11/21/13 CEA: 1.7 WNL

Transcription

1 Case Scenario 1 A 70 year-old white male presented to his primary care physician with a recent history of rectal bleeding. He was referred for imaging and a colonoscopy and was found to have adenocarcinoma. He is here today for a laparoscopic segmental resection. 11/8/13 Colonoscopy: Transverse colon mucosal lesion with the near constriction of the lumen. These changes involve a 5 cm segment of colon that looked worrisome for colon cancer, status post multiple biopsies and tattoo injection. Polyps noted in the sigmoid colon. Diminutive 3-4, 4-5 mm in diameter, around 5 is number noted, removed by cold biopsy. 11/8/13 Pathology from colonoscopy: Colon at 70 cm biopsy: invasive moderately to poorly differentiated adenocarcinoma. Multiple foci suspicious for lymphovascular space invasion are present. MSI is negative. Sigmoid polyps (5): The largest of the polyps measure 5 mm in largest dimension. Invasive moderately to poorly differentiated adenocarcinoma is found in the head of the polyp and invades into the submucosa. The malignancy is confined to the head of the polyp. Foci suspicious for lymphovascular space invasion are present. Surgical margins are negative. No malignancy is identified in the remaining 4 polyps. 11/14/13 CT C/A/P: There is an annular carcinoma of the mid transverse colon with circumferential direct extension into paracolic fat. Pericolic tumor abuts loops of small bowel but there is no good evidence of small bowel invasion and there is no small bowel obstruction. There is paracolic lymph node metastasis in the area around the transverse colon. No focal liver mass is identified. There is no good evidence of peritoneal carcinomatosis. 11/21/13 CEA: 1.7 WNL 12/3/13 Colonoscopy: 1. Malignant-appearing lesion consistent with a biopsy-proven adenocarcinoma in proximal transverse colon at approximately cm from the anal verge. 2. No evidence of polypectomy scar at 40 cm in the sigmoid colon. 12/11/13 Operative Report An attempted laparoscopic segmental resection converted to open extended right hemicolectomy with ileocolonic anastomosis and en-bloc resection of abdominal wall and small bowel. Resection of small bowel mesenteric implant: Findings: 8 x 6 cm transverse colon cancer involving the abdominal wall and small bowel terminal ileum. No liver metastasis.

2 12/11/13 Pathology from Colon resection: Final Diagnosis: KRAS wild type A. COLON, RIGHT, RESECTION: SEGMENT OF RIGHT COLON AND TERMINAL ILEUM DEMONSTRATING A TUBULOVILLOUS ADENOMA IN THE COLON, SEE GROSS DESCRIPTION. MULTIPLE (11) LYMPH NODES ARE NEGATIVE FOR CARCINOMA. B. RIGHT COLON, PROXIMAL TRANSVERSE AND SMALL BOWEL, RESECTION: HISTOLOGIC TUMOR TYPE: INVASIVE COLONIC ADENOCARCINOMA. HISTOLOGIC TUMOR GRADE: POORLY DIFFERENTIATED. TUMOR SIZE AND LOCATION: TUMOR MEASURES 8 X 8 X 7 CM. AND INVOLVES THE PROXIMAL TRANSVERSE COLON. EXTENT OF INVASION: TUMOR INVADES THROUGH MUSCULARIS WALL TO INVOLVED PERICOLONIC ADIPOSE TISSUE AND FOCALLY ADJACENT ABDOMINAL WALL. TUMOR IS ALSO ADHERENT WITH FIBROSIS TO THE SMALL BOWEL. MACROSCOPIC TUMOR PERFORATION: NOT APPRECIATED. LYMPH-VASCULAR INVASION: NOT APPRECIATED. PERINEURAL INVASION: NOT APPRECIATED. MARGINS: THE RADIAL MARGIN IS POSITIVE FOR TUMOR WHILE THE MUCOSAL MARGINS ARE NEGATIVE. REGIONAL LYMPH NODES: 3 OF 7 PARACOLIC LYMPH NODES IN THE BLOCK RESECTION ARE POSITIVE FOR METASTATIC COLONIC ADENOCARCINOMA, FOCALLY DEMONSTRATING EXTRANODAL EXTENSION. ADDITIONAL FINDINGS: TUMOR IS PRESENT IN SEROSAL NODULES OF THE SMALL BOWEL AND IS PRESENT AT THE SEROSAL SURFACE. C. MESENTERIC LYMPH NODE FROM BASE OF MIDDLE COLIC ARTERY: METASTATIC ADENOCARCINOMA COLONIC TYPE DIFFUSELY REPLACING NODAL STRUCTURE. D. LYMPH NODES, ILEOCOLONIC, DISSECTION: MULTIPLE (10) LYMPH NODES ARE NEGATIVE FOR CARCINOMA. E. MESENTERIC NODULE, BIOPSY: METASTATIC COLONIC ADENOCARCINOMA PRESENT. 12/20/13 MRI Abdomen: Interval postoperative changes of partial colectomy. 1/23/14 Modified FOLFOX-6

