NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Figure 8-31: Trans-sacral resection of a rectal cancer. (From Greenfield LJ, Mulholland MW, Oldham KT, et al, eds. Surgery: Scientific Principles and Practice , 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 1997:1141.)

Case 8.27 Metastasis in Colorectal Cancer You perform a curative resection for colon cancer in a 49-year-old who has stage II cancer. You decide to follow patient with serial CEA measurements and yearly colo- noscopy. Initial CEA values are low and stable, and repeat colonoscopy is normal at 1 and 2 years. During the next visit, the CEA is now significantly elevated. Q: What evaluation is appropriate? A: A CXR and CT of the abdomen to look for metastasis are warranted. A repeat colonos- copy may be necessary, depending on when the last one was performed. Q: What further evaluation and management is appropriate? A: The patient is a candidate for surgical resection if there is no extrahepatic demonstra- ble metastatic cancer, no local recurrence of the primary cancer, an acceptable anesthetic risk from the cardiopulmonary standpoint, and a lesion that is in a surgically resectable location . The more current spiral CT scans and MRI studies are reliable; they demonstrate additional hepatic metastasis in more than 80% of cases. These tests are necessary if the initial CT scan is inadequate. A CXR and colonoscopy are appropriate, but further workup is unnecessary unless the patient has additional symptoms or findings. Typically, unresectable lesions are multiple lesions in both lobes, lesions intimate with vascular structures (e.g., hepatic veins, portal vein), lesions invading local structures (e.g., the diaphragm), or lesions occurring in cirrhotic livers. Cirrhosis increases the periop- erative risk as a result of limited hepatic reserve following resection as well as technical difficulties in transecting a fibrotic liver. SAMPLE The patient’s evaluation is negative except for a new 2-cm lesion in the right lobe of the liver.