Colon Case Scenarios



Colon Case ScenariosCOLORECTAL CASE #1A 67 year old male presents with a history of rectal bleeding and leakage. He had a colonoscopy Jan 16, 2018 which revealed a circumferential mass. A biopsy was positive for poorly differentiated adenocarcinoma. CT scan of the pelvis showed thickening of the rectum with mild left periaortic and retroperitoneal lymph nodes. Rectal exam revealed a 5.5cm tumor on left side, mobile.2/5/2018: Endoscopic ultrasound: 4.8cm mass with extension into perirectal fat, no positive lymph nodes seen.Patient was advised to have neoadjuvant chemoradiation.3/6/2018 patient began 5FU at Dr Chemo’s office.RADIATION THERAPY TREATMENT SUMMARY:Course: C1-pelvisTreatment Site: pelvisEnergy: 18X/6XDose/Fx (cGy): 180#Fx: 25 / 25Dose Correction (cGy): 0Total Dose (cGy): 4,500Start Date: 3/6/2018End Date: 4/10/2018Elapsed Days: 35Course: C1-pelvisTreatment Site: pelvisEnergy: 18X/6XDose/Fx (cGy): 180#Fx: 3 / 3Dose Correction (cGy): 0Total Dose (cGy): 540Start Date: 4/13/2018End Date: 4/15/2018Elapsed Days: 2TREATMENT TECHNIQUE: 3D conformal XRT, 6/18 MV photons. Pelvis (primary site+nodes) 4,500 cGy in 25 fractions followed by a boost (PET positive primary site+peri-rectal node) 540 cGy in 3 fractions.5/21/2018: OPERATION PERFORMED: Exploratory laparotomy, total mesorectal excision, excision of segment of sigmoid colon.PATH:1) RECTUM AND SEGMENT OF SIGMOID COLON, TOTAL MESORECTAL EXCISION AND SIGMOID COLON EXCISION: - Moderately differentiated adenocarcinoma- Treatment effect present - Tubulovillous adenoma - Margins: Negative for dysplasia, and carcinoma - Two of twenty-two lymph nodes positive for metastatic carcinoma (2/22)- Two tumor deposits identified 2) DISTAL SIGMOID AND ANASTOMOTIC RINGS: - Negative for dysplasia or carcinoma CAP Checklist Primary Carcinoma of the Colon and Rectum: SPECIMEN: Rectum and sigmoid colon PROCEDURE: Mesorectal excision and portion of sigmoid colon excisionTUMOR SITE: RectumTUMOR SIZE: Greatest dimension: 0.4 cm (microscopic measurement)MACROSCOPIC TUMOR PERFORATION: Not identified HISTOLOGIC TYPE: Adenocarcinoma HISTOLOGIC GRADE: Low grade (moderately differentiated)MICROSCOPIC TUMOR EXTENSION: Tumor invades through muscularis propria into the subserosal adipose tissue or the nonperitonealized pericolic or perirectal soft tissues but does not extend to the serosal surface MARGINS: Distance of invasive carcinoma from the closest margin: Distal margin at 1.5 cmProximal margin: Uninvolved by invasive carcinoma Distal margin: Uninvolved by invasive carcinoma Circumferential (radial) margin: Uninvolved by invasive carcinoma Mesenteric margin: Not applicable TREATMENT EFFECT: Present; residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response, score 2)LYMPH-VASCULAR INVASION: Small vessel lymphovascular invasion presentPERINEURAL INVASION: Not identified TUMOR DEPOSITS: Present, 2 Number of lymph nodes examined: 22Number of lymph nodes involved: 2ADDITIONAL PATHOLOGIC FINDINGS: Tubulovillous adenomaANCILLARY STUDIES: MSI, BRAF and K-RAS by molecular /polymerase chain reaction (PCR) are being obtained on block 1D. These results will be reported separately as an addendum. Addendum: Block 1A was sent and results are reported as follows: K-RAS mutation analysis: Negative, K-RAS mutation not detected BRAF mutation analysis: Negative, BRAF V600 mutation not detected. Microsatellite instability analysis (MSI): Negative, microsatellite stable NRAS mutation analysis: Negative, NRAS mutation not detected Patient saw Dr Chemo after recovery from surgery and began FOLFOX chemotherapy for two months when it was discontinued due to side effects.Scenario 1Primary SiteC20.9Clinical Grade3Tumor Size Summary048Histology8140Pathological Grade9Tumor Size Clinical048Behavior3Post Therapy Grade2Tumor Size Pathological004MP RuleM2H RuleH7Stage Data itemsClinical TcT3Pathological TPost-Therapy TypT3cT SuffixpT SuffixypT SuffixClinical NcN0Pathological NPost-Therapy NypN1bcN SuffixpN SuffixypN SuffixClinical McM0Pathological MPost-Therapy McM0Clinical Stage 2APathological StagePost-Therapy Stage3BSummary Stage 2018 4-Regional by BOTH direct extension AND regional lymph node(s) involvedEOD Primary Tumor400EOD Regional Nodes300EOD Mets 00SSDIsLymphovascular Invasion2 CEA PreTX Lab ValueXXXX.9CEA PreTX Interpretation9Tumor Deposits02Perineural