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Case history

image A 75-year-old man presented to his GP complaining of fatigue, progressive weight loss of 12 kg and low mood. His past medical history consisted of peripheral vascular disease (PVD) presenting with calf claudication and hypertension diagnosed 20 years previously. He was an ex-smoker with a history of 40 pack-years and drank 4-6 units of alcohol per week. He was a retired librarian who lived alone after his wife died 2 years previously.

His medications included aspirin 75 mg/day, ramipril 10 mg/day, amlodipine 10 mg/day, bendroflumethiazide 2.5 mg/day, simvastatin 20 mg/day and naftidrofuryl oxalate 200 mg three times daily.

His performance status was 2 and his BMI was 21.2 kg/m2 (height 175 cm, weight 65 kg). Physical examination revealed a palpable mass in the left lower abdomen. His score on the Patient Health Questionnaire (PHQ-9) was 10 (moderate depression).

Further investigations revealed microcytic anaemia with haemoglobulin 94 g/l and low iron levels 6 µmol/l. A colonoscopy was organized and a partially obstructing tumour was seen in the sigmoid. Biopsies confirmed a moderately differentiated adenocarcinoma of the colon. Staging was completed with a CT scan of chest, abdomen and pelvis, which showed, apart from the colonic tumour, pericolonic lymphadenopathy and a 7.5 cm abdominal aortic aneurysm (AAA).

The patient was started on mirtazapine for his depression and was assessed by a dietitian for his weight loss. Nutritional supplements were initiated in addition to carer support at home with meal preparation. After discussion with the vascular team it was decided that AAA repair with endoscopic repair of abdominal aortic aneurysm (EVAR) should proceed. A colonic stent was inserted and preoperative intravenous iron was given to optimize his haemoglobulin. EVAR was performed without complications. During admission, sodium was found to be low at 124 mmol/l and bendroflumethiazide was stopped. A laparoscopic anterior resection of his sigmoid tumour was performed 6 weeks afterwards. Histology showed a pT3N2 (6/18 lymph nodes) M0 adenocarcinoma of the sigmoid colon with lymphovascular invasion.

The patient was referred to the oncology team to discuss adjuvant chemotherapy after his surgery. Both options of single-agent capecitabine and doublet chemotherapy with fluoropyrimidine and oxaliplatin were discussed. After considering potential benefit and side effects, single-agent capecitabine was considered more appropriate.

What is the optimal management of his anaemia, weight loss and depression?

What are the usual causes of hyponatraemia in older people?

How do AAA and PVD affect his management?

What are the evidence-based data regarding surgical options in this population and what is the role of stenting used as a bridge to surgery?

What is the evidence for adjuvant chemotherapy?

What is the optimal management of his anaemia, weight loss and depression?

Preoperative anaemia has been associated with increased 30 day mortality and morbidity in patients undergoing major surgery.1 Iron deficiency anaemia in patients with colorectal cancer is common, but further causes of anaemia in the older population should also be excluded2...

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