Colorectal Cancer Consultation

I met with Arthur Pendelton on 14/05/2024. He is 68 years old and is a male who attended today with his wife, Margaret.

He has recently received a diagnosis of cT3N1M0 rectal adenocarcinoma.

The patient describes bright red blood per rectum lasting 4 months. The patient reports tenesmus and narrower stool caliber. The patient also denies unintentional weight loss, abdominal pain, or melena. He has had iron deficiency anemia for 6 months, and it may have worsened during the past 2 months.

This was his 2nd colonoscopy. In 2016, he underwent a screening colonoscopy, which showed two benign hyperplastic polyps in the sigmoid colon.

Family History

Paternal uncle diagnosed with colon cancer at age 72; mother had T2DM.

Surgical/Medical History

HTN, T2DM, hyperlipidemia, laparoscopic cholecystectomy (2012), open right inguinal hernia repair (2018).

Procedures

Colonoscopy (Dr. R. Patel - 02/05/2024): Partially obstructing, ulcerated mass in the mid-rectum at 8 cm from the anal verge; tattooed distally; biopsies taken.

Known Allergies

Penicillin (maculopapular rash)

Medications: metformin 1,000 mg PO BID, ramipril 5 mg PO daily, atorvastatin 20 mg PO daily, ferrous fumarate 300 mg PO daily

Lifestyle Notes: Ex-smoker (quit 15 years ago, 20 pack-year history), consumes 2–3 alcoholic beverages per week, retired accountant, ECOG 0.

Investigations

MRI Pelvis (08/05/2024):

• 4.2 cm semi-annular mid-rectal mass located 8 cm from the anal verge
• Tumor extends 3 mm into the perirectal fat (T3b)
• Two suspicious mesorectal lymph nodes measuring up to 7 mm (N1)
• Circumferential resection margin (CRM) is clear (distance 6 mm)
• Extramural vascular invasion (EMVI) negative

Pathology - Rectal Biopsy (05/05/2024):

• Invasive moderately differentiated adenocarcinoma
• MMR proficient (intact MLH1, MSH2, MSH6, PMS2), KRAS wild-type

Oncology: No prior history of malignancy, chemotherapy, or pelvic radiation.

Examination

On examination, there were stable vital signs and a BMI of 26.4 kg/m². Additional evidence of mild conjunctival pallor was present. Digital rectal examination produced a palpable, firm posterior wall mass at 8 cm from the anal verge, mobile and non-tender, with normal sphincter tone. He had a soft, non-distended abdomen and well-healed laparoscopy scars. He had absence of palpable abdominal masses, hepatosplenomegaly, or inguinal lymphadenopathy.

Impression/Plan

I have requested a CT chest/abdomen/pelvis and a baseline CEA level for complete systemic staging, should he require total neoadjuvant therapy (TNT).

His case will be discussed at the upcoming Multidisciplinary Colorectal Tumor Board. He has locally advanced mid-rectal adenocarcinoma (cT3bN1M0). Despite suspicious mesorectal nodes, the circumferential resection margin is uninvolved on MRI. It remains uncertain whether he will require upfront neoadjuvant chemoradiotherapy versus short-course radiation. He is considered a good candidate for surgery.

He was notably calm and engaged and asked several appropriate peri-operative questions during the consultation; these were answered. In the meantime, I will refer him to Medical and Radiation Oncology for a formal view on neoadjuvant therapy.

I have recommended staging completion followed by neoadjuvant therapy and subsequent laparoscopic low anterior resection (LAR) with diverting loop ileostomy.

I will review him after these investigations. If he does not require neoadjuvant therapy, we will arrange surgical resection within 3 to 4 weeks.

Arthur Pendelton will be contacted by my office.

Thank you for involving me in his care.

(45 min)