Rectal Cancer Treatment Complicated by a New Bleeding Disorder

What happened, in summary

A 62-year-old woman was diagnosed with adenocarcinoma of the lower rectum. MRI showed a locally advanced rectal tumor with involved mesorectal nodes and no distant metastasis described in the TNM findings. She received neoadjuvant treatment with 4 cycles of FOLFIRINOX, followed by 2 cycles of FOLFOX together with local radiation and capecitabine. Imaging showed a modest reduction in the rectal tumor and mesorectal lymph nodes, and surgery was scheduled. Immediately before the operation, blood testing unexpectedly showed a prolonged clotting time. Further testing found markedly reduced von Willebrand factor activity and antigen, raising concern for an acquired bleeding disorder despite no previous personal or family history of abnormal bleeding. She received von Willebrand factor/factor VIII replacement and tranexamic acid around the operation. The treatment corrected her clotting levels sufficiently for surgery, and she had no major or unusual bleeding during or after the procedure. She underwent robot-assisted abdominoperineal resection with a permanent colostomy. After recovery, she completed 6 cycles of adjuvant 5-fluorouracil. The rectal cancer then entered complete remission. Repeat coagulation testing after chemotherapy showed normalization of the von Willebrand findings, which remained normal five months later.