GENERAL SURGERY Case Presentation III-B Dr. Erasmo

1. GENERAL SURGERY Case Presentation III-B Dr. Erasmo Members: de Leon, Gemma de Mesa, Angelica de Vera, Jestha dela Cruz, Ciara

3. HPI

8. Basis: Usual manifestation of Colon Cancer

9. Basis: Other manifestation of Colon Cancer

10. Double contrast Barium enema • Colonoscopy • CT Scan • MRI • Virtual colonoscopy

11. colon is first filled with barium • the barium is drained out, leaving only a thin layer of barium on the wall of the colon • colon is then filled with air • This provides a detailed view of the inner surface of the colon, making it easier to see narrowed areas (strictures), diverticula, or inflammation. • This technique can miss the (less common) flat polyp.

12. A lighted probe called a colonoscope is inserted into the rectum and the entire colon to look for polyps and other abnormalities that may be caused by cancer. • A colonoscopy has the advantage that if polyps are found during the procedure they can be immediately removed. • Tissue can also be taken for biopsy.

13. an x-ray test that produces detailed cross-sectional images of your body • Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. • A computer then combines these pictures into images of slices of the part of your body being studied. • Unlike a regular x-ray, a CT scan creates detailed images of the soft tissues in the body. • This test can help tell if colon cancer has spread into your liver or other organs.

14. provide detailed images of soft tissues in the body • uses radio waves and strong magnets instead of x-rays • useful in looking at abnormal areas in the liver that might be due to cancer spread • They can also help determine the extent of rectal cancers. • little more uncomfortable than CT scans • First, they take longer -- often up to an hour. • Second, you have to lie inside a narrow tube, which is confining and can upset people with claustrophobia

15. replaces X-ray films in the double contrast barium enema with a special computed tomography scan • requires special workstation software in order for the radiologist to interpret • This technique is approaching colonoscopy in sensitivity for polyps. • However, any polyps found must still be removed by standard colonoscopy.

16. Surgery is the ONLY hope • Adjuvant chemotherapy for Colon CA • Stage III disease • High risk Stage II disease • Obstruction • High grade histology

17. What is your interpretation of Abdominal films?

25. .

27. A proctosigmoidoscopy is done 4 hours after admission and reveals the following at the 18 cm level

28. Staging

29. Management plan • Diagnosis - colonoscopy , • Staging • Operability • Optimum treatment strategy

30. Treatment • Stage 0 – complete excision of the polyps • Stage I malignant polyp – segmental colectomy • Stage I and II Localized colon Carcinoma - Surgical resection + adjuvant chemotherapy • Stage IV Distant Metastasis – Surgical resection, hepatic resection of synchronous metastasis and adjuvant chemotherapy

31. Optimum Treatment Strategy • Surgery is the only hope for CURE • Adjuvant chemotherapy for Colon CA • > Stage 111 disease • High risk Stage 11 disease • Obstruction / Perforation • High grade histology • Adjuvant chemo-radiotherapy for Rectal CA • > Stage 11 disease • Either pre-operative or post-operative

32. Objectives in Treatment To remove the primary tumor along with its lymphovascular supply • Any organ or tissue that has been invaded should be resected en – bloc with the tumor • Presence of synchronous cancers or adenomas or a strong family history - subtotal or total colectomy

33. What do you think should be performed? Family history : • Father died of colon cancer at age 50 • Aunt died of colon cancer at age 52 • Two cousins have abdominal cancer and undergoing chemotherapy Total or subtotal colectomy

34. Preparations for Surgery • Cardiopulmonary status • Anemia • Co-morbid conditions • Nutritional status • Renal function • Liver function

35. A subtotal colectomy is performed. Histopath reveals a full thickness moderately differentiated adenocarcinomawith 2 out of 16 positive pericolic lymph nodes. Both lines of resection are negative for tumor. Full thickness Adenocarcinima – T3 Metastasis to 2 pericolic lymph node – N1 Presence of distant metastasis cannot be assessed – ? T3 N1 M – Stage III

36. Further Plans Currently recommended standard adjuvant therapy for stage III colon cancer : INH Consensus Conference 1. Postoperative day 21-35: Begin levamisole 50 mg orally three times daily for three consecutive days, repeated every two weeks for one year. 2. Postoperative day 21-35: FU 450 mg/m2/day by rapid intravenous injection for five consecutive days beginning simultaneously with levamisole. 3. Twenty-eight days after the start of chemotherapy, begin weekly FU 450 mg/m2 by rapid intravenous injection for 48 weeks.

37. Follow up Aim : to diagnose in the earliest possible stage any metastasis or tumors that develop later but did not originate from the original cancer • Medical exam and physical exam - every 3 to 6 months for 2 years, then every 6 months for 5 years. • CEA antigen blood level measurements • CT- scan of the chest, abdomen and pelvis annually for the first 3 years • Colonoscopy after 1 year