Management of Local Recurrences
17 results
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Anorectal Disease- A 40-year-old man presents to your office and reports pain and swelling with the inability to defecate for the last few days. Symptoms started after an episode of constipation where he strained on the toilet for quite some time. On examination, the patient has exquisite tenderness in the perianal area along with other findings, as shown in the image. What is the most appropriate treatment?
- 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 60-year-old male patient with a history of radiation for prostate cancer presents with pneumaturia and recurrent urinary tract infections. Workup reveals a 1-cm defect in the anterior rectum just above the dentate line, corresponding to a urethral defect on cystoscopy. There is evidence of radiation damage to the rectum but no active infection and no evidence of cancer recurrence. Which of the following is the most definitive management?
- 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?
- Malignancy
- A 38-year-old HIV-positive male patient is diagnosed with a cT3N1M0 squamous cancer of the anal canal. The patient’s CD4 count is 250 cells/mm3. What is the most appropriate next step in 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 60-year-old man is referred for a finding of a 4-cm presacral mass during the workup for leg pain. Magnetic resonance imaging (MRI) shows an enhancing, heterogenous 4-cm mass with irregular margins and osseous destruction. What is the most common cause of this lesion?
- 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 65-year-old healthy man underwent colonoscopy for constipation. An endoscopically traversable mid-sigmoid tumor was found. The colonoscopy was otherwise normal. Biopsy showed moderately differentiated adenocarcinoma. His carcinoembryonic antigen (CEA) level is 1.8 ng/mL and computed tomography (CT) of the chest, abdomen, and pelvis showed no metastatic disease. Intraoperatively, no metastatic disease was noted. There was a mid-sigmoid tumor infiltrating a small part of the dome of the bladder with a loop of small bowel attached to the same area. What is the best way to manage this patient?
- 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?
- 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 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?
- Benign Disease
- A 75-year-old man with no significant medical history presents to the emergency department with recurrent bright red blood per rectum. Previous workup included computed tomography angiography (CTA), upper endoscopy, and anoscopy, which were all negative. Previous colonoscopy showed pancolonic diverticulosis with blood throughout the colon. He is now receiving his fifth unit of packed red blood cells. His blood pressure remains 80/50 mmHg despite resuscitation. What is the best next step in this patient’s management?
- A 65-year-old male patient with chronic cirrhosis due to primary sclerosing cholangitis underwent a subtotal colectomy and end ileostomy for refractory ulcerative colitis (UC) 2 years ago. He presents to the emergency department for uncontrolled bleeding from his ileostomy at the mucocutaneous junction. What is the best definitive treatment for this bleeding?
- Colon and Rectal Surgery Educational Program (CARSEP)