Local Excision
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Malignancy- A 62-year-old woman presents to the office with a 1-month history of rectal pain, bleeding, and perianal mass. On digital rectal examination and anoscopy, a 3-cm firm mass is noted at the left lateral anal canal. Inguinal examination is unremarkable. Biopsy of the mass shows moderately differentiated squamous cell carcinoma. Staging computed tomography (CT) of the chest and abdomen and magnetic resonance imaging (MRI) of the pelvis demonstrate a T2N1M0 tumor. What is the best next step in her management?
- An otherwise healthy 50-year-old patient reports rectal fullness and pain while sitting. On examination, the rectal mucosa is smooth; however, you can palpate a large firm mass that appears extraluminal and extends to the tip of your examining finger. Cross-sectional imaging reveals a large heterogeneous presacral mass that measures 7 cm x 10 cm. The best next step in management is
- A 56-year-old obese man with locally advanced distal rectal cancer is treated with total neoadjuvant chemoradiation therapy. His is a 45-pack-per-year smoker. Restaging reveals no sign of metastasis. Magnetic resonance imaging (MRI) rectal protocol reveals partial clinical response and flexible sigmoidsociopy that shows a 3-cm tumor involving the sphincteric complex. What is the best surgical approach in his care?
- A 45-year-old man is seen in the clinic for persistent perianal itching. Examination of the perianal skin revealed a 1.5-cm plaque-like lesion at the left lateral position, approximately 2 cm from the anal verge. Punch biopsy of the lesion demonstrates basal cell carcinoma. There is no distant metastatic disease. What is the most appropriate next step in treatment?
- A 64-year-old man presents with a lesion on the perianal skin, as shown in the figure. Biopsy in the office demonstrates verrucous carcinoma. The most definitive management in this patient is
- A 72-year-old women reports perianal rash, pruritus, and intermittent bleeding for the past 3 years. She has tried topical creams and topical steroids without improvement. On examination, a 1-cm raised erythematous lesion is seen at the anal margin. A biopsy of the lesion demonstrates large cells with pale, clear cytoplasm. Endoscopic examination is unremarkable. What is the recommended treatment for her?
- A 68-year-old woman reports severe anal pain and bleeding. Examination demonstrates a 2-cm ulcerated lesion just proximal to the dentate line. Biopsies reveal BRAF mutation anal melanoma. Imaging demonstrates enlarged presacral and obturator lymph nodes. The best next step in management is
- A healthy 65-year-old male patient is diagnosed with a moderately differentiated rectal adenocarcinoma, microsatellite stable. Staging was negative for metastatic disease. Pelvic magnetic resonance imaging (MRI) shows possible involvement of the prostate with mesorectal lymph nodes suspicious for metastasis. What is the current recommended course of treatment for this patient, given these findings?
- A 61-year-old man is found to have a 2-cm mass in the mid-rectum (8 cm from the anal verge) on diagnostic colonoscopy. Biopsy reveals moderately differentiated adenocarcinoma. Computed tomography (CT) reveals no evidence of metastatic disease, and magnetic resonance imaging (MRI) demonstrates a cT3, node-negative cancer. After presentation at a multidisciplinary tumor board, the patient agrees to total neoadjuvant therapy. The patient has a complete clinical response to treatment and opts for close radiologic and endoscopic surveillance in an effort to avoid surgery. On a surveillance proctoscopy 6 months after treatment, the patient is found to have a 7-mm recurrence at the original cancer site. Which of the following is the best next step in management?
- A 45-year-old man undergoes a screening colonoscopy, which shows a 1.5-cm polyp in the rectum located 5 cm from the anal verge. Biopsy reveals well-differentiated invasive adenocarcinoma without lymphovascular invasion, perineural innovation, or tumor budding. Staging computed tomography (CT) does not show any evidence of metastatic disease, and his carcinoembryonic antigen (CEA) level is normal. Magnetic resonance imaging (MRI) of the pelvis reveals the polyp to be a T-1 lesion without any evidence of lymph node metastasis. What is the most appropriate next step in treatment?
