Management of Local Recurrences
24 results
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Malignancy- A 50-year-old man had a 1-cm sessile sigmoid polyp removed with cold snare technique in one piece and tattooed distally during screening colonoscopy. Final pathology report showed a sessile serrated adenoma with a focus of well-differentiated adenocarcinoma invading the lower third of the submucosa but not invading the muscularis propria. There is no lymphovascular invasion. Staging with computed tomography of the chest, abdomen, and pelvis is negative for metastatic disease and carcinoembryonic antigen level is normal. What is the most acceptable next step for this patient?
- A 64-year-old woman with a history of cervical intraepithelial neoplasia presents with a firm 3-cm mass protruding at the anal verge. Anoscopy shows a fixed mass just distal to the dentate line. A biopsy of the lesion is performed, which has the findings shown in the Figure. Colonoscopy findings are unremarkable and computed tomography of the chest, abdomen, and pelvis reveals no evidence of distant disease. Magnetic resonance imaging reveals no locoregional nodal or sphincter involvement. The next best step in management for this patient is:
- A 56-year-old man presents to the office with biopsy-proven midrectal adenocarcinoma on colonoscopy. Rigid sigmoidoscopy in the office shows a 5-cm circumferential mass 8 cm from the anal verge. Staging evaluation with computed tomography of the chest, abdomen, and pelvis and magnetic resonance imaging of the pelvis preoperatively demonstrates a T3N1M0 cancer. What is the next step in management for this patient?
- A 62-year-old man was found to have 1-cm posterior rectal lesion that is 3 cm from the anal verge. Histopathologic findings are consistent with a well-differentiated adenocarcinoma without lymphovascular or perineural invasion. Magnetic resonance imaging shows that the tumor is limited to the submucosa and there are no suspicious mesorectal lymph nodes. Metastatic workup uncovers no findings. What is the most appropriate management?
- A 64-year-old man received neoadjuvant chemoradiotherapy followed by a low anterior resection 3 years ago for the treatment of rectal cancer. He complains of persistent fecal urgency, occasional fecal incontinence, clustered stools, and incomplete evacuation, which has persisted since the time of surgery. What is the most likely cause of these symptoms?
- A 57-year-old man is found to have a submucosal mass in the distal rectum on colonoscopy. Biopsy reveals spindle cells which stain positive for CD117 on immunohistochemistry. The lesion is posterior and 5 cm from the anal verge on rigid proctoscopy. Magnetic resonance imaging measures the size of the lesion as 1.3 cm with extension into the muscularis propria. What is the appropriate treatment?
- A 49-year-old woman was seen in the clinic for hemorrhoids. On examination, a hard nodular area is palpable in the right lateral anal canal wall. You examine the patient under anesthesia and perform a biopsy. The pathology report reveals anal squamous cell carcinoma. Staging imaging reveals a T2N0 lesion with no evidence of metastasis. What is the next step in management?
- A 52-year-old man is diagnosed with a 1.5-cm anal canal squamous cell cancer. He is HIV positive and has been taking highly active antiretroviral therapy for several years; his CD4 count is 225 while his viral load is undetectable. Which of the following is the most appropriate management for this patient?
- A 53-year-old man is diagnosed with rectal adenocarcinoma 7 cm from the anal verge. Preoperative pelvic magnetic resonance imaging (MRI) demonstrates a threatened circumferential radial margin. After total neoadjuvant chemoradiation, a repeat MRI demonstrates a persistently threatened radial margin. Which of the following adjuncts should be considered in operative planning for this patient?
