View source for WBR0826

 {{WBRQuestion
|QuestionAuthor=Vendhan Ramanujam
|ExamType=USMLE Step 3
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|Prompt=A 38 years old Caucasian male is admitted following complaints for 2 months history of diarrhea.  It is associated with abdominal pain, progressing from the upper to the lower abdomen, and weight loss.  The patient has no previous history of similar illness or surgery. He denies alcohol or tobacco use.  His vital signs are heart rate 82 beats/min, respiratory rate 16/minute, blood pressure 110/70 mm Hg and oral temperature 37.2 C.  Physical examination revealed a distended abdomen with increased bowel sounds and a palpable mass at the left lower quadrant of the abdomen.  Routine laboratory tests revealed no alterations in the principal biochemical parameters, except for the levels of the following tumoral markers:<BR>
<BR>
CA 19-9 = 85.7 U/ml (normal value: up to 37 U/ml)<BR> 
CEA = 13.7 ng/ml (normal value: up to 3 ng/ml)<BR> 
CA 50 = 51.3 U/ml (normal value: up to 19 U/ml)<BR>
<BR>
Abdominal USG revealed a mass of 9 × 5 cm of mixed echogenicity in the proximity of the sigmoid colon with some hypoechoic lymph nodes of increased volume in the adipose adjacent tissue.  It was followed by colonscopy with biopsy, where a polypoid vegetating mass, involving the 2/3 of the intestinal circumference was found in the caecum.  Histopathological examination of the mass showed microscopic aspects of adenocarcinoma.  The abdominal CT with intravenous contrast showed the mass with an increase in the volume of mesenteric lymph nodes.  What will be the line of management in this patient?
 
|Explanation=The patient has a stage 3 [[colon cancer]] that is found in the cecum.  The line of treatment for this patient will be surgery with chemotherapy and a post operative follow up that includes<BR>
<BR> 
1.	[[Carcinoembryonic antigen]] (CEA) monitoring every 3 months until 3 years<BR> 
2.	[[Colonoscopy]] at 1 year, 3 years and 5 years<BR> 
3.	Abdomen and chest CT every year until 3 years<BR>   

'''Educational Objective:'''
The following is the line of management of different stages of colon cancer

<table border="1" cellspacing="0" cellpadding="0" > 
<tr>
<td valign="top" bgcolor="#cccccc" width=40 align="center" ><p>'''0'''</p></td>
<td valign="top" ><p>CA in situ; Involving mucosa alone</p></td>
<td valign="top" ><p>End polypectomy ± Radical surgery</p></td>
</tr>

<tr>
<td valign="top" bgcolor="#cccccc" width=40 align="center" ><p>'''1'''</p></td>
<td valign="top" ><p>Involving mucosa, sub mucosa and muscularis propria </p></td>
<td valign="top" ><p>Surgery alone</p></td>
</tr>

<tr>
<td valign="top" bgcolor="#cccccc" width=40 align="center" ><p>'''2'''</p></td>
<td valign="top" ><p>Involving mucosa, sub mucosa, muscularis propria, subserosa and even direct infiltration of adjacent structures</p></td>
<td valign="top" ><p>Surgery + Chemotherapy</p></td>
</tr>

<tr>
<td valign="top" bgcolor="#cccccc" width=40 align="center" ><p>'''3'''</p></td>
<td valign="top" ><p>Lymph node involvement</p></td>
<td valign="top" ><p>Surgery + Chemotherapy</p></td>
</tr>

<tr>
<td valign="top" bgcolor="#cccccc" width=40 align="center" ><p>'''4'''</p></td>
<td valign="top" ><p>Distant metastasis</p></td>
<td valign="top" ><p>Surgery (for limited metastasis) + Chemotherapy </p></td>
</tr>

</table>


Stage 2 and 3 includes post operative follow up:<BR>
1.	CEA monitoring every 3 months until 3 years<BR>
2.	Colonoscopy at 1 year, 3 years and 5 years<BR>
3.	Abdomen and chest CT every year until 3 years<BR>  


|AnswerA=End polypectomy with radical surgery


|AnswerAExp='''Incorrect'''-[[Polypectomy]] with or without radical surgery is for stage 0 colon cancer.
|AnswerB=End polypectomy without radical surgery
|AnswerBExp='''Incorrect'''-Polypectomy with or without radical surgery is for stage 0 colon cancer.
|AnswerC=Right colectomy with ileo-colic anastomosis
|AnswerCExp='''Incorrect'''-Surgery alone is for stage 1 colon cancer.
|AnswerD=Right [[colectomy]] with ileo-colic anastomosis, chemotherapy and post operative follow up
|AnswerDExp='''Correct'''-The line of treatment for this stage 3 patient will be surgery with chemotherapy and a post operative follow up that includes<BR>
<BR> 
1.	CEA monitoring every 3 months until 3 years<BR> 
2.	Colonoscopy at 1 year, 3 years and 5 years<BR> 
3.	Abdomen and chest CT every year until 3 years<BR>
|AnswerE=Right colectomy with a ileo-colic anastomosis and chemotherapy alone without post operative follow up
|AnswerEExp='''Incorrect'''-Right colectomy with a ileo-colic anastomosis and chemotherapy alone without a post operative follow up is not the appropriate line of management for colon cancer, since they have a higher probability for recurrence.
|RightAnswer=D
|WBRKeyword=Colorectal cancer, Polypectomy
|Approved=Yes
}}