- A 63-year-old otherwise healthy woman comes to see you for chafing and ulceration related to a perianal skin tag. It has been present ever since she was pregnant years ago; however, in the past 6 months, there is an area that has been bleeding persistently. On examination, she has a large 3-cm perianal skin tag, with a small area of ulceration at the base measuring about 1–2 mm. You take her for excision of this tag, and the pathology comes back as invasive, well-differentiated squamous cell carcinoma, 6 mm in width, with margins negative at least 1 cm from the edge of the specimen. Staging workup and imaging are negative. The recommended next step in treatment is
- A 57-year-old man undergoes total neoadjuvant therapy (TNT) for management of a cT3N1M0 rectal cancer. After completion of both chemotherapy/radiotherapy and consolidation chemotherapy, the presence of complete clinical response to treatment is assessed by
- Which technical/surgical factor during proctectomy most influences the risk of local recurrence?
- A 62-year-old woman has a sigmoid colectomy for colon cancer seen at colonoscopy. Final pathology reveals a T3N0M0 lesion (0/22 lymph nodes postive, widely negative margins). Her 1-year surveillance colonoscopy is normal with a well-healed colorectal anastomosis. Eighteen months postcolectomy the patient reports weight loss; her carcinoembryonic antigen (CEA) level is noted to be 12.4. The most likely site of recurrent disease is
- A 57-year-old woman presents with worsening abdominal fullness and poorly localized abdominal pain. One year ago she had uneventful appendectomy. She brings you her medical showing that a low-grade appendiceal neoplasm was found on pathology. Computed tomography (CT) demonstrates evidence of multiple fluid filled lesions throughout the abdomen. What is the most appropriate next step in her treatment?
- During screening colonoscopy, a 0.9-cm rectal polyp was removed using a saline lift snare polypectomy. Pathology was significant for well-differentiated submucosal neuroendocrine tumor without lymphovascular involvement or penetration into the muscularis propria. What is the best next step in management?
- A 60-year-old woman undergoes screening colonoscopy. A 2.5-cm submucosal lesion is found in the mid-rectum at 8 cm from the anal verge. Biopsy shows a well-differentiated neuroendocrine tumor. The most appropriate next step in treatment is
- A 47-year-old female patient presents 28 weeks after completing chemoradiation therapy for P16-positive HPV-associated squamous cell carcinoma of the anus. The patient continues to report intermittent bleeding and pain, which has continued to slowly improve. On physical examination, she has evidence of residual disease. The best next step in management for this patient is
- A 65-year-old man undergoes screening colonoscopy. A 1-cm submucosal mass is seen in the mid rectum. Biopsy results show spindle cells with KIT (CD117) positivity with a low mitotic rate. Complete staging is performed without any evidence of metastatic or locally advanced tumor. What is the most appropriate management?
- A 50-year-old man presents with abdominal pain. Colonoscopy with biopsy revealed a large B cell lymphoma in the ascending colon. Staging workup reveals a nonobstructing mass in the ascending colon without evidence of metastatic or multifocal disease. The best next step is
- Anorectal Disease
- A 73-year-old woman has been followed for a chronic posterior anal fissure with continued bright red blood spotting which has failed to heal with medical management including calcium channel blockers. On digital rectal examination, the patient has decreased tone and an anorectal manometry demonstrates slightly decreased anal pressures. What is the best next treatment for her?
- A patient presents with multiple draining sinus tracks of the perineum and groin with associated dense induration that have persisted despite multiple courses of oral tetracycline. The best next step in treatment is
- A 73-year-old, otherwise healthy woman reports 6 months of perianal itching. Examination reveals a left-sided, scaly perianal skin rash. A biopsy reveals large cells that contain pale, clear cytoplasm with a large nucleus. Colonoscopy and computed tomography (CT) of the chest, abdomen, and pelvis are normal. What is the best treatment option?
- A 45-year-old man, who reports sex only with men (MSM), has been referred to you for evaluation of a whitish anorectal lesion identified on initial screening colonoscopy. Biopsies confirmed high-grade squamous intraepithelial lesion (HSIL), for which he ultimately underwent excision and fulguration. What is the recommended surveillance?
- Patient presents with bleeding per rectum with bowel movements and partial hemorrhoidal prolapse with straining and spontaneous reduction. Patient had a colonoscopy 12 months ago that only showed enlarged hemorrhoids. Patient has been on supplemental fiber for the past 6 months. The best next treatment for this patient’s rectal bleeding is