3 Case Scenario 1 Worksheet Primary Site C18.4 Morphology 8140/3 Sequence 01 Grade 3 Stage/ Prognostic Factors CS Tumor Size 080 CS SSF CS Extension 655 CS SSF CS Tumor Size/Ext Eval 3 CS SSF CS Lymph Nodes 300 CS SSF CS Lymph Nodes Eval 3 CS SSF Regional Nodes Positive 04 CS SSF Regional Nodes Examined 29 CS SSF CS Mets at Dx 36 CS SSF CS Mets Eval 3 CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF Summary Stage 7-Distant Derived AJCC TNM Stage (indicate c or p in the space before the T, N, or M) Clinical AJCC TNM Stage T3 N1 M0 Pathologic AJCC TNM Stage IIIB pt4b pn2a pm1b pstage IV T4b N2a M1b pstage IV Treatment Diagnostic Staging Procedure 02 Surgery Codes Radiation Codes Surgical Procedure of Primary Site 41 Radiation Treatment Volume 00 Scope of Regional Lymph Node 5 Regional Treatment Modality 00 Surgery Surgical Procedure/ Other Site 0 Regional Dose Systemic Therapy Codes Boost Treatment Modality 00 Chemotherapy 3 Boost Dose Hormone Therapy 0 Number of Treatments to Volume 00 Immunotherapy 0 Reason No Radiation 1 Hematologic Transplant/Endocrine 0 Radiation/Surgery Sequence 0 Procedure Systemic/Surgery Sequence 3

4 Case Scenario 1 Worksheet Primary Site C18.7 Morphology 8210/3 Sequence 02 Grade 3 Stage/ Prognostic Factors CS Tumor Size 999 CS SSF CS Extension 160 CS SSF CS Tumor Size/Ext Eval 3 CS SSF CS Lymph Nodes 000 CS SSF CS Lymph Nodes Eval 0 CS SSF Regional Nodes Positive 98 CS SSF Regional Nodes Examined 00 CS SSF CS Mets at Dx 00 CS SSF CS Mets Eval 0 CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF Summary Stage 1 Localized Derived AJCC TNM Stage (indicate c or p in the space before the T, N, or M) Clinical AJCC TNM Stage ctx N0 M0 Pathologic AJCC TNM Stage Stage 99 pt1 cn0 cm0 Stage I pt1 Nx M Stage 99 Treatment Diagnostic Staging Procedure 00 Surgery Codes Radiation Codes Surgical Procedure of Primary Site 28 Radiation Treatment Volume 00 Scope of Regional Lymph Node 0 Regional Treatment Modality 00 Surgery Surgical Procedure/ Other Site 0 Regional Dose Systemic Therapy Codes Boost Treatment Modality 00 Chemotherapy 00 Boost Dose Hormone Therapy 00 Number of Treatments to Volume 00 Immunotherapy 00 Reason No Radiation 1 Hematologic Transplant/Endocrine 00 Radiation/Surgery Sequence 0 Procedure Systemic/Surgery Sequence 0

5 CASE SCENARIO 2 1/22/13 HISTORY 76 year-old white male presented with nausea, vomiting, and abdominal pain. CT showed small bowel obstruction. 1/14/13 CT Abdomen/Pelvis: Possible small bowel obstruction with transition point in the right anterior abdomen. There is colonic diverticulosis. There are hypodense liver lesions, most likely nonmalignant, and cholelithiasis. 1/15/13 CEA 1.9 (Normal < 3.0) 1/22/13 Colonoscopy: 2-3 mm diminutive polyp in right colon, 2 mm polyp in sigmoid colon at 30 cm, 1 cm polyp in sigmoid colon at 40 cm, and 5 mm polyp in sigmoid colon at 50 cm. 1/22/13 Final pathologic diagnosis: A. Large intestine, right side polyp, biopsy: Tubular adenoma B. Large intestine, 1 cm sigmoid polyp at 40 cm. Polypectomy: Invasive, moderately differentiated adenocarcinoma arising in a sessile tubular adenoma. (See comment.) C. Large intestine, 2 mm polyp at 30 cm. Biopsy: Hyperplastic polyp. D. Large intestine, 5 mm polyp at 50 cm. Biopsy: Tubular adenoma. Diagnostic Comments: The sigmoid polyp at 40 cm. represents a grade II adenocarcinoma arising in a sessile tubular adenoma. (The polyp does not contain a stalk.). The adenocarcinoma invades beyond the muscularis mucosae into the submucosa and extends to less than 0.1 mm. from the inked, cauterized base; however, the extent of cautery precludes definitive assessment of the status of the margin. Although there is retraction artifact, features diagnostic of lymph-vascular invasion are not seen. The adenocarcinoma comprises approximately 70% of the entire lesion. FOLLOW-UP: Segmental resection of the sigmoid colon offered as treatment, but the patient opted for active surveillance. The patient had a colonoscopy done on November 26, 2013, which reveals no evidence of recurrent malignancy.

