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Obana Protocol

1. The patient is a 67-year-old male who presented with a 10.7 cm fungating rectal mass found to be a well-differentiated adenocarcinoma on biopsy. 2. Imaging showed the tumor involved the muscularis propria and was within 1 mm of the mesorectal fascia, classifying it as at least stage T3c. 3. The patient has a history of hypertension and diabetes. The plan is for neoadjuvant chemotherapy and radiation therapy prior to surgical resection of the rectal tumor.

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40 views

Obana Protocol

1. The patient is a 67-year-old male who presented with a 10.7 cm fungating rectal mass found to be a well-differentiated adenocarcinoma on biopsy. 2. Imaging showed the tumor involved the muscularis propria and was within 1 mm of the mesorectal fascia, classifying it as at least stage T3c. 3. The patient has a history of hypertension and diabetes. The plan is for neoadjuvant chemotherapy and radiation therapy prior to surgical resection of the rectal tumor.

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paiskopaxiew888
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We take content rights seriously. If you suspect this is your content, claim it here.
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JOSE R.

REYES MEMORIAL MEDICAL CENTER


DEPARTMENT OF SURGERY

MULTIDISCIPLINARY TEAM CONFERENCE


July 6, 2023
Presenter: ELYSSA FRITZI N. HIPOLITO, MD

GENERAL DATA
RO, 67 years old, male, married, Filipino, Born Again Christian from Caloocan

HISTORY OF PRESENT ILLNESS


7 months prior to consult, noted episodes of hematochezia, no abdominal pain. No consult was
done, no medications were taken. 4 months prior, now noted constipation, scyballous stools and
occasional melena hence consult at their private physician, wherein laxative was given. A week after,
patient now had diarrhea, still with hematochezia and weight loss.
3 months prior, he consulted at Family Medicine-ER due to persistent hematochezia. Stool
culture was requested and eventually turned out to be negative. Was advised consult at Colorectal
Surgery OPD for further evaluation and management. Seen at Colorectal Surgery OPD, DRE was done
which showed rectal mass. Chest CT scan, pelvic MRI, CEA were requested and patient was scheduled
for colonoscopy with biopsy. He underwent colonoscopy which showed a fungating mass 8-13cm FAV
and biopsy revealed well-differentiated adenocarcinoma. Patient was then referred to Medical Oncology
and Radiation Oncology.

REVIEW OF SYSTEMS
General: (-) fever
Eyes: (+) blurring of vision, (-) visual loss
ENT: (-) sore throat, (-) ear pain, (-) epistaxis, (-) gum bleeding
Respiratory: (-) dyspnea, (-) orthopnea, (-) cough
Cardiovascular: (-) chest pain, (-) palpitations
Musculoskeletal: (-) joint/muscle pain
Hematologic: (-) bruising
Endocrine: (-) polydipsia, (-) heat/cold intolerance
Neurologic: (-) headache, (-) weakness, (-) seizure

PAST MEDICAL HISTORY


(+) Hypertension – 5 years, on amlodipine 10mg/tab OD
(+) Diabetes mellitus – 10 years, on isophane insulin 22u in AM, 10u in PM, regular insulin 6u for CBG
>180mg/dL
(+) proliferative diabetic retinopathy, OU
s/p Trabeculectomy, OS (PGH, 1/23/2020)
s/p Panretinal photocoagulation, OU
s/p Intravitreal injection of Avastin × 7, OU

FAMILY HISTORY
(+) Hypertension – mother
(+) Diabetes mellitus – mother
(+) Cervical cancer- cousin

PERSONAL AND SOCIAL HISTORY


Patient is a previous smoker, occasional alcoholic beverage drinker, and denies illicit drug use.

PHYSICAL EXAMINATION
General Survey: Awake, conscious, coherent, not in respiratory distress, ambulatory
Weight 54 kg
Height 160 cm
BMI of 21 kg/m2
ECOG 1
Vital Signs: BP: 130/70 mmHg; HR: 97 beats per minute; RR: 20 cycles per minute, T: 36.8 oC, 99%
O2 saturation
Head and Neck: Anicteric sclera and pink palpebral conjunctiva
Chest: symmetric chest expansion, clear breath sounds
Abdomen: Flat, non- distended, normoactive bowel sounds, soft, non-tender
Extremities: Full equal pulses; motor 5/5 and sensory 100% on all extremities
Digital rectal examination: lax sphincteric tone, noncollapsed rectal vault, (+) circumferential fungating
mass 8cm FAV, (+) stool and blood on examining finger

