Surveillance After Rectal Cancer Treatment
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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?
- A 22-year-old female patient presents to your office with rectal bleeding and family history of colon cancer in her sister who was diagnosed at age 28 years. Esophagogastroduodenoscopy demonstrates three gastric and duodenal adenomas. Colonoscopy demonstrates hundreds of polyps throughout her colon. Pathology demonstrates tubular adenomas. You perform a flexible sigmoidoscopy that confirms nine polyps in her rectum; the polyps range from 4 mm to 9 mm in size. She is interested in having children in the near future. What is the recommended next step in her management?
- A healthy 51-year-old man has a poorly differentiated right colon adencarcinoma with mucinous features and mismatch repair (MMR) deficient protein expression. After germline testing was performed, a diagnosis of Lynch syndrome made. The patient reports no issues with incontinence to gas or stool. What is the recommended surgery in this patient?
- A 50-year-old man with Lynch syndrome presents to you after a right colectomy 6 years ago for a T2N0 colon cancer with 16 negative nodes. The patient has been lost to follow-up and has had no surveillance after his resection. A colonoscopy is performed which now reveals a large pedunculated polyp in the sigmoid colon that was removed with hot snare. Pathology reveals adenocarcinoma extending to the base of the polyp. Staging computed tomography (CT) shows no evidence of distant metastasis. Which of the following options is the best recommendation for this patient?
- A 70-year-old woman with a medical history of hypertension and hypothyroidism reports rectal bleeding, maroon blood mixed in with her stool, and weight loss to her primary care physician. She is referred to undergo diagnostic colonoscopy. She is found to have a hepatic flexure mass with biopsies taken and tattoo placed distally, with pathology returning as moderately differentiated adenocarcinoma, mismatch repair (MMR) protein expression intact. Laboratory testing includes a complete blood count, basic chemistry, and carcinoembyronic antigen (CEA) with findings of anemia and a mildly elevated CEA level. What imaging is recommended for completion of the staging work-up in this patient?
- 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 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
- 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
- Benign Disease
- A patient who has recently undergone colonoscopy and esophagogastroduodenoscopy (EGD) for rectal bleeding with 100s of polyps found within the colon and the rectum relatively spared (10 diminutive adenomatous polyps) was also noted to have several diminutive duodenal polyps on EGD, none with high grade dysplasia. Which of the folliowing is the recommended chemoprophylaxis for ths patient?
- A 30-year-old man with ulcerative proctitis on mesalamine presents with right upper quadrant pain. Laboratory results were notable for an elevated alkaline phosphatase and gamma glutamyl transferase. Magnetic resonance cholangiopancreatography (MRCP) revealed multiple bile duct strictures. When should the next surveillance colonoscopy occur?
- A 55-year-old man with a history of ulcerative colitis (UC) diagnosed in his early 20s presents with a new diagnosis of distal rectal moderately differentiated adenocarcinoma. Mismatch repair (MMR) protein expression is intact; routine surveillance endoscopy showed a mass starting ~2 cm from the anal verge with all other biopsies negative for dysplasia. Laboratory results reveal unremarkable levels of carcinoembryonic antigen (CEA), comprehensive metabolic panel (CMP), and complete blood count (CBC). Systemic staging is negative for metastatic disease. Local staging with magnetic resonance imaging (MRI) reveals a T3N1 lesion. Based on a multidisciplinary tumor board discussion, the patient is planned for total neoadjuvant chemotherapy with upfront chemoradiation followed by consolidation chemotherapy. After this therapy is completed, what is the optimal surgical course for this patient?
- Anorectal Disease