- Benign Disease
- A 48-year-old woman with Crohn’s disease presents to the clinic for evaluation of right lower quadrant abdominal pain. Her surgical history is significant for proctocolectomy with end ileostomy. What began as a small pustule adjacent to her ileostomy has rapidly progressed into a painful 1-cm ulcer (Figure). Physical examination demonstrates peristomal ulcerations with serpiginous, irregular, and violaceous borders. The most appropriate management for this patient is:
- A 74-year-old woman with no significant medical history is admitted with lower gastrointestinal bleeding. The patient undergoes a normal esophagogastroduodenoscopy; colonoscopy reveals diverticulosis and blood throughout the colon with no site of active bleeding or adherent clot. Two days later, the patient develops recurrent hematochezia with transient hypotension that responds to transfusion. A technetium 99m–tagged red blood cell scan demonstrates active bleeding in the right colon. The best next step in management is:
- A 58-year-old man with chronic ulcerative colitis is found to have a 3-cm mass approximately 5 cm from the anal verge on surveillance colonoscopy. Biopsies reveal moderately differentiated adenocarcinoma. On rectal examination, the mass is fixed and tethered. Staging reveals a T3N0 lesion, with no evidence of distant metastasis. The best next step in management is:
- An 85-year-old man presents to your office with complaints of intermittent rectal bleeding. His history is notable for prostate cancer treated with external beam radiation. Sigmoidoscopy reveals mucosal pallor, superficial ulceration, and telangiectasias in the distal rectum, and a biopsy specimen is obtained from the anterior rectal wall. Two weeks later, the patient develops pelvic pain, fever, and a watery rectal discharge that occurs while voiding. This presentation is most concerning for:
- Anorectal Disease
- A 40-year-old woman with a history of Crohn's disease presents to your office with quiescent proctitis and a 4-mm rectovaginal fistula just above the anorectal ring. There is no appreciable sphincter defect. What is your best recommendation for repair?
- A 36-year-old woman has a history of obstetric injury and low rectovaginal fistula. Magnetic resonance imaging shows a 45 degree anterior sphincter defect. The patient reports weekly fecal incontinence. What is the recommended treatment?
- A 27-year-old woman presents with a grade 4 perineal laceration 2 weeks after vaginal delivery. At the time of delivery, a repair was attempted. She presents today reporting passage of flatus and stool from the vagina. On examination under anesthesia, the patient is found to have a low rectovaginal fistula. What is the next step in management?
- A 27-year-old man presents to the clinic with chronic seropurulent drainage from the superior gluteal cleft for 3 months. Examination reveals a 1.5-cm pilonidal cyst with a chronic midline sinus. Rectal examination findings are normal. What is the best next step in management?
- A 45-year-old woman presents with induration and chronic draining sinuses in the perineum, axilla, and groin. She underwent a screening colonoscopy 2 years ago, the result of which was normal. What is the best long-term management strategy to prevent recurrence?
- You evaluate a patient with a 3-month history of pruritis ani. Examination reveals perianal erythema and excoriation. You treat the patient with dietary modification and calamine-zinc barrier. The patient returns in 3 months reporting no symptomatic improvement. What is the next step in management?
- A 56-year-old HIV positive man with anal condyloma acuminata undergoes excision and fulguration of these lesions under general anesthesia. The pathology shows foci of high-grade dysplasia related to human papillomavirus. What is the next step in the management?
- A 25-year-old HIV-positive man underwent high-resolution anoscopy (HRA) and was found to have 3 small, flat, plaquelike lesions at the anal verge and in the anal canal. Biopsies indicated high-grade dysplasia. Which is the next step in management?
- Pelvic Floor
- A 37-year-old man with developmental delay and lifelong intermittent rectal prolapse presents to the emergency department with the findings shown in the Figure. Attempts at reduction of the prolapse are unsuccessful, and while waiting for the operating room, the mucosa develops patchy necrosis. What is the best next step in management?
- A 40-year-old-woman presents to the clinic with a history of rectal bleeding, difficult defecation, and mucus discharge. Colonoscopy reveals thickening of the anterior rectal wall and multiple shallow ulcers. Rectal ulcer biopsy reveals fibrous obliteration of the lamina propria and no malignancy. What is the most appropriate next step?
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