ANCILLARIES

Chest CT Scan with IV contrast (iScan, 5/3/23)


There is a 1.2 cm non-calcified subpleural nodule in the lateral segment of the middle lobe.
Few patchy areas of reticulonodular densities in the right upper lobe are noted.
Linear density in the middle lobe is seen.
No evidence for enlarged mediastinal and hilar lymph nodes.
Negative for pleural nor pericardial effusion.
The heart is not enlarged. The great vessels are normal in caliber. The aorta and coronary arteries are
calcified.
The trachea and both mainstem bronchi are patent without endobronchial lesion.
The esophagus is intact without discrete mass.
No lytic or blastic lesions are evident. Hypertrophic degenerative changes along the thoracolumbar
vertebrae are seen.

IMPRESSION:
Non-calcified subpleural nodule in the lateral segment of the middle lobe. Follow-up is recommended.
Few patchy areas of reticulonodular densities in the right upper lobe may relate to an infectious process
Linear density suggestive of subsegmental atelectasis or fibrosis in the middle lobe
Atherosclerotic vessel disease
Osteodegenerative changes

MRI of the Lower Abdomen with Gadolinium (Rectal Protocol) (UERM, 5/4/23)
Findings:
There is mild motion artifact degradation of the images.
PRIMARY TUMOR: MORPHOLOGY, LOCATION, AND CHARACTERISTICS:
Distance to the anal verge: 6.0 cm
Distance to the top of sphincter complex/anorectal junction: 1.4 cm
Relationship to anterior peritoneal reflection: Straddles and above.
Craniocaudal length: 10.7 cm
Tumor location: Mid to upper rectum.
Morphology: Nearly annular to annular.
Mucinous composition: No mucin.
No involvement of the anal-sphincter complex.
MR-T CATEGORY: At least T3c (tumor penetrates 5-15 mm beyond muscularis propria), with projection
of tumor beyond the muscularis propria at least 13 mm. at the 6 o'clock position at the upper rectal
level. Tumor abuts the seminal vesicles and the prostate gland without definite evidence of infiltration.
EMVI: Yes
Location of EMVI: 9 o'clock position, at the upper rectal region (series 11, images 11 and 13).
MESORECTAL FASCIA (MRF) (FOR T3 TUMORS ONLY)
Shortest distance of tumor to MRF: 0-1 mm, at the 9 to 10 o'clock position of the mid rectum, just below
and at the level of the anterior peritoneal reflection (series 11, images 19-22).
TUMOR DEPOSITS: None identified.
LYMPH NODES:
Mesorectal/superior rectal lymph nodes and/or tumor deposits: None identified.
Suspicious extra mesorectal and locoregional lymph nodes: None identified. Note of nonspecific bilateral
iliac and inguinal and mesenteric lymph nodes, measuring up to 6 mm. in short axis diameter, without
suspicious features.
OTHERS: Normal appearance of urinary bladder. Nonspecific poorly defined decreased T2 signal
involving the peripheral prostatic zones bilaterally, as well as the left seminal vesicle, probably
secondary to chronic inflammatory changes. No findings to suggest osseous metastasis.

Impression:
Primary Tumor Location: 10.7 cm. long nearly annular to annular tumor involving the mid to upper
rectum.
MRI Stage: At least T3c N0.
Sphincter involvement: No.
MRF Status: Involved (tumor margin <1 mm from the MRF, at the mid rectal level).
EMVI: Yes.
Probable chronic inflammatory changes involving the bilateral peripheral prostatic zones and left
seminal vesicle.

CEA (Key Health Diagnostic Laboratory, 5/8/23)


CEA 4.154 (NV nonsmoker <5ng/mL, smoker <10ng/mL)

Colonoscopy with Biopsy (JRRMMC, 5/22/23)


Scope inserted up to cecal, appendiceal orifice, ileocecal valve identified
Ileal intubation done
Noted fungating mass 8-13cm FAV

Surgical Pathology Report (JRRMMC, 5/22/23)


Colonoscopy with biopsy:
Adenocarcinoma, well-differentiated
WORKING IMPRESSION
Rectal adenocarcinoma, Well-differentiated, St. IIA (mrT3cN0M0), 8cm from anal verge
Hypertension St. II
Diabetes Mellitus Type 2
s/p colonoscopy with biopsy (JRRMMC, 5/22/23)

PLAN:
For neoadjuvant chemotherapy and radiation therapy

CHALLENGES:
Role of chemotherapy and radiation therapy as neoadjuvant treatment for rectal carcinoma

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