A 68-year-old woman is evaluated because of rectal bleeding that began recently and a sense of fullness in the rectum. Flexible sigmoidoscopy shows a mass 11 cm from the anus, and biopsy reveals adenocarcinoma. The patient is referred to a colorectal surgeon, and a low anterior resection is performed. The primary tumor, a 4-cm moderately differentiated adenocarcinoma, penetrates the bowel wall. No lymph nodes are involved. What is the most appropriate next step in this patient‟s management?

Related MCQs

• A 72-year-old man is evaluated because of constipation, abdominal pain, and distention that have worsened over the past week. Two years ago, he was diagnosed with stage III rectal cancer (primary tumor and renal involvement) and underwent low anterior resection. Chemotherapy with 5-fluorouracil and leucovorin followed, and pelvic radiation was given with concurrent infusion of 5-fluorouracil. He has been having regular bowel movements, and results of his most recent colonoscopy (1 year ago) were unremarkable. On physical examination, his pulse rate is 100/min. He has orthostatic hypotension, a slightly distended abdomen with hyperactive bowel sounds, and some guarding to deep palpation in the left lower quadrant. Plain radiograph of the abdomen shows distended loops of small bowel, with no stool in the distal colon or rectum. The patient is hospitalized for bowel rest and intravenous hydration. What is the next step in this patient‟s management?
• A 57-year-old man is found to have a rectal mass 3 cm from the anal verge on digital rectal examination. Subsequent colonoscopy and biopsy confirm rectal adenocarcinoma. EUS examination demonstrates penetration of the tumor into, but not through, the muscularis propria, but shows significant perirectal lymph nodes. CT scan of chest/abdomen/pelvis demonstrates no metastases. The patient is staged as T2N1M0. What procedure should be attempted to remove the primary lesion in this patient?
• A 63-year-old man is evaluated because of a several-month history of increasing fatigue and some vague upper abdominal discomfort. His medical history includes gastroesophageal reflux disease, coronary artery disease, and clinical depression, all of which are well controlled with medications. The patient has been working full time. On physical examination, he has mild hepatomegaly. His hemoglobin is 12.2 g/dL, serum alkaline phosphatase level 280 U/L, and serum aspartate aminotransferase level 65 U/L. CT scan of the abdomen and pelvis shows multiple hepatic lesions ranging in size from 1 cm to 4 cm; mesenteric, para-aortic, and paracaval lymphadenopathy, and a colonic mass at the splenic flexure. Colonoscopy reveals a nonobstructing, non bleeding lesion; biopsy shows it to be poorly differentiated adenocarcinoma. Fine- needle aspiration of one of the liver lesions confirms the presence of malignant cells consistent with a primary colon cancer. What is the most appropriate next step in
• For previous patients, after the appropriate evaluation, the patient undergoes surgery. No intraoperative evidence of metastases is identified. Postoperatively, the pathology report reveals that the tumor is an adenocarcinoma invading into the pericolonic fat, with 2 involved lymph nodes. After the patient recovers from surgery, which of the following is the most appropriate next step in his management?
• A 59-year-old man was referred because of a change in bowel habit. He had noticed no alteration in stool calibre, gastrointestinal bleeding or unintended weight loss. There was no family history of colonic polyps or gastrointestinal malignancy. Physical examination was normal. A rectal examination revealed no masses. A sigmoidoscopy revealed a 4-mm polyp in the mid-rectum, which was removed with forceps, and histology revealed a tubular adenoma. What is the most appropriate next step in management?
• A 61-year-old man with a 120-pack-year smoking history is evaluated for a persistent and worsening cough and found to have a 3-cm mass in the right upper lobe on chest radiography. CT-directed needle biopsy is positive for squamous cell carcinoma. CT scans of the abdomen and pelvis, bone scan, and MRI of the head are negative for metastatic disease. Positron emission tomography scan shows uptake only in the right upper lobe mass, and pulmonary function tests indicate that the patient has adequate pulmonary reserve to undergo resection. The patient undergoes a right upper lobectomy. All margins are clear, and all peribronchial lymph nodes are negative for tumor within the resected specimen. What is the most reasonable adjuvant therapy for this patient?
• A 70-year-old man with an 80-pack-year smoking history is evaluated because of a chronic cough of 6 months duration. Chest radiograph shows a 3-cm mass in the left perihilar region, and bronchoscopic biopsy confirms poorly differentiated adenocarcinoma. There are no significant findings on physical examination, and all blood studies are normal. Bone scan and CT scan of the head are normal, but CT scans of the chest and abdomen show the mass and two 1-cm nodules in the right lobe of the liver. Intravenous contrast perfusion of the two nodules during the CT scan is not suspicious for hemangioma. Positron emission tomography scan shows distinct uptake in the left perihilar mass but only faint focal activity in the right lobe of the liver.Pulmonary function tests show mild obstructive disease. What is the best next step in this patient‟s management?
• A 29-year-old man was diagnosed with stage II (that is, spread from the primary tumor to retroperitoneal lymph nodes) nonseminomatous germ cell tumor 1 year ago. Treatment included orchiectomy and retroperitoneal lymph node dissection. He now presents with an elevated level of β-human chorionic gonadotropin hormone and multiple pulmonary lesions ranging in size from 0.61 to 3.22 cm. Needle biopsy specimen of the largest lesion reveals a germ cell tumor consistent with the initial diagnosis. He is asymptomatic. What is the best treatment for this patient?
• A 78-year-old woman with coronary artery disease and severe chronic obstructive pulmonary disease is admitted to the hospital with painless jaundice. CT scan reveals the presence of multiple lesions in the liver, suggestive of metastases, and a nearly obstructing upper rectal mass. Colonoscopy demonstrates a large, ulcerated tumor in the proximal rectum and a residual lumen of less than 1 cm in diameter. While in the hospital, the patient develops a large bowel obstruction. What is the best treatment modality for this patient?
• A 68-year-old man presents to his primary care physician for a routine physical examination. The patient‟s medical history is significant for hypertension. The patient is found to have guaiac-positive stools and is subsequently referred for colonoscopy. Colonoscopy reveals a “golf ball”-size, near-obstructing tumor in the descending colon, not admitting the scope. The biopsy is positive for adenocarcinoma of the colon. Which of the following is the next step in the management of this patient?