.

Diagnostic workup

On examination he was pale but stable. There was vague tenderness in the right iliac fossa, no palpable mass, and a normal per-rectal examination.

Initial investigations:

  • Haemoglobin 9.4 g/dL, microcytic hypochromic picture
  • Serum ferritin low
  • CEA mildly elevated
  • Faecal occult blood positive

A colonoscopy was performed. It revealed a circumferential, friable mass in the ascending colon approximately 60 cm from the anal verge, with the remaining colon normal. Biopsy confirmed moderately differentiated adenocarcinoma.

Staging was completed with:

  • Contrast-enhanced CT scan of the thorax, abdomen and pelvis, which showed a 5.5 cm ascending colon mass with localised pericolic lymphadenopathy and no distant metastases
  • Baseline tumour markers (CEA, CA 19-9)
  • Routine pre-operative bloods, anaesthetic assessment, and cardiac evaluation

The case was discussed at the Apollo tumour board. Consensus was upfront surgery, given the absence of metastatic disease and the fitness of the patient.

Surgical approach

A laparoscopic right hemicolectomy with D3 lymphadenectomy was planned. The indication for D3, which involves a more extensive lymph node dissection along the superior mesenteric vessels, was the locally advanced nature of the tumour and the patient's young age, where thorough lymph node sampling offers the best prognostic and therapeutic yield.

Operative course:

  • Four trocars placed, 12 mm supraumbilical plus three 5 mm working ports
  • Diagnostic laparoscopy showed no peritoneal deposits, no liver metastases
  • Medial-to-lateral dissection along the superior mesenteric vein
  • Central vascular ligation of the ileocolic, right colic, and middle colic branches at their origin
  • D3 clearance of all nodes along the vascular pedicles
  • The right colon was mobilised laparoscopically, then delivered through a small periumbilical extension
  • Extracorporeal side-to-side stapled ileo-colic anastomosis
  • Estimated blood loss 80 mL, operative time 195 minutes

Intra-operative course was uneventful. He was shifted to the ward directly, no ICU required.

Post-operative course

Enhanced recovery protocols were followed:

  • Early mobilisation on the evening of surgery
  • Sips of water at 6 hours, free fluids at 24 hours, soft diet by day 3
  • Epidural analgesia for 48 hours, then oral paracetamol and short-course NSAID
  • No post-operative ileus, no wound complications
  • Discharged on day 5

The final histopathology report confirmed:

  • Moderately differentiated adenocarcinoma, 5.5 cm
  • pT3 pN1 (2 of 28 nodes positive), no lymphovascular invasion, clear resection margins
  • Stage IIIB disease (AJCC)

Adjuvant chemotherapy referral

Given the node-positive status, the patient was referred for adjuvant chemotherapy. The medical oncology team started a standard 6-month FOLFOX regimen at three weeks post-operative. He tolerated chemotherapy reasonably well, with expected fatigue and two cycles of dose reduction for neutropenia.

Outcome at 18 months

At 18 months from surgery:

  • No clinical, biochemical, or radiological evidence of recurrence
  • CEA has returned to normal
  • Surveillance CT at 12 months was clear
  • Patient has returned to full work, normal exercise, and has regained his pre-illness weight

He remains on a structured oncology follow-up schedule for a minimum of five years.

Discussion

Two points are worth highlighting for other clinicians and for patients reading this case.

The first is the importance of taking persistent altered bowel habit seriously in younger adults. Colorectal cancer incidence in the under-50 population is rising globally, and symptoms are often dismissed as functional. Any patient with iron-deficiency anaemia of unclear cause, particularly with a change in bowel pattern, deserves prompt endoscopic evaluation.

The second is the value of D3 lymphadenectomy in locally advanced cases. The procedure adds technical complexity and requires a surgeon comfortable with the central mesenteric anatomy, but it offers the best opportunity for accurate staging and for clearance of otherwise missed nodal disease. The minimally invasive approach does not compromise oncologic quality when performed by a trained surgeon.

Patient outcomes in colon cancer depend on early diagnosis, a clean resection, proper nodal clearance, and disciplined adjuvant therapy and follow-up. In this case all four were aligned, and the result has been a young man back to his normal life, appropriately monitored.

Case presented with patient consent. All identifying details have been changed. Clinical interpretation and outcomes are specific to this case and do not represent a treatment recommendation for other patients.