Invasion0Circumferential Resection MarginXX.1KRAS0Microsatellite Instability (MSI)0Surgical Diagnostic Staging Procedure02SurgerySurgical Procedure of Primary Site30Scope of Regional Lymph Node Surgery5Surgical Procedure Other Site0Systemic TherapyChemotherapy03Hormone Therapy00Immunotherapy00Hematologic Transplant0Systemic/ Surgery Sequence4RadiationPhase 1Phase 2Phase 3Rad Primary Treatment Volume5454Radiation to Draining Lymph Nodes0606Rad Treatment Modality0202Ext Beam Rad Planning Technique0404Dose per Fraction00180180Number of Fractions025003Total Dose004500000540# of Phases of Rad Tx to this Volume02Rad Treatment Discontinued Early00Total Dose005040Radiation/ Surgery Sequence2COLORECTAL CASE #2Oct 16, 2018: Patient is admitted via direct admission for colonoscopy prep. She is to have a colonoscopy in the morning. She's had significant GI bleeds in the past. She lives alone and it was not felt safe to do prep on her own there. She's had issues with volume depletion and syncope in the past.LABORATORYCEA: 2.6 (normal < 3.0)COLONOSCOPY IMPRESSION: Cecal polypoid mass, suspected to be malignant in nature, this was extensively biopsied and tattooed; it could not be endoscopically removed. 3 separate colon polyps, removed with cold snare. Sigmoid diverticuli. Small external hemorrhoids. Suboptimal prep again secondary to stool throughout the colon.COLONOSCOPY PATH: COLON, CECAL MASS BIOPSY: Adenocarcinoma, moderately differentiated ASCENDING COLON POLYPS BIOPSIES: Sessile serrated adenoma with low grade dysplasia Tubular adenoma RECTAL POLYP BIOPSY: Tubular adenoma Oct 18, 2018: OPERATION PERFORMED Laparoscopic hand-assisted right hemicolectomy, lysis of adhesions.RIGHT COLON, RIGHT HEMICOLECTOMY PATH: - Moderately differentiated adenocarcinoma - Tumor size: 3.6 cm - Margins negative for carcinoma - Thirty five lymph nodes negative for carcinoma (0/35)CAP checklist: SPECIMEN TYPE: Terminal ileum, cecum and proximal right colon PROCEDURE: Right hemicolectomy TUMOR SITE: Cecum TUMOR SIZE: 3.6 cmAdditional dimensions: 3 x 1.5 cmMACROSCOPIC TUMOR PERFORATION: Not identified HISTOLOGIC TYPE: Adenocarcinoma HISTOLOGIC GRADE: Low grade (moderately differentiated) MICROSCOPIC TUMOR EXTENSION: Tumor invades through the muscularis propria into the subserosal adipose tissue or to the nonperitonealized pericolic soft tissues but does not extend to the serosal surfaceMARGINS: Distance of invasive carcinoma from closest margin: Mesenteric margin at 3 cm Proximal margin: Uninvolved by invasive carcinoma Distal margin: Uninvolved by invasive carcinoma Circumferential (radial) margin: Not applicable Mesenteric margin: Uninvolved by invasive carcinoma TREATMENT EFFECT: Not known LYMPH-VASCULAR INVASION: Not identified PERINEURAL INVASION: Not identified TUMOR DEPOSITS: Present, 1Number of lymph nodes examined: 35Number of lymph nodes involved: 0ADDENDUM: K-RAS mutation analysis: Negative; K-RAS mutation not detectedNRAS mutation analysis: Negative; NRAS mutation not detectedBRAF mutation analysis: Negative; BRAF V600 mutation not detectedMismatch Repair Test (MMR): MLH1 expressedMSH2 expressedMMR-Proficient if both MLH1 and MSH2 are expressedConsultation with Dr HemOnc: Conversation was held with patient about adjuvant chemotherapy. NCCN guidelines would support chemo with the high-risk feature of MMR-Proficient, however patient’s other health issues (age over 75, atrial fibrillation, ischemic cardiomyopathy, and history of breast cancer approximately 5 years ago), patient was reluctant to pursue. I can support patient’s decision to forego chemo at this time.?Scenario 2Primary SiteC18.0Clinical Grade2Tumor Size Summary036Histology8140Pathological Grade2Tumor Size Clinical999Behavior3Post Therapy GradeTumor Size Pathological036MP RuleM2H RuleH7Stage Data itemsClinical TcTXPathological TpT3Post-Therapy TcT SuffixpT SuffixypT SuffixClinical NcNXPathological NpN1cPost-Therapy NcN SuffixpN SuffixypN SuffixClinical McM0Pathological McM0Post-Therapy MClinical Stage 99Pathological Stage3BPost-Therapy StageSummary Stage 2018 3EOD Primary Tumor300EOD Regional Nodes200EOD Mets 00SSDIsLymphovascular Invasion0CEA PreTX Lab Value2.6CEA PreTX Interpretation0Tumor Deposits01Perineural Invasion0Circumferential Resection Margin30.0KRAS0Microsatellite Instability (MSI)0Surgical Diagnostic Staging Procedure02SurgerySurgical