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Friday Green Surgery Presentation: Anooj Patel

An 88-year-old female presented with rectal bleeding and was found to have a 3.5 cm rectal mass upon colonoscopy, MRI of the pelvis showed the mass involving the posterior rectal wall and suspicious lymph nodes. Biopsy of the mass revealed high-grade dysplasia/intraepithelial adenocarcinoma. She received chemoradiation and surgery and will require follow up including CEA levels and chemotherapy.

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47 views

Friday Green Surgery Presentation: Anooj Patel

An 88-year-old female presented with rectal bleeding and was found to have a 3.5 cm rectal mass upon colonoscopy, MRI of the pelvis showed the mass involving the posterior rectal wall and suspicious lymph nodes. Biopsy of the mass revealed high-grade dysplasia/intraepithelial adenocarcinoma. She received chemoradiation and surgery and will require follow up including CEA levels and chemotherapy.

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a
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Friday Green Surgery

Presentation
ANOOJ PATEL
3/23/201

Presentation

 88 y/o white female presents to her PCP for follow up of hyperlipidemia.


Denies any CV sx (chest pain, palpitations, dyspnea, orthopnea, PND…
etc).
 Per EMR note: Pt mentions having “some rectal bleeding” which she
attributes to her hemorrhoids– 3/23/2018
 Last colonoscopy 11 years ago, findings not found in EMR
Past Medical History

 Bilateral Breast Cancer -2004 - mastectomy partial/ lumpectomy


 Hemianopia, binasal -2003
 Heterozygous Factor V Leiden Mutation -2006
 Hx of pulmonary embolus
 Osteoporosis
 Zenker’s Diverticulum -2008
 Glaucoma
Allergies

 Brimonidine
 Codeine
 Opioid Analgesics
Medications
Family History/Social History

 No family history of colorectal cancer, Crohn’s disease or ulcerative


colitis
 Never a smoker
 0.6 oz alcohol/week
Physical Exam

 No rectal exam documented from initial visit 3/23/2018


 Objective from 3/23/2018
Differential

 Internal hemorrhoids
 Diverticulosis
 Angiodysplasia (AVMs)
 Colorectal Cancer
 Polyps
 IBD(crohns/UC)
 Upper GI bleed
Tests ordered

 Colonoscopy 5/22/2018
 Visit with Coumadin clinic to lower warfarin dose 1-2 weeks before
colonoscopy
Syncopal Episode while out for
dinner with husband -4/21/2018
Tests Ordered at the ED

 Physical Exam was benign overall


 Vitals: BP 118/59, HR 81, Temp 36.6C, 100% Spo2 RA.
 Negative Stress Test
 Reassuring EKG
 Echo remarkable only for incidental atrial septal aneurysm
 Carotid US and Echo negative
 Troponins: negative
 CBC/BMP: within normal limits
 PT/INR: Therapeutic levels (20.3 s & 1.80)
ED Assessment

 F/u with PCP for “suspected vasovagal syncope”


Colonoscopy - 5/22/2018

Anal and digital rectal


exam were within
normal limits as
determined by the
gastroenterologist
Pathology + Colorectal Visit –
5/29/2018

 A. “Sigmoid colon polyp”


 Tubular Adenoma of colon
 B. “Rectal”
 Superficial portion with villo-tubular adenoma showing HIGH GRADE
DYSPLASIA/INTRAEPITHELIAL ADENOCARCINOMA
 “Fragments are superficial, no lamina propria invasion could be definitely
documented on the original and deeper cuts into the block”
Risk Factors for colorectal cancer

 Increasing Age
 Obesity
 Physical inactivity
 Smoking
 Heavy Alcohol use
 Certain diets (red meat)
 Polyps
 FH colorectal cancer
 UC or crohns
 Inherited :Lynch syndrome or FAP

Source: cancer.org
Possible symptoms of colorectal
cancer

 Asx Screen
 Iron deficiency anemia
 Changing in caliber of stool (pencil-thin)
 Weight Loss/fatigue
 Constipation/Diarrhea ( change in bowel habits)
 Abdominal discomfort
 Blood in the stool
Physical Exam + Tests Ordered
5/29/2018

 Tests
ordered
 CT
chest/abd/pe
lvis
 MR pelvis
 CEA
MR Images
MR/CT results/CEA

 “2.8 cm from anal verge there is a low rectal short segment mass
involving posterior rectal wall from the 4:00 to 8:00 positions,
measuring approx 3.5 cm in length. Mass causes retraction of the rectal
wall…extension into mesorectal fat”
 Multiple small lymph nodes, nonspecific, but suspicious for metastasis
 CT chest/abd/pelvis does not show metastatic disease
 CEA: 1.4
Staging Colorectal Cancer
Staging Colorectal Cancer
Colorectal Cancer Staging
Prognostic Stage Groups
Why did we order MRI Pelvis?

 So we can stage the cancer better!


 Why do we care about staging so much in rectal cancer?
 Affects our management! + surgical resection strategy
 For example: T2 tumors can be managed initially by surgery
 T3 tumors neoadjuvant chemotherapy
Pt’s Prognostic
Stage

Pt TNM
staging is:
T3, N0-N1, M0
Prognostic Stage and Survival Rates

Source: cancer.org
Treatment

 Chemo
 common regimens include FOLFOX (oxaliplatin, 5-FU, and leucovorin),
5-FU and leucovorin, CAPEOX (capecitabine plus oxaliplatin), or
capecitabine alone.
 Why is chemo indicated in rectal but not colon cancer?
 Radiation
 Pt received chemoradiation (7/16/2018-8/23/18)
 Xeloda (Capecitabine) 500 mg 3 tablets 2x daily on day of radiation
 Radiation: planned total dose: 50.4 Gy, pelvis + bilateral inguinal regions
Post chemo-radiation MRI pelvis

Digital Rectal Exam showed no palpable mass on 9/19/18


Surgery

 11/08/2018
Treatment algorithms for Rectal
Cancer- slide in progress

 T1-2 = invading submucosaSurgical resection- APR or LAR. APR if


low lying rectal mass and cannot get negative margins. LAR if higher up
(above peritoneal reflection???) Adjuvant chemo
 T1sm1N0 (submucosal invason <1000 um) = local excision TEM: transanal
endoscopic microsurgery
 T3-T4 neoadjuvant Chemo - APR or LAR depending on where -
Adjuvant chemo
 Metastatic???? dependent on where it metastaized to-->
Post op-care- slide in progress

 Chemo, follow CEA levels


Questions for Kevin

 Images- did I screenshot the right frames?


 Syncope stuff necessary?
 Any good resources for treatment algorithms for various stages of
rectal cancer? Uptodate is very complex, do I need to include this??
 Things to go over with Kevin:
 Images
 Post op- adjuvant chemo, similar to preop?
 Differential broad enough?

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