A 70-year-old white male presented with a history of stage III colon cancer and recent abdominal pain. Imaging showed no evidence of recurrent or metastatic disease. Due to a rising CEA level, the physician recommended a follow up PET scan, which ultimately revealed a focal area of uptake indicating cancer that was initially missed on the first PET scan. This case highlights the difficulty of distinguishing pathological from physiological uptake on PET alone without comparison to recent CT images.

1. Case study
Eman youssif

2. Clinical History
HISTORY OF PRESENT ILLNESS:
The patient is a 70 year old white male status post resection of a stage III adenocarcinoma of the
sigmoid colon,
approximately 10 days since his surgery. His surgery went well. He has been eating well and tolerating
food well, and moving
his bowels with no problems. Approximately two weeks prior to surgery he also had significant
coronary artery disease and
underwent a CABG at that time, and has done well from that surgery as well.
His pathology showed a highly aggressive T3, N2 adenocarcinoma of the colon, stage III with
angiolymphatic invasion. 6 of 11
lymph nodes were positive The margins on the tumor were negative, and I believe given the fact that
he is a relatively young
man and in good health that he should be considered for an aggressive adjuvant chemotherapy
approach.
He underwent adjuvant 5FU leucovorin chemotherapy for a Stage III, T3, N2 colon cancer. The patient
has been well until
recently when he had some vague abdominal pain. A flexible sigmoidoscopy was negative. An
ultrasound of the liver showed
calcifications leading to the CT scan which is also negative.
FAMILY HISTORY:
Positive for coronary artery disease. Mother died of cancer of unknown etiology and had one son who
died of lymphoma at
age 46.
REVIEW OF SYSTEMS:
The patient denies myocardial infarction, stroke, pancreatitis, or peptic ulcer disease.

3. PHYSICAL EXAMINATION:
GENERAL: Alert white male in no acute distress.
SKIN: Not jaundiced. Positive for a few spider angiomata over upper torso. Chest has a healed sternotomy.
NECK: No carotid bruits in the neck.
HEART: Regular rate and rhythm.
LUNGS: Clear.
ABDOMEN: There is a healed midline scar. It is soft and nontender. There is no palpable mass. No ascites.
EXTREMITIES: No edema.
PRIOR IMAGING RESULTS:
I currently have not reviewed his CT as the images are not available.

4. ORIGINAL NUCLEAR MEDICINE PET SCAN
STATED REASON FOR REQUEST:
Colorectal cancer.
RADIOPHARMACEUTICAL ADMINISTERED:
11.05mCi F-18 FDG IV.
TECHNIQUE:
Emission and transmission scanning from the neck through the pelvis was obtained approximately one hour
post-injection.
Images were reconstructed with and without attenuation correction. Blood glucose level was 175mg/dl.
Comparison is made to a prior CT of the abdomen and pelvis from 8- 9-01. FINDINGS:
There are no areas of increased uptake to suggest recurrent or metastatic disease. However, sensitivity of this
study is
decreased due to the patient's hyperglycemia.
IMPRESSION:
No evidence of recurrent or metastatic disease, as above.
Diagnosis
No evidence of recurrent or metastatic disease, as above.
ASSESSMENT AND PLAN:
A 70 year old white male with a history of Stage III colon cancer, now with a rising CEA level and negative CT
scan. Given
that PET scan is negative I think we should rec

5. Discussion
One of the pitfalls of PET imaging alone, particularly when a recent CT scan is not available, is trying to
distinguish pathologic
uptake of FDG from physiologic uptake. When linear bowel uptake is present, if there is a small lesion adjacent
to it, it can be
very difficult to differentiate it from the background bowel, as in this case.
This patient's initial scan was interpreted as normal with only linear physiologic bowel uptake. Because his CEA
level
continued to rise, a short term follow up exam was performed about 2 months later. On the follow up exam, a
focal area of
FDG uptake is now visible away from adjacent linear physiologic bowel uptake. In retrospect, this lesion was
present on the
initial PET study, but because there was no recent CT available for comparison and the lesion's location was
adjacent to
bowel, it was difficult prospectively to resolve the two structures.
With PET•CT because you can inspect all areas of FDG uptake with an accurately co-registered CT and examine
the fusion
images, differentiation of physiologic from pathologic uptake becomes much, much easier.
Data courtesy of Dr. Todd Blodgett, University of Pittsburgh Medical Center
* Any of the protocols presented herein are for informational purposes and are not meant to substitute for
clinician judgment in how best to
use any medical devices. It is the clinician that makes all diagnostic determinations based upon education,
learning and experience

6. References:
http://ri-pet.
org/archives/colorectal_cancer/Colorectal-Full-
Case-Study-1.pdf

7. case2
44 year old male accountant married with two
children attends your GP surgery. He presents
with a
marked change in bowel habit over 1 month. He
is not
a frequent attendee at the practice and in fact
has not
been seen for 4 years. He is a non smoker and
drinks
approximately 25-30 units’ alcohol per week.

8. Persistency of symptoms
• PR bleeding
• Tenesmus
• Weight loss
• Abdominal pain
• Anorexia
• Nausea and vomiting
• Recent foreign travel
• Family history of bowel cancer

9. Abdominal examination-palpable mass or liver
• Rectal examination –palpable mass
• Systemic review ?Anaemia or jaundice

10. He reports feeling more tired at work but
no other
symptoms and you find no other
abnormalities on
examination.
• He also gives a family history of colon
cancer , his
father had colon cancer at the age of 55
and is alive
and well now.

