World Journal ofClinical Cases

World J Clin Cases 2020 May 6; 8(9): 1561-1755

ISSN 2307-8960 (online)

Published by Baishideng Publishing Group Inc

W J C C World Journal ofClinical Cases

Contents Semimonthly Volume 8 Number 9 May 6, 2020

REVIEW1561 Nutrition management in acute pancreatitis: Clinical practice consideration

Lakananurak N, Gramlich L

MINIREVIEWS1574 Bone disease in chronic pancreatitis

Ahmed A, Deep A, Kothari DJ, Sheth SG

1580 Role of microRNAs in the predisposition to gastrointestinal malignanciesBaz M, Ibrahim T

1586 Recurrent anal fistulas: When, why, and how to manage?Emile SH

ORIGINAL ARTICLE

Case Control Study

1592 Removal of biofilm is essential for long-term ventilation tube retentionMa Q, Wang H, Chen ZN, Wu YQ, Yu DZ, Wang PJ, Shi HB, Su KM

Retrospective Cohort Study

1600 Neutrophil gelatinase-associated lipocalin does not predict acute kidney injury in heart failureFerrari F, Scalzotto E, Esposito P, Samoni S, Mistrorigo F, Rizo Topete LM, De Cal M, Virzì GM, Corradi V, Torregrossa R,

Valle R, Bianzina S, Aspromonte N, Floris M, Fontanelli A, Brendolan A, Ronco C

1608 Prognosis factors of advanced gastric cancer according to sex and ageAlshehri A, Alanezi H, Kim BS

Observational Study

1620 Attitudes, knowledge levels and behaviors of Islamic religious officials about organ donation in Turkey:

National survey studyAkbulut S, Ozer A, Firinci B, Saritas H, Demyati K, Yilmaz S

1632 Serotonin transporter and cholecystokinin in diarrhea-predominant irritable bowel syndrome: Associations

with abdominal pain, visceral hypersensitivity and psychological performanceQin G, Zhang Y, Yao SK

WJCC https://www.wjgnet.com May 6, 2020 Volume 8 Issue 9I

ContentsWorld Journal of Clinical Cases

Volume 8 Number 9 May 6, 2020

CASE REPORT1642 Cholesteryl ester storage disease of clinical and genetic characterisation: A case report and review of

literatureRashu EB, Junker AE, Danielsen KV, Dahl E, Hamberg O, Borgwardt L, Christensen VB, Wewer Albrechtsen NJ, Gluud LL

1651 Seroconversion of HBsAG coincides super-infection with hepatitis A: A case reportBeisel C, Addo MM, zur Wiesch JS

1656 Liver cirrhosis in a child associated with Castleman's disease: A case reportKobayashi S, Inui A, Tsunoda T, Umetsu S, Sogo T, Mori M, Shinkai M, Fujisawa T

1666 Granulocyte colony-stimulating factor-producing squamous cell carcinoma of the tongue exhibiting

characteristic fluorine-18 deoxyglucose accumulation on positron emission tomography–computed

tomography: A case reportShimamoto H, Hirota Y, Kashima Y, Kinoshita N, Yokokawa M, Ikeda T, Harada H

1674 Expander implantation for correction of high-riding nipple with enlarged nipple-areola complex using

revision mastopexy: A case reportQin F, Yu NZ, Yang E, Zeng A, Hao Y, Zhu L, Wang XJ

1679 Pyoderma gangrenosum confused with congenital preauricular fistula infection: A case reportZhao Y, Fang RY, Feng GD, Cui TT, Gao ZQ

1685 Central nervous system relapse in a pediatric anaplastic large cell lymphoma patient with CLTC/ALK

translocation treated with alectinib: A case reportYang J, Li J, Gu WY, Jin L, Duan YL, Huang S, Zhang M, Wang XS, Liu Y, Zhou CJ, Gao C, Zheng HY, Zhang YH

1693 Colonic perforation in a nasopharyngeal carcinoma patient treated with fluorouracil: A case reportLu WJ, Li G, Gao L

1698 Thoracoscopic resection of a huge esophageal dedifferentiated liposarcoma: A case reportYe YW, Liao MY, Mou ZM, Shi XX, Xie YC

1705 COVID-19 managed with early non-invasive ventilation and a bundle pharmacotherapy: A case reportPeng M, Ren D, Liu XY, Li JX, Chen RL, Yu BJ, Liu YF, Meng X, Lyu YS

1713 Application of curved ablation in liver cancer with special morphology or location: Report of two casesCao N, Cai HJ, Sun XX, Liu DL, Huang B

