Second Year Surgery Case Presentation

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  • Second Year Surgery Case Presentation

    1. 1. CASE 13 Surgery Presentation
    2. 2. CASE PRESENTATION <ul><li>A resection was performed on for cure in a 51 year old man who was found to have Stage II colon cancer. </li></ul><ul><li>His initial CEA was low </li></ul><ul><li>No recurrent masses were found in a repeat colonoscopy at one year and two years. </li></ul><ul><li>CEA at one year was still low; however, at two years is found to be elevated several fold. </li></ul>
    3. 3. DIFFERENTIAL DIAGNOSIS <ul><li>Colorectal cancer </li></ul><ul><li>Liver cancer </li></ul><ul><li>Prostate cancer </li></ul><ul><li>Stomach cancer </li></ul><ul><li>Pancreatic cancer </li></ul><ul><li>Lung cancer </li></ul><ul><li>Breast cancer </li></ul>Citation: Schwartz’s Principles of Surgery, 8 th edition, 2005
    4. 4. DIFFERENTIAL DIAGNOSIS (CONT.) <ul><li>Diverticulitis </li></ul><ul><li>Peptic Ulcer Disease </li></ul><ul><li>Bronchitis </li></ul><ul><li>Liver Abscess </li></ul><ul><li>Pancreatitis </li></ul><ul><li>Cirrhosis </li></ul>Citation: Schwartz’s Principles of Surgery, 8 th edition, 2005
    5. 5. ADDITIONAL TESTS <ul><li>Detailed H&P </li></ul><ul><li>Abdominal CT </li></ul><ul><li>PET scan </li></ul><ul><li>CBC to evaluate infection </li></ul><ul><li>CMP to evaluate liver enzymes </li></ul><ul><li>Lipase and amylase to evaluate pancreatic function </li></ul><ul><li>PSA levels </li></ul><ul><li>Rectal ultrasound </li></ul>
    6. 6. POSSIBLE SCENARIOS Scenario Management Large extraluminal mass in the abdomen CT with oral and IV contrast to determine if fluid-filled. If abscess, FNA and percutaneous CT-guided catheter drainage If not, biopsy. No mass is found Further investigate non-malignant causes of CEA increase Solitary 2 cm mass is found in the right lobe of the liver Surgical resection Widely disseminated diffuse mass effect is seen throughout the abdomen and pelvis First line therapy: 5-fluorouracil and leucovorin. Second line: irinotecan. Surgery for palliative care in the case of obstructions and adhesions, or diagnostic/staging purposes.
    7. 7. PROGNOSIS <ul><li>What would we tell the patient about his prognosis in the case of a solitary 2 cm mass found in the right lobe of the liver? </li></ul><ul><li>Surgery is limited to unilobar disease without extrahepatic disease. </li></ul><ul><ul><li>20 – 30% 5-year survival </li></ul></ul><ul><ul><li>< 6% operative mortality </li></ul></ul><ul><li>Resection of liver metastases may be beneficial in selected patients with colorectal or gastric carcinoma </li></ul>(J Clin Oncol 1997 Mar;15;938, Am J Gastroenterol 1997 Mar;92;490 in J Watch 1997 Apr 15;17(8);65)
    8. 8. PROGNOSIS (CONT) <ul><li>What would we tell the patient about his prognosis in the case of a solitary 2 cm mass found in the right lobe of the liver? </li></ul><ul><li>If unresectable, treated with regional chemotherapy (5-florouracil) through the hepatic artery. </li></ul><ul><ul><li>(Surgery: Scientific Principles and Practice 3 rd edition, ph 1128) </li></ul></ul><ul><li>If no treatment at all, mean survival time is 12 months. </li></ul><ul><ul><li>( Ugeskr Laeger. 1989 Apr 24;151(17):1045-8. PMID: 2660370) </li></ul></ul>

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