11. Colorectal cancer
• Inflammatory bowel disease
• Coeliac disease
• Infective (if foreign travel )

12. He is subsequently seen in the 2 week rule colorectal clinic and
goes on to have a colonoscopy after a normal rigid
sigmoidoscopy. He is told after the procedure that he has a
suspicious mass that is likely to be cancer and that a needle
biopsy test is now awaited to confirm this diagnosis and a CT
scan is being provisionally booked.
The patient is now very apprehensive, he has been on the
internet and spoken to a relative who recently had
chemotherapy for bowel cancer and has these questions. How
would you answer them?

13. Q1. What histological types of cancer are there in the
bowel?
• Colon –adenocarcinoma
• Rectum –adenocarcinoma
• Anus –squamous cell cancer

14. Q3. Are his children now likely to get colon cancer?
Unlikely
• Based on the family history of a first degree relative
from another generation
• Patients tumour will be tested by IHC for MMR to
exclude HNPCC

15. Q4. Is he likely to be cured?
• Dukes A -90% 5yr cancer free survival
• Dukes B -80% 5yr cancer free survival
• Dukes C -50 % 5yr cancer free survival (surgery alone )
-70% 5yr cancer free survival (+chemotherapy)

16. Q5. Is he definitely going to need chemotherapy?
• Dukes A – not required
• Dukes B –absolute survival benefit of chemotherapy ~3.6%
discuss with oncologist
• Dukes C –benefit established
~15 -20% risk reduction in cancer recurrence
• Recommended in all Dukes C cancer patients of adequate fitness

17. Q6. Will he be able to have more children after
chemotherapy?
• More than likely but cant guarantee
• Chemotherapy agents utilised in this setting do not
commonly cause infertility
• Sperm cryopreservation or ova harvesting offered to
patients after discussion

18. Diagnosis
• Dukes C cancer distal transverse colon
• L hemicolectomy –Laparoscopic , no complications ,
in patient stay 3 days
• Based on pathology
• Adjuvant IV chemotherapy FOLFOX administered
for 24 weeks

19. Part three – Management in primary care
8 months later you see him again and he has just
completed chemotherapy. He wants to return to work
full time but he has peripheral neuropathy in his feet
can’t ride his bicycle. He drops things on occasions and
struggles with doing the buttons on his shirt. He is still
tired, his concentration is slow and his attention span
is very short. His bowels are slightly erratic and his
appetite is poor due to lack of taste.

20. Q1. Which symptoms are likely to go and when and
which may persist?
SHORT TERM
• Concentration usually recovers within 2months
• Tiredness usually recovers within 2-3 months
• Appetite and taste returns within 8 weeks
• Bowels may take 2 -3 months and can be affected by diet
following bowel surgery

21. Colon cancer patients
Trials ongoing for adjuvant aspirin post surgery for colorectal cancer
Patients with family history of colon cancer
Cancer registry data suggests benefit for use of aspirin in reducing
cancer specific and overall mortality
Primary Prevention
Data from vascular studies suggests benefit but confounding factors
24 Women's cancers Breast cancer introduction25 The Royal Marsden
He remains worried about recurrence now that he is
not on active treatment and asks about his chances if
the cancer comes back in the liver.
Women'

22. Reference:
http://www.royalmarsden.nhs.uk/SiteC
ollectionDocuments/gp-education/
20121011/colorectal-cancer-case-
study.pdf

23. case3
Chief Complaint: 65-year-old woman with a loss of appetite, abdominal cramps, constipation, and
blood in her stool.
History: Delores Murphy, a 65-year-old white female, was in good health until about 6 weeks ago,
when she noted occasional cramps in the left lower quadrant of the abdomen associated with
constipation. The episodes of cramping last about 30 minutes each and are most severe in the hour
following her meals. She has taken laxatives which have partially relieved her symptoms, but she
has had a decreased appetite and 12-pound weight loss over the past four weeks. In addition, she
has become increasingly fatigued over this period. When questioned about her bowel habits, she
reported bright red blood in her stools and a smaller caliber (i.e. diameter) of stool over the past
two weeks.

24. case4
a case study in colorectal
cancer screening.

25. OBJECTIVES:
To elicit community preferences for colorectal cancer (CRC) screening by faecal occult blood test (FOBT) using
discrete choice modeling (DCM). To provide policymakers with information that would assist them in designing
the future national screening program.
METHODS:
301 participants in central Sydney, aged 50 to 70 years, at 'average' risk of CRC, participated in a face-to-face
discrete choice study interview in which screening profiles were posed to derive estimates for preferences for
CRC FOBT screening.
RESULTS:
Three characteristics were varied in our screening profiles, namely: benefit (CRC deaths prevented); potential
harm (false positive induced colonoscopy); and notification policy (of test result). Ninety-four respondents
(32%) did not trade off CRC deaths prevented for any reduction in harms. Twelve per cent always chose no
screening. The remaining 56% traded benefits and harms. These latter respondents (n = 164) were willing to
accept 853 (false positive induced) colonoscopies for one CRC death prevented.
CONCLUSIONS:
While survival was all that mattered for just over one-third of the sample and 12% would choose no screening,
the remaining individuals were prepared to trade CRC deaths prevented against other characteristics. CRC
screening will not receive unqualified community support, irrespective of harms.
IMPLICATIONS:
In any future national CRC screening program, consideration of these insights about community assessment of
benefits, harms, costs and other characteristics of CRC screening is warranted.

26. reference
http://www.ncbi.nlm.nih.gov/pubme
d/14705310

27. thanku