1721 Giant ventral hernia simultaneously containing the spleen, a portion of the pancreas and the left hepatic

lobe: A case reportLuo XG, Lu C, Wang WL, Zhou F, Yu CZ

WJCC https://www.wjgnet.com May 6, 2020 Volume 8 Issue 9II

ContentsWorld Journal of Clinical Cases

Volume 8 Number 9 May 6, 2020

1729 Endoscopic ultrasonography elastography in the diagnosis of intrapancreatic ectopic spleen: A case reportGe N, Sun SY

1735 Mesonephric adenocarcinoma of the uterine cervix with rare lung metastases: A case report and review of

the literatureJiang LL, Tong DM, Feng ZY, Liu KR

1745 Portal hypertension in a patient with biliary hamartomas: A case reportLi QQ, Guo XZ, Li HY, Qi XS

LETTER TO THE EDITOR1752 Rare primary lymphoepithelioma-like carcinoma of the renal pelvis

Lai SC, Seery S, Diao TX, Wang JY, Liu M

WJCC https://www.wjgnet.com May 6, 2020 Volume 8 Issue 9III

ContentsWorld Journal of Clinical Cases

Volume 8 Number 9 May 6, 2020

ABOUT COVER Editorial Board Member of World Journal of Clinical Cases, Paul E Sijens,PhD, Associate Professor, Department of Radiology, University MedicalCenter Groningen and University of Groningen, Groningen 9713 GZ,Netherlands

AIMS AND SCOPE The primary aim of World Journal of Clinical Cases (WJCC, World J Clin Cases)is to provide scholars and readers from various fields of clinical medicinewith a platform to publish high-quality clinical research articles andcommunicate their research findings online. WJCC mainly publishes articles reporting research results and findingsobtained in the field of clinical medicine and covering a wide range oftopics, including case control studies, retrospective cohort studies,retrospective studies, clinical trials studies, observational studies,prospective studies, randomized controlled trials, randomized clinicaltrials, systematic reviews, meta-analysis, and case reports.

INDEXING/ABSTRACTING The WJCC is now indexed in PubMed, PubMed Central, Science Citation Index

Expanded (also known as SciSearch®), and Journal Citation Reports/Science Edition.

The 2019 Edition of Journal Citation Reports cites the 2018 impact factor for WJCC

as 1.153 (5-year impact factor: N/A), ranking WJCC as 99 among 160 journals in

Medicine, General and Internal (quartile in category Q3).

RESPONSIBLE EDITORS FORTHIS ISSUE

Responsible Electronic Editor: Yan-Xia Xing

Proofing Production Department Director: Yun-Xiaojian Wu

Responsible Editorial Office Director: Jin-Lei Wang

NAME OF JOURNALWorld Journal of Clinical Cases

ISSNISSN 2307-8960 (online)

LAUNCH DATEApril 16, 2013

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Submit a Manuscript: https://www.f6publishing.com World J Clin Cases 2020 May 6; 8(9): 1693-1697

DOI: 10.12998/wjcc.v8.i9.1693 ISSN 2307-8960 (online)

CASE REPORT

Colonic perforation in a nasopharyngeal carcinoma patient treatedwith fluorouracil: A case report

Wei-Jia Lu, Gong Li, Lei Gao

ORCID number: Wei-Jia Lu(0000-0003-1027-979X); Gong Li(0000-0002-7003-4244); Lei Gao(0000-0002-4239-7718).

Author contributions: Lu WJ and LiG wrote the manuscript; Gao L wasinvolved in the patient’s medicalcare, initiated and supervised thestudy, and wrote and revised themanuscript; all authors have givenfinal approval of the version to bepublished and agreed to beaccountable for all aspects of thework in ensuring that questionsrelated to the accuracy or integrityof any part of the work areappropriately investigated andresolved.

Informed consent statement:Informed written consent wasobtained from the patient forpublication of this report and anyaccompanying images.

Conflict-of-interest statement: Theauthors declare that they have noconflict of interest.

CARE Checklist (2016) statement:The authors have read the CAREChecklist (2016), and themanuscript was prepared andrevised according to the CAREChecklist (2016).