6 Case Scenario 2 Worksheet Primary Site C18.7 Morphology 8210/3 Grade 2 Stage/ Prognostic Factors CS Tumor Size 999 CS SSF or 999 CS Extension 160 CS SSF CS Tumor Size/Ext Eval 3 CS SSF CS Lymph Nodes 000 CS SSF CS Lymph Nodes Eval 0 CS SSF Regional Nodes Positive 98 CS SSF Regional Nodes Examined 00 CS SSF CS Mets at Dx 00 CS SSF CS Mets Eval 0 CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF Summary Stage 1 Localized only Derived AJCC TNM Stage (indicate c or p in the space before the T, N, or M) Clinical AJCC TNM Stage TX N0 M0 Pathologic AJCC TNM Stage Stage group 99 Treatment pt1 cn0 cm0 Stage group I T1 NX Stage group 99 Diagnostic Staging Procedure 00 Surgery Codes Radiation Codes Surgical Procedure of Primary Site 28 Radiation Treatment Volume 00 Scope of Regional Lymph Node 0 Regional Treatment Modality 00 Surgery Surgical Procedure/ Other Site 0 Regional Dose Systemic Therapy Codes Boost Treatment Modality 00 Chemotherapy 00 Boost Dose Hormone Therapy 00 Number of Treatments to Volume 000 Immunotherapy 00 Reason No Radiation 1 Hematologic Transplant/Endocrine 00 Radiation/Surgery Sequence 0 Procedure Systemic/Surgery Sequence 0

7 Case Scenario 3 1/22/14 History and Physical A 57 year-old white male presented today for a low anterior resection of the rectum. He originally presented 8/6/13 for a colonoscopy with a biopsy and was found to have a 4.2cm fungating tumor located in his upper rectum. A biopsy confirmed adenocarcinoma. An MRI was performed for staging purposes and the tumor was found to extend into the surrounding peri-rectal adipose tissue, but did not involve any surrounding structures or organs. There was no indication of any lymph node involvement. A CT of the abdomen and chest were negative for metastatic involvement. His CEA was found to be elevated at 19.4 ng/ml. The patient opted for neoadjuvant treatment. He was started on 5-FU and Leucovorin with concurrent radiation treatment on 8/23/13. He received 45 Gy in 25 fractions to the tumor, the presacral nodes and the internal iliac nodes. An additional boost of 5.4 Gy was given to the tumor in 3 fractions. He is here today for a total mesorectal excision (TME) of his rectal tumor. 1/22/14 Pathology Total Mesorectal Excision Tumor Site: Rectum Tumor Size: 1.2 x.8 x.5 cm Histologic Type: Adenocarcinoma Histologic Grade: Low grade Tumor Extension: Tumor confined to the submucosa Proximal and Distal Margins: Uninvolved by invasive carcinoma Circumferential Margin: Uninvolved by invasive carcinoma. Treatment effect: Present-Grade 2 Lymph-Vascular Invasion: Not identified Perineural invasion: Not identified Tumor Deposits: Not identified Number of Lymph Nodes Involved: 1 A single inferior mesenteric lymph node was identified with metastatic adenocarcinoma Number of Lymph Nodes Examined: 36 1/23/14 Discharge Summary The patient is recovering from his surgery and has been discharged home. During his stay we had a long discussion on the role of adjuvant chemotherapy in the treatment of his disease. 4/15/14 Follow-up Note The patient has just completed a full course of 5-FU, leucovorin, and oxaliplatin (FOLFOX).

8 Case Scenario 3 Worksheet Primary Site C20.9 Morphology 8140/3 Grade 9 Stage/ Prognostic Factors CS Tumor Size 042 CS SSF CS Extension 455 CS SSF CS Tumor Size/Ext Eval 5 CS SSF CS Lymph Nodes 200 CS SSF CS Lymph Nodes Eval 6 CS SSF Regional Nodes Positive 01 CS SSF Regional Nodes Examined 36 CS SSF CS Mets at Dx 00 CS SSF CS Mets Eval 0 CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF CS SSF Summary Stage Clinical AJCC TNM Stage 4-Regional by both direct extension & regional nodes T3 N0 M0 Stage group IIA Derived AJCC TNM Stage (indicate c or p in the space before the T, N, or M) Treatment Pathologic AJCC TNM Stage ct3 ypn1a cm0 Stage group IIIB ypt1 ypn1a cm0 Stage group IIIA Diagnostic Staging Procedure 02 Surgery Codes Radiation Codes Surgical Procedure of Primary Site 30 Radiation Treatment Volume 29 Scope of Regional Lymph Node 5 Regional Treatment Modality 20 Surgery Surgical Procedure/ Other Site 0 Regional Dose Systemic Therapy Codes Boost Treatment Modality 20 Chemotherapy 03 Boost Dose Hormone Therapy 00 Number of Treatments to Volume 028 Immunotherapy 00 Reason No Radiation 0 Hematologic Transplant/Endocrine 00 Radiation/Surgery Sequence 2 Procedure Systemic/Surgery Sequence 4