50-year-old man with rectal bleeding. Clinical case. 6
Is there a clinical situation that you can discuss? Could you describe a clinical case that would illustrate how to establish correct diagnosis in colon cancer or rectal cancer? Perhaps from a physician’s perspective and also from a patient’s perspective. How to make the best treatment for colorectal cancer? You have a lot of experience in treating colorectal cancer. Perhaps we could think of a composite situation that is relevant for colorectal cancer diagnosis and treatment. Yes, sure. Let’s imagine that we have a 50-year-old male who developed rectal bleeding. The first step would be to go to your primary care doctor. That’s what this patient did. He went to a primary care doctor. His general practitioner did digital rectal exam, but he did not feel anything. The next important diagnostic step was to send this patient for colonoscopy. Colonoscopy was performed. Colonoscopy did find a rectal cancer that was distal in the rectum. Cancer was about four centimeters in size. Then this patient came to see a surgeon and medical oncologist and radiation oncologist. That’s what usually happens when the patient with rectal cancer gets evaluated. There is a multidisciplinary evaluation. Exactly. When these patients get referred to one of the cancer centers, medical oncologist, a radiation oncologist, and surgeon see this patient. We also discuss the patients at our multidisciplinary tumor board afterwards. Everybody is on the same page how to treat the patient. This is what happens when this patient comes to see me. I am, as a surgeon, I’m trying to evaluate his cancer. I’m trying to determine a stage of rectal cancer in this patient. I’m trying to see how distal is this rectal tumor. In other words, how how distal rectal cancer is. That will guide my surgical method of treatment that I can offer to that patient. Let’s say the patient has no metastatic disease. He got CT scan of the chest, abdomen, and pelvis. He had no metastatic disease, but they were able to see some enlarged lymph nodes on a CT scan. Given this is rectal cancer, we are going to offer this patient rectal MRI. Rectal MRI was performed. It did show enlarged lymph nodes. It was T3 rectal tumor. We call this rectal cancer to be locally advanced. A discussion of treatment options with medical oncologist and radiation oncologist will happen. This patient will be offered a neoadjuvant chemotherapy and radiation therapy. There are different nuances to chemotherapy and radiotherapy. This I will not discuss right now. But it is important for me as a surgeon also to see how far this rectal tumor is located from anal verge. Meaning is it involving anal sphincter muscles? I may be able to give this patient the sphincter-preserving surgical resection of rectal cancer. Alternatively, this patient needs abdominoperineal resection and permanent colostomy. Even though the rectal cancer was distal, but it was still just above the sphincter muscles. Patient received the chemotherapy and radiation therapy. We waited six more weeks after completion of radiotherapy and chemotherapy. Surgeons were able to perform a low anterior resection of rectal cancer tumor. This is anal sphincter-preserving procedure. This patient had temporary ileostomy. Because you have to protect you connection between ends of bowel that are sutured together down there in the pelvis. Then you can reverse (stop) that ileostomy later on. There is an important thing to know for the patients with rectal cancer. It is especially relevant for patients with distal rectal cancer. Surgeons can remove majority of the rectum or the whole rectum. After surgery, bowel function postoperatively is not how it used to be before. These patients have more frequent bowel movements. They have what is called “clustering”. Patients go to the bathroom once. Then ten minutes later they have to go again. And ten minutes later they they need to go again. Majority of patients end up adjusting to this reduction in anal sphincter function. And they do okay. But that’s something to keep in mind after rectal cancer surgical operaton. This is what was known as LARS syndrome, Low Anterior Resection Syndrome. Exactly. When you see a patient with rectal cancer, it’s very very important to discuss all the post-operative outcomes that could potentially happen. It is important to discuss LARS syndrome. Because it’s something that the patient should be prepared for after the completion of treatment of rectal cancer. Discussion of patient’s expectations after the treatment is a very important step. Colorectal surgeon and other physicians participating in the treatment plan creation have to discuss all these issues with the patient. Exactly! There’s a lot of things in the rectal cancer treatment to discuss. There is a need for the neoadjuvant chemotherapy and radiotherapy. Sometimes lymph nodes are borderline for cancer. That is why having a tumor board-based discussion of patient’s situation is important. You are meeting with medical oncologist, radiation oncologists, multiple other surgeons. It’s very important in the management of patients with colorectal cancer. But perhaps we can circle back to the initial rectal cancer diagnosis event. Sometimes a person notices the rectal bleeding or some sort of a discomfort. Then it’s very very important to follow up on these symptoms. It is crucial to not pretend that it could be just “hemorrhoids”. That unfortunately often happens. It is important to really make sure that this is not something more serious, as you discussed in this hypothetical rectal cancer diagnosis case. Exactly correct, that’s exactly right! Sometimes the rectal bleeding gets dismissed as a hemorrhoid bleeding, or something more benign. It’s very very important to perform a colonoscopy to rule out colorectal cancer. Dr. Melnitchouk, thank you very much for this conversation. It’s very important for patients and their families around the world to really understand the decision-making process in colon cancer and rectal cancer. It is complicated to find optimal treatment of colorectal cancer. It’s very important to be thorough, and to make sure that the best results of the colon cancer treatment are achieved. Thank you very much! Thank you for talking with me!
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