Open-Access: This article is anopen-access article that wasselected by an in-house editor andfully peer-reviewed by externalreviewers. It is distributed inaccordance with the CreativeCommons AttributionNonCommercial (CC BY-NC 4.0)license, which permits others todistribute, remix, adapt, buildupon this work non-commercially,

Wei-Jia Lu, Guangzhou University of Chinese Medicine, Guangzhou 510006, GuangdongProvince, China

Gong Li, Lei Gao, Department of Radiotherapy, the Second Affiliated Hospital of GuangzhouUniversity of Chinese Medicine, Guangzhou 510006, Guangdong Province, China

Corresponding author: Lei Gao, PhD, Doctor, Department of Radiotherapy, the SecondAffiliated Hospital of Guangzhou University of Chinese Medicine, No. 55, Neihuanxi Road,Panyu District, Guangzhou 510006, Guangdong Province, China. dxcflk@gzucm.edu.cn

AbstractBACKGROUNDNasopharyngeal carcinoma (NPC) is a commonly encountered type of tumor.Fluorouracil (FU) is an effective treatment providing satisfactory oncologicoutcomes in nasopharyngeal carcinoma patients. We describe a unique case ofcolonic perforation in an NPC patient treated with FU. Thus far, only two cases ofintestinal perforation associated with FU treatment have been reported. We hopethat the analysis of the relationship between the adverse effects of FU andphysiological factors will help to reduce the incidence of colonic perforation inpatients with nasopharyngeal carcinoma treated with FU.

CASE SUMMARYA 67-year-old female patient suffered from NPC stage pT3N2M0. She had ahistory of three surgical procedures: Partial enterectomy, partial sigmoidectomy,and sigmoidostomy. After the administration of 2.75 g FU, a bloody stoolappeared and the patient developed abdominal pain. Subsequent examinationindicated colitis and intestinal perforation.

CONCLUSIONFU is a commonly used drug in NPC chemotherapy. The most common adverseeffect of FU is gastrointestinal reaction, and the colonic perforation found here isthought to be caused by gastrointestinal mucosal injury consequential to the FUtreatment. When selecting chemotherapy drugs, their side effects and thephysical condition of patients should be considered, particularly in patients witha history of gastrointestinal surgery.

Key words: Chemotherapy; Nasopharyngeal carcinoma; Fluorouracil; Colonic perforation;Reaction; Case report

©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.

WJCC https://www.wjgnet.com May 6, 2020 Volume 8 Issue 91693

and license their derivative workson different terms, provided theoriginal work is properly cited andthe use is non-commercial. See:http://creativecommons.org/licenses/by-nc/4.0/

Manuscript source: Unsolicitedmanuscript

Received: December 22, 2019Peer-review started: December 22,2019First decision: April 1, 2020Revised: April 8, 2020Accepted: April 15, 2020Article in press: April 15, 2020Published online: May 6, 2020

P-Reviewer: Cihan YB, NakashimaT, Noussios G, Shimada SS-Editor: Zhang LL-Editor: Wang TQE-Editor: Liu JH

Core tip: Intestinal perforation associated with fluorouracil treatment is very rare. Thepossible reason of the perforation in the case presented here is that the patient hasundergone intestinal surgeries, her physical condition was poor, and the use offluorouracil has damaged the intestinal mucosa. In general, patients with intestinalperforation require an immediate surgical treatment. However, the use of radiotherapyand chemotherapy in patients after intestinal surgery is challenging.

Citation: Lu WJ, Li G, Gao L. Colonic perforation in a nasopharyngeal carcinoma patienttreated with fluorouracil: A case report. World J Clin Cases 2020; 8(9): 1693-1697URL: https://www.wjgnet.com/2307-8960/full/v8/i9/1693.htmDOI: https://dx.doi.org/10.12998/wjcc.v8.i9.1693

INTRODUCTIONFluorouracil (FU) is commonly used in nasopharyngeal carcinoma chemotherapy. Arecent article by Fata et al[1] provides a reminder that FU does cause, directly orindirectly, gastrointestinal mucosal damage, and the awareness among oncologists ofthis problem and resulting complications is necessary. The current report presents acase of colonic perforation induced by FU in a patient with a history of three surgicalprocedures: Partial enterectomy, partial sigmoidectomy, and sigmoidostomy. Colonicperforation is a rare complication of FU therapy. So far, only two cases of intestinalperforation associated with FU treatment have been reported[2,3], and the uniquenessof the medical history of the patient presented here further highlights the clinicalrelevance of the current report.

CASE PRESENTATION

Chief complaintsA 67-year-old female patient felt left mandibular lymph node enlargement,accompanied by headache and tinnitus.

History of present illnessThe left neck mass was found in May 2019, and the mass gradually increased, but shedid not show symptoms of nasal congestion or nosebleed.

History of past illnessSeven years ago, she underwent partial enterectomy, partial sigmoidectomy, andsigmoidostomy.