Procedure of Primary Site40Scope of Regional Lymph Node Surgery5Surgical Procedure Other Site0Systemic TherapyChemotherapy82Hormone Therapy00Immunotherapy00Hematologic Transplant00Systemic/ Surgery Sequence0RadiationPhase 1Phase 2Phase 3Rad Primary Treatment Volume00Radiation to Draining Lymph NodesRad Treatment Modality00Ext Beam Rad Planning TechniqueDose per FractionNumber of FractionsTotal Dose# of Phases of Rad Tx to this Volume00Rad Treatment Discontinued Early00Total Dose000000Radiation/ Surgery Sequence0COLORECTAL CASE #31/12/18PREOPERATIVE DIAGNOSIS: Irregular bowel habits, lower abdominal pain and rectal bleeding.POSTOPERATIVE DIAGNOSIS: Large colon polyp removed.PROCEDURE PERFORMED: Colonoscopy with snare polypectomyINDICATIONS: This pleasant 40-year-old female presents with irregular bowel habits. She can have up to 10 bowel movements in a day. On normal days she will have 3-4 bowel movements a day. Stools are generally formed. She will have lower abdominal pain when she has more frequent bowel movements. She had some rectal bleeding on one occasion.DESCRIPTION OF PROCEDURE: The risks and limitations of colonoscopy were discussed with the patient and a permit form was obtained. We discussed the fact that screening colonoscopy decreases the risk of colon cancer significantly. A rectal exam was performed and was normal. With the patient in the left lateral decubitus position, the Olympus video colonoscope was passed to the cecum. The ileocecal valve and appendiceal orifice were identified. The colonic mucosa had a normal appearance throughout. There was a large 2 cm polyp with a narrow base removed with jumbo snare. The polyp was located at 40 cm from the anus in the descending colon. No diverticuli were noted. On withdrawing the scope, careful circumferential inspection in a well-prepped colon was carried out. Care was taken to expose and inspect the proximal sides of the ileocecal valve, haustral folds, flexures, and rectal valves. The patient tolerated the procedure well. There were no immediate complications.SPECIMEN REMOVED: Colon polypCOMPLICATIONS: None.COLONIC MUCOSA AND SUBMUCOSA PATH (ASCENDING COLON POLYP AT 40 CM): Well differentiated adenocarcinoma arising in tubulovillous adenomaCAP checklist PROCEDURE: Excisional biopsy (polypectomy) TUMOR SITE: Ascending colon at 40 cmSIZE OF INVASIVE CARCINOMA: 0.7 cm HISTOLOGIC TYPE: Adenocarcinoma HISTOLOGIC GRADE: Low grade MICROSCOPIC TUMOR EXTENSION: SubmucosaMARGINS: Cannot be assessed LYMPH-VASCULAR INVASION: Not identified TYPE OF POLYP IN WHICH INVASIVE CARCINOMA AROSE: Tubulovillous adenoma 1/14/18 CEA: 12.7 (normal < 3.0)TREATMENT SUMMARYPatient had consultation with colorectal surgeon specialist who recommended repeat colonoscopy within 1 month. If any abnormal residual area seen, partial colectomy should be strongly considered.Subsequent colonoscopy within six weeks showed normal tissue, no residual. Patient made decision to refuse surgery at this time but to have close follow-up with frequent scopes.Scenario 3Primary SiteC18.2Clinical Grade9Tumor Size Summary007Histology8140Pathological Grade1Tumor Size Clinical999Behavior3Post Therapy GradeTumor Size Pathological007MP RuleM2H RuleH2Stage Data itemsClinical TPathological TpT1Post-Therapy TcT SuffixpT SuffixypT SuffixClinical NPathological NpNXPost-Therapy NcN SuffixpN SuffixypN SuffixClinical MPathological McM0Post-Therapy MClinical Stage 99Pathological Stage99Post-Therapy StageSummary Stage 2018 1EOD Primary Tumor100EOD Regional Nodes000EOD Mets 00SSDIsLymphovascular Invasion0CEA PreTX Lab ValueXXXX.9CEA PreTX Interpretation9Tumor DepositsX9Perineural Invasion9Circumferential Resection MarginXX.7KRAS9Microsatellite Instability (MSI)9Surgical Diagnostic Staging Procedure00SurgerySurgical Procedure of Primary Site28Scope of Regional Lymph Node Surgery0Surgical Procedure Other Site0Systemic TherapyChemotherapy00Hormone Therapy00Immunotherapy00Hematologic Transplant00Systemic/ Surgery Sequence0RadiationPhase 1Phase 2Phase 3Rad Primary Treatment Volume00Radiation to Draining Lymph NodesRad Treatment Modality00Ext Beam Rad Planning TechniqueDose per FractionNumber of FractionsTotal Dose# of Phases of Rad Tx to this Volume00Rad Treatment Discontinued Early00Total Dose000000Radiation/ Surgery Sequence0 ................
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