Tubulovillous adenoma, a tumor board presentation

tumor board presentation

1. Tubulovillous Adenoma By Dr. M. Asad Parvez PGR Surgical Unit 2

2. Personal Information Patient Arshad Ali, 65 years of age, resident of Faisalabad, married

3. Presenting Complaints and HOPI History: The patient, a known smoker, presented with absolute constipation, abdominal pain, abdominal distension and vomiting for 2 days, on 30-12-24. Pt was in USOH when he noticed that stoma was not working, and developed gradual onset abdominal pain progressively increasing in intensity, not associated with fever, vomiting, weight loss. He was subsequently managed conservatively on the lines of Sub acute intestinal obstruction and was sent on leave and was planned for further workup. No family history of malignancy. No history of jaundice, bone pains, convulsions. Past Surgical and Treatment History: He is a known case of Moderately differentiated Adenocarcinoma of rectosigmoid junction, which was diagnosed on biopsy after he underwent emergent exploratory laparotomy and Hartmann procedure due to Sub acute intestinal obstruction 4 years back (5-10-2021). Subsequently he underwent 12 sessions of chemotherapy (oxaliplatin) from 30-11-21 to 13-06-22.

4. Past Medical History: -Patient is chronic smoker. -Patient is known asthmatic, for which he uses Xaltide inhaler -DM –ve, HTN -ve

5. Examination GPE: No supraclavicular lymphadenopathy, axillary or cervical lymphadenopathy No jaundice or pallor. Vitals: B.P = 120/80 mmHg, P.R = 67 bpm, RR = 20 / min, Sp02 = 99%, Temp = Afebrile Systemic: Respiratory = NVB + 0 + B/L EAE CVS = S1 + S2 + 0 CNS = GCS 15/15, No Motor or sensory anomaly GIT = Abd distended, soft, non tender, dilated veins visible over abdomen. Stoma site visible in LIF with stoma bag applied. Midline scar of previous exploratory laparotomy visible. Swelling of about 4 x 4 cm at upper end of midline incision scar, cough impulse positive, reducible, no overlying skin changes. Defect of about 3 cm width in rectus sheath. Swelling of about 10 x 5 cm located midway between stoma site and midline scar at level of stoma, cough impulse +ve, reducible, defect of about 4 cm in rectus sheath. No visceromegaly or mass palpable. Bowel sounds audible. Stoma site = Stoma patent, surrounding skin normal. DRE = Anal tag at 6 o clock position, Anal tone normal, No blood staining or fecal staining of finger.

6. Investigations CBC: Hb = 9.1 g/dl , WBC = 10400/ cmm , PLT = 196000/ cmm , PT = 15s, aPTT = 35s CEA: 26-1-22 : 3.38 (normal) 3-1-2025: 1.27 (normal) LFTS : Bilirubin = 0.7 mg/dl, ALT/SGPT = 22 U/L RFTS : Serum Urea = 24mg/dl, Serum Creatinine = 0.8 mg/dl Serum Electrolytes: Sodium = 141 meq /L, K = 4.1 meq /L Hepatitis Status: AntiHCV = -ve, HbsAg = -ve, HIV Screening = -ve

7. Investigations USG Abdomen: (14-1-2025) Calculus of 4mm in gallbladder. Otherwise unremarkable

8. Investigations Histopathology (5-10-21) Well to moderately differentiated adenocarcinoma. Bifocal, 42mm and 14mm, 2 lesions. Larger tumor invades through muscularis propria into the subserosal tissue (pT3). No regional lymph node mets . (pN0) Smaller tumor is infiltrating muscularis propria only. Multiple tubulovillous adenomas without high grade dysplasia. 22 reactive lymph nodes Proximal, distal and mesenteric resection margins, free of tumor. CT Abd and Pelvis with IV contrast (9-11-21) Significantly thick walled tectum extending into rectosigmoid junction with enhancing nodular lesions in rectum with fat stranding and peri rectal L.N, approximately 5 cm above the anal verge. Liver showing benign looking subcentimetric cystic lesions in segment VI.

9. Colonoscopy (15-2-22, during chemo) Multiple masses and small sessile polyps throughout colon upto 15 cm from anal verge. Multiple biopsies taken Inserted through colostomy site, multiple masses and small sessile polyps seen. Histopathology: Tubulovillous adenoma with moderate dysplasia. CT NCAP with IV Contrast (13-7-22, post chemo) No residual or recurrent lesion Colonoscopy (18-1-2025): Rectum : 20cm distal segment with multiple wide based polyps Colon : A polyp around end colostomy site + polyps in segment of 5 cm proximal to colostomy, rest of colon could not be examined due to inadequate preparation Multiple biopsies taken to exclude malignancy Histopathology: Sections show tubular and villous arrangement of glands showing focal high grade dysplasia. Diagnosis: Tubulovillous adenoma with focal high grade dysplasia. Due to superficial nature of biopsy, invasion could not be adequately assessed. Clinicoradiological correlation advised

10. Investigations CT Neck, Chest, Abd and Pelvis with IV contrast: (27-1-2025) Hernial defect in anterior abdominal wall measuring 39mm between left rectus sheath and left oblique muscles through which bowel is herniating. Another hernial defect in anterior abdominal wall at para midline location measuring 44 mm in rectus sheath. A small segment of colon at level of splenic flexure shows circumferential wall thickness with maximum wall thickness of 15.9 mm. However, no stricture formation, no retro grade bowel dilatation. Advised colonoscopy and histopathology correlation. Multiple hypoattenuating sub centimetric lesions noted in liver one in segment VI measures 7.5 mm likely metastatic. However, correlation with previous films is recommended.

11. Case is opened for discussion Stage 4, TXNXM1 Chemotherapy as metastatic disease Investigate for Intestinal polyposis syndromes

12. Thank you