01,02 & 03.MDT Colon .pptxmmmmmmmmmmmmmmmm

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1. Colorectal Case Scenarios Need MDT decisions Dr. Abdelrahman Salah

2. Case 1 Male, 44 y, Positive family history of colon cancer (His father at age 55) Bleeding per rectum and Marked changes in bowel habits & Patient clinically not obstructed Patient underwent hemorrhoidectomy by G. surgeon but the bleeding per rectum still Tumor marker: CEA & CA19.9 >>>> Normal CT abdomen >>>>>> Mass at the rectosigmoid mass 7*3 cm with prominent lymph nodes.

3. Colonoscopy: Mass at 16 cm from anal verge extend to upper rectum by rigid sigmoidoscopy (Large, Exophytic mass nearly occluding the lumen) >> Biopsied Histopathology: Moderate differentiated adenocarcinoma grade II MRI Large Exophytic mass at 15.5 cm from anal verge (6.5*2.6 cm) at rectosigmoid junction.

4. Patient received concurrent chemoradiotherapy MRI of pelvis >>>>>> Partial response with shrinkage of the size of the mass 2*3 cm. Operation: Low anterior resection with side to end anastomosis Pathology: 1. Moderate differentiated adenocarcinoma in Sigmoid colon. 2. Free surgical margin (proximal and Distal). 3. Circumferential margin infiltrated. 4. Positive LNs (2/15). 5. Tumor Buds Present. 6. No Perineural invasion and + ve Lymphovascular invasion. Patient scheduled for Chemotherapy (Recommended by NCI Oncology).

5. Case 2 A 34-year-old male with no past medical or surgical history Referred by physician for low hemoglobin of 3.1 g/dL. The patient did not have a history of gastrointestinal bleeding, alcohol consumption, or smoking. The patient was admitted to the hospital for symptomatic anemia evaluation, and he received three units of blood transfusion after which his hemoglobin normalized.

6. There was no family history of gastrointestinal malignancies. CT abdomen and the pelvis showed a 9 cm circumferential wall thickening of the proximal ascending colon with prominent lymph nodes in the abdomen. CT chest and a CT triple phase of the liver >>>>>> Free

7. Carcinoembryonic antigen (CEA) level was 6.1 ng/mL (reference range: 0-2.5 ng/mL). Colonoscopy which revealed a 30 mm ulcerated, circumferential mass extending from the ileocecal valve to the hepatic flexure Biopsed and a 20 mm polyp in the descending colon that was removed by polypectomy (Endoscopic mucosal resection)

8. Histopathology of the circumferential mass showed invasive poorly differentiated adenocarcinoma and descending colon polyp showed tubulo-villous adenoma and tubular adenoma (positive margin with high tumor budding).

9. The patient underwent a right hemicolectomy & left hemicolectomy with ileo-rectal anastomosis. Pathology report: Poorly differentiated adenocarcinoma + (2/38 LNs) & all margins are free Started on chemotherapy as recommended by oncology. CEA levels normalized six months post-chemotherapy and a CT abdomen and pelvis showed no metastasis.

10. Case 3 A 37-year-old female DRE: suspicious rectal mass Fresh bleeding per-rectum Coloscopy: Mass 10 cm from anal verge >>>> Biopsied Pathology: Moderately differentiated Adenocarcinoma grade II CT Abdomen: Suspicious HFL 6.5 mm in segment II CT chest: suspicious pulmonary nodule (Lower left lung). PET/CT: 1. Rectal mass 6 cm from anal verge (15 Suv ) 2. Active lung nodule 19mm in left lower lung (16.5 suv ) 3. Active HFL 6.5 mm in segment II (4.6 Suv ) CEA 90 (Elevated) &CA19.9 Normal

11. Patient took short course radiotherapy 1 week. Operation: 1. Low anterior resection (TME) 2. Appendectomy ??!! 3. Segmentectomy (segment II of the liver) 4. Cholecystectomy (Calcular GB) 5. Loop ileostomy. Pathology: 1. Infiltrating mucinous adenocarcinoma Grade II 2. All margin are free 3. Positive LN (8/25) with extra-nodal Extension 4. Donuts >>>> Free 5. Appendix >>> Free 6. Segment II >>>> + ve metastatic Mucinous adenocarcinoma 7. GB >>> Free except fundal adenomyomatous nodule ypT3,N2b, M1b

12. 2 Sessions of chemotherapy Closure of ileostomy due to psychic elements Waiting for chemotherapy

13. Thank you