Indications for Neoadjuvant Therapy
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Indications for Neoadjuvant Therapy
Malignancy- A 34-year-old patient presents with vague pelvic discomfort. Digital rectal examination (DRE) reveals a 3-cm anterior soft, compressible lesion that is 4 cm from the anal verge. Pelvic magnetic resonance imaging (MRI) shows a presacral solid mass that measures 2.5 cm x 2 cm with its most proximal part at S3 level. There is a clear plane between the lesion and the rectum anteriorly and the sacrum posteriorly. What is the best next step in treatment of 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 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 48-year-old man with T3N1 rectal adenocarcinoma is treated with total neoadjuvant therapy. He undergoes repeat clinical staging with computed tomography (CT) of his chest, abdomen, and pelvis, and magnetic resonance imaging (MRI) of his pelvis. He is found to have flexible sigmoidoscopy revealing a complete clinical response. Which of the following is an accurate prognosis?
- 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 healthy 47-year-old patient undergoes a laparoscopic sigmoidectomy with a primary colorectal anastomosis for the diagnosis of colon cancer. Pathology reveals a pT3N2Mx malignancy that is mismatch repair (MMR) stable. The best next step in the management of 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?
Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy
Malignancy- 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 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?
- A 68-year-old man with a history of a hemorrhoidectomy and fecal urgency presents with a T3n1m0 rectal cancer 5 cm from the anal verge. He has no family history of colorectal cancer. What is the most important consideration when counseling the patient about his surgical treatment options?
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