Notochord

At Stanford, I see diseases I've never heard of. We recently admitted a patient with a pelvic chordoma. When I first heard that word, I didn't even know how to spell it. But with some investigation, I realized it was a cancer of the notochord, an embryonic remnant. It makes sense; anything can form cancers, even parts of us that are no more. This slow growing tumor had become extensive and unresectable and in his sixties, this patient required placement of a colostomy to drain stool as well as a suprapubic catheter to drain urine. These had been working reasonably well and the patient was doing fine until one day, on routine tests, an outside hospital found a significantly elevated creatinine, a sign of declining kidney function. She was sent to us for further workup. When I saw her, I found something odd on exam - I saw urine in the colostomy bag. We got analyses of the urine from the colostomy bag and the suprapubic catheter, and the plot thickened. There seemed to be a fistula (connection) between the urinary tract and the gastrointestinal tract. Renal, urology, and colorectal surgery were consulted and we sent for a nuclear study I had never heard of - radiolabeled lasix. I interpreted the images as soon as they came up - there was tracer in the colon. Unfortunately, the patient was not a good operative candidate and so in consultation with all the surgical services, we decided not to try to treat this surgically. Instead, she will live her life with a strange anastamosis and might be dialysis bound due to chronic tubular necrosis from seeding of the kidneys from the colon. It is unfortunate, but also something that is not textbook at all. There is a stereotype that internists don't look under dressings or in drains and that is mostly true; I am glad I did this time though.

Image of a chordoma in the brain from Wikipedia, shown under Creative Commons Attribution Share-Alike License.