Physical examinationOn admission, the bilateral cervical lymph nodes of the patient were enlarged, and theswollen lymph node under the left jaw was the largest, with a size of 3.2 cm × 2.6 cm.She had no exophthalmos and no difficulty in deglutition or opening the mouth. Notenderness or rebound tenderness was found on abdominal palpation.

Laboratory examinationsBlood analysis (Figure 1) and urine analysis were normal on August 15, 2019. Chest X-ray, electrocardiogram, and arterial blood gas were also normal.

Imaging examinationsIn August 2019, nasopharyngoscopy identified an undifferentiated non-keratinizingcarcinoma. Additionally, magnetic resonance imaging of the nasopharynx, neck, andskull base documented bilateral thickening of the parapharyngeal wall and posteriorparapharyngeal wall, and multiple lymph node metastases present bilaterally in theparapharyngeal space and the neck. These findings were consistent withnasopharyngeal carcinoma.

Further diagnostic work-upSingle-photon emission computed tomography/computed tomography revealedthickened mucous membranes in the bilateral and posterior parietal walls of thenasopharynx, with soft tissue mass shadows.

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Figure 1

Figure 1 The values of white blood cells (WBC), neutrophils (NEUT), and red blood cells (RBC), fibrinogen(FB) and D-dimer, and hemoglobin (Hb) and platelets (PLT) before (August 15, 2019) and after theadministration of fluorouracil (August 19, 2019). A: WBC, NEUT, and RBC; B: FB and D-dimer; C: Hb and PLT.

FINAL DIAGNOSISBased on the combination of imaging, clinical, and pathological results, thenasopharyngeal malignant tumor was diagnosed as pT3N2M0.

TREATMENTThe original treatment plan was to administer the TPF chemotherapy regimen(paclitaxel 180 mg + cisplatin 30 mg + FU 5 g). The first intravenous injection of 0.5 gFU was performed on August 16, 2019, and the remaining 4.5 g was divided into twointravenous doses. On August 19, 2019, after injecting the first of the remaining 2.25 gdoses of FU, the patient developed abdominal pain and bloody stool. Of note,cisplatin and paclitaxel were planned to be given to the patient on that day, but theywere not administered. Blood tests were performed, which showed an increase in D-dimer, white blood cells, neutrophils, red blood cells, and hemoglobin and a decreasein fibrinogen and platelets compared with the results obtained on August 15 (Figure1). A computed tomographic scan (Figure 2) of the abdomen showed freeintraperitoneal air. Colonoscopy revealed mucosal ulceration and erosion in thesigmoid colon and descending colon. The patient was immediately taken to theoperating room for an emergent laparotomy. During the procedure, a perforation wasfound in the descending colon, and a large amount of exudate flowed out of theperforation. A partial colectomy was performed. Colitis was diagnosed based onpathologic examination of surgical specimens.

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Figure 2

Figure 2 Computed tomography image of the abdomen documenting the inflammatory exudate (Δ) andenterostomy (▲) (August 19, 2019).

OUTCOME AND FOLLOW-UPAfter the surgery, the patient was treated with antibiotics. She had diffuse abdominaltenderness to deep palpation. On presentation, her blood pressure was 122/83, pulse85/min, temperature 37.1 °C, respiratory rate 18/min, and oxygen saturation 97%.The patient's condition gradually stabilized over a period of 24 d, but due to theintestinal damage, the induction chemotherapy had to be postponed. The patient andher family have expressed their understanding regarding the reason for postponingthe original treatment plan.

DISCUSSIONInduction cisplatin-FU chemotherapy prior to definitive radiation improves freedomfrom distant metastases, disease-free survival, and overall survival in patients withlocoregional stage IV nasopharyngeal carcinoma without increasing treatment-relatedmorbidity [4 ]. In recent years, docetaxel, cisplatin, and FU-based inductionchemotherapy has been widely applied in the treatment of locoregionally advancednasopharyngeal carcinoma[5]. FU can effectively reduce the recurrence of tumors andprolong survival in patients with nasopharyngeal carcinoma, regardless of whetherthe surgery was performed.

