Management of Local Recurrences
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Management of Local Recurrences
Locally Recurrent Rectal Cancer
Management of Colon Cancer (2022)- Management of Malignant Polyps
- Pilonidal Disease and Hidradenitis Suppurativa
- Local Excision
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 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 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 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?
- Rectal Cancer: Nonoperative Management
- Rectal Cancer: Local Excision
- Gastrointestinal Stromal Tumors, Neuroendocrine Tumors, and Lymphoma
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?
- Colorectal Cancer: Postoperative Adjuvant Therapy and Surveillance
- Colorectal Cancer: Preoperative Evaluation and Staging
- Management of Rectal Cancer (2020)
- Endoscopic Management of Polyps and Endoluminal Surgery
- Colorectal Cancer: Management of Distant Metastases
- Crohn’s Disease: Surgical Management
- Management of Pilonidal Disease (2019)
- Presacral Tumors
- Benign Disease
- 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:
- Malignancy
- 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 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 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 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?
- Anal Squamous Cell Cancers (Revised 2018)
- Indications for Extended Resection
- Rationale for Multimodality Therapy
- Surgical Management of Crohn's Disease (2020)
- Proctectomy for Rectal Cancer
- Anorectal Disease
- 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 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?
- Hemorrhoids
- Anal Intraepithelial Neoplasia
- Anal Cancer
- Pediatric Colorectal Disorders
- Surveillance After Rectal Cancer Treatment
- Rectal Cancer: Neoadjuvant Therapy
- About ASCRS Textbook of Colon and Rectal Surgery
- Management of Hemorrhoids (2024)
- Rectourethral and Complex Fistulas: Evaluation and Management
- Sexually Transmitted Infections of the Colon and Rectum
- Management of Rectal Cancer 2023 Supplement (2023)
- Anorectal Crohn’s Disease
- Anal Fissure and Anal Stenosis
- Colonic Diverticular Disease
- Pelvic Floor
- Anastomotic Complications
- 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?
- Lower Gastrointestinal Hemorrhage
- Colon and Rectal Surgery Educational Program (CARSEP)
- ASCRS Question Bank
- Rectal Cancer Pathology Assessment