SEER Training Modules

Case 3

Primary Site

Rectosigmoid junction

Physical Exam

03/15/XX

General: Essentially negative. Pt admitted because of hemoccult positive stools.
Rectal exam: Palpable lesion 10-11 cm from anal verge.

X-Rays & Scans

03/15/XX

CT abdomen: negative.
CT pelvis: abnormal thickening c/w rectal carcinoma.

Scopes

03/17/XX

Colonoscopy: 6 cm obstructive lesion 10 cm from anal verge

Laboratory

03/15/XX

CEA: 8.3 (elevated)

Operative Findings

See colonoscopy.

Pathological Reports

03/17/XX

Biopsy, rectal mass: infiltrating adenoca arising in mixed adenomatous villous adenoma.

06/20/XX

Rectosigmoid colon: previous biopsy site, moderately differentiated infiltrating adenocarcinoma showing invasion beyond muscularis propria. 0/8 LNs positive, margins free, tumor size 3.5 cm.

Treatment

03/31/XX

Chemotherapy: 5FU concurrent with radiation preoperatively followed by four rounds of FOLFOX postoperatively.

03/31/XX

Radiation: Began 4500 cGy to pelvis, 180 cGy in 25 treatments with 18MV photons.

06/20/XX

Surgery: Low anterior resection with colorectal anastomosis, incidental appendectomy and regional lymph node dissection.