However, the toxic and side effects of FU require careful consideration. Themechanism of adverse effects of FU involves a deficiency of the catabolic pathway, inwhich the drug competes with uracil, the naturally occurring pyrimidine, as anenzyme substrate. Dihydropyrimidine dehydrogenase (DPD, EC 1.3.1.2) is the initialand rate-controlling enzyme of the catabolism of endogenous pyrimidine andfluoropyrimidine nucleotides. DPD enzyme is expressed in most tissues, including thetumors, and is highly active in the liver and peripheral lymphocytes. The activity ofDPD is highly variable among individuals. Low levels of DPD activity have beenassociated with an increased risk of toxicity during the FU treatment[6]. The mostcommon adverse reaction triggered by FU is gastrointestinal tract response. Thepatient presented with colonic perforation, acute diffuse peritonitis, and acuteinfection, and these conditions were, to a large extent, associated with the use of FU.Surgical treatment of colonic perforation resulting from the administration of FU iscrucial, and the prognosis depends essentially on the time to diagnosis. It is veryimportant to increase the knowledge about intestinal perforation in order to improvethe diagnostic accuracy[7].

Perforations of the colon are thought to be caused by damage to the gastrointestinalmucosa consequential to the treatment with FU. Gastrointestinal perforation is aknown adverse event of bevacizumab[8-10], but it occurs only rarely during FUtherapy[2,3]. In particular, descending colon perforation is less frequent than gastricand duodenal perforation. Because of the scarcity of reports of descending colonperforation in patients treated with FU, its frequency and mechanism are not

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completely understood. It is possible that the patient had an enterostomy, and FUmay be secondary to the inhibition of the methylation reaction catalyzed bythymidylate synthetase (EC 2.1. 1.45), which transfers a methyl group from N, N’-methylene-tetrahydrofolic acid to deoxyuridylic acid, contributing to the breakup ofthe gastrointestinal mucosa, which leads to intestinal perforation. Accordingly, wehave a reason to believe that the colonic perforation presented in this case report wasassociated with the FU treatment.

In conclusion, although induction chemotherapy can improve the overall survival,side effects of drugs and the patient's physical condition should be all considered inselecting the optimal treatment modality, particularly in patients with a history ofgastrointestinal surgery. The possibility of performing colonoscopy beforechemotherapy should be taken into account in these patients.

ACKNOWLEDGEMENTSWe thank all the members of our department for their help in this study.

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4 Geara FB, Glisson BS, Sanguineti G, Tucker SL, Garden AS, Ang KK, Lippman SM, Clayman GL,Goepfert H, Peters LJ, Hong WK. Induction chemotherapy followed by radiotherapy versus radiotherapyalone in patients with advanced nasopharyngeal carcinoma: results of a matched cohort study. Cancer1997; 79: 1279-1286 [PMID: 9083147 DOI:10.1002/(sici)1097-0142(19970401)79:7<1279::aid-cncr2>3.0.co;2-c]

5 Zhou R, Zhu J, Chen X, Liu Y, Wang Y, Zhang T. The efficacy and safety of docetaxel, cisplatin andfluorouracil (TPF)-based induction chemotherapy followed by concurrent chemoradiotherapy forlocoregionally advanced nasopharyngeal carcinoma: a meta-analysis. Clin Transl Oncol 2020; 22: 429-439[PMID: 31165410 DOI: 10.1007/s12094-019-02142-7]

6 Wettergren Y, Carlsson G, Odin E, Gustavsson B. Pretherapeutic uracil and dihydrouracil levels ofcolorectal cancer patients are associated with sex and toxic side effects during adjuvant 5-fluorouracil-based chemotherapy. Cancer 2012; 118: 2935-2943 [PMID: 22020693 DOI: 10.1002/cncr.26595]

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8 Badgwell BD, Camp ER, Feig B, Wolff RA, Eng C, Ellis LM, Cormier JN. Management of bevacizumab-associated bowel perforation: a case series and review of the literature. Ann Oncol 2008; 19: 577-582[PMID: 18024857 DOI: 10.1093/annonc/mdm508]

9 Sfakianos GP, Numnum TM, Halverson CB, Panjeti D, Kendrick JE 4th, Straughn JM Jr. The risk ofgastrointestinal perforation and/or fistula in patients with recurrent ovarian cancer receiving bevacizumabcompared to standard chemotherapy: a retrospective cohort study. Gynecol Oncol 2009; 114: 424-426[PMID: 19552944 DOI: 10.1016/j.ygyno.2009.05.031]

10 Puthillath A, Mashtare T, Wilding G, Khushalani N, Steinbrenner L, Ross ME, Romano K, WisniewskiM, Fakih MG. A phase II study of first-line biweekly capecitabine and bevacizumab in elderly patientswith metastatic colorectal cancer. Crit Rev Oncol Hematol 2009; 71: 242-248 [PMID: 19081732 DOI:10.1016/j.critrevonc.2008.10.012]

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