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1. MULTIDISCIPLINARY TEAM
MEETING
CASES TO BE DISCUSSED:
• NAWAB ALI/48Y/MALE- CASE OF CA RECTUM
• SOBIA/40Y/F- CASE OF ANORECTAL ADENOCARCINOMA
• SHAHEENA/60Y/F- CASE OF MALIGNANT EPITHELIAL
NEOPLASM

2. CASE NO. 1
• CASE SUMMARY:
 Nawab Ali s/o Noor Muhammad, resident of pattoki, is a 48 years old male, and he
presented to us with:
 Abdominal distension- 4 days
 Constipation- 3 days
PAST HISTORY:
• Developed PR bleed and mucus discharge associated with a rectal mass 1 year ago
and diagnosed as a case of Rectal mucinous adenocarcinoma stage IIIc, after it was
excised and histopathology sent.
• Underwent 4 cycles of chemo- last done on 13/10/23
• Radiotherapy done for 12 days (Record N/A)
PAST SURGICAL HISTORY: Underwent palliative diversion colostomy on17-7-2023 due
to intestinal obstruction

3. • EXAMINATION FINDINGS:
 Pallor+
 B/L Inguinal lymphadenopathy
 Abdomen- Laprotomy scar+.
Colostomy.
Skin excoriation present near the inguinal region. (Pressure sores)
Abdomen - tense and distended. Fluid thrill +. BS+
(Stoma started working)
 ECOG STATUS: 3

4. INVESTIGATIONS:
• HISTOPATHOLGY (26/4/2023):
 Poorly differentiated mucinous adenocarcinoma with signet ring cell
features

6. • MRI PELVIS (20/5/23)
T3N2Mx mid and lower rectal tumor with positive
CRM and lymphadenopathy and lymphovascular
invasion.
Circumferential thickening of mid and lower rectum
for a segment of 9 cm, 5 cm away from the anal
verge

8. • COLONOSCOPY (25/5/2023):
Nodular mass palpable on DRE
RECTUM- nodular, ulcerated friable mass extending upto
5cm from anal verge
Level on insertion: Upto hepatic flexure
Rest of the colonic mucosa is normal

10. CT SCANS:
• CT CAP (1/6/2023)
 Circumferential thickening of mid and lower rectum for a segment of 9cm
which is 5cm away from anal verge.
 Enlarged mesorectal and pre-sacral nodes, largest measuring 12mm and
13 mm, respectively.
 No metastatic lesions appreciated

12. o CT CAP (16/11/23)
o Complete obliteration of visualised rectal lumen due to circumferential
thickening of mid and lower rectum.
o Proximal extent is from rectosigmoid junction
o Presacral space obliterated
o Fat planes between rectum and prostate obliterated
o Rest of the visceras are normal
o INTERVAL PROGRESSION OF DISEASE PROCESS AS COMPARED TO
PREVIOUS CT

14. LABS:
• S/CEA: 11.42 (Normal: Smoker- upto 5ng/ml)
• CBC- Hb 10.3, TLC , PLT 453
• RFTS: S/Urea- 48.77, Creatinine- 1.01
• LFTs: S/Bili: 0.3, ALT 11, AST 9, ALP 70
• S/E: Na 34, K 3.94, Cl 99.9
• Coagulation Profile: PT 14, PTT 34

15. MANAGEMENT:
• Therapeutic ascitic tap done- 12/2/2024
• Sample sent for cytology- report expected on
16/2/2024

16. DISCUSSION

17. CASE NO.2
• CASE SUMMARY:
 Sobia w/o Asif, resident of Lahore is a 40 years
old female, presented to us with:
 Pain in anal region- since 6 months associated
with gradual weight loss
 H/O constipation – on and off for 1 month,
relieved with enema

18. EXAMINATION FINDINGS:
• ECOG STATUS: 0
• GPE: Slight pallor
• Abdomen-SNT, BS +
• DRE- Normal anal tone, no fecal or blood staining
Ballooning of rectum
A Polypoidal growth about 4cm from EAS at 7 o’clock position.

19. INVESTIGATIONS

20. Colonoscopy
(30/1/2023)
• Level of insertion- Just above the anal canal
• Nodular, polypoidal, fungating growth almost
completely obstructing the lumen.

22. Histopathology
(30/1/2023):
• Minute focus of poorly differentiated
adenocarcinoma
• Immunohistochemical stain: CDX 2- Positive

24. CT CAP (6/2/2024)
• Long segment, circumferential thickening of
rectosigmoid region with surrounding fat stranding
and measuring upto 10 cm.
• Locoregional lymphadenopathy.
• Fat planes between mass and uterus are indistinct.
However, no signs of frank invasion.
• Rest of the oragns show no metastatic or suspicious
looking lesions.

26. LABS:
• U/S Abdomen- Normal
• Hb 11.7, TLC 6.98, PLT 324
• ESR: 46
• S/E: Normal
• RFT: Normal
• V/M: Negative

27. DISCUSSION

28. CASE NO. 3
• CASE SUMMARY:
• Shaheena w/o Riaz Ahmed, resident of Okara, is 60 years old female who
presented to us with:
• H/O right inguinal swelling- 3-4 months ago
• Followed by I&D- 3 months ago
• Now, she is complaining of profuse bleeding from the unhealed wound
site
• PAST SURGICAL HX: Right knee surgery- Last year in September
Herniorraphy for paraumbilical hernia- 5-6 years ago

29. COMORBIDITIES
• DM +- taking Insulin
• HTN+
• IHD+- on antiplatelet medication, aspirin

30. EXAMINATION FINDINGS:
• Open wound with muscle exposed
• 2x2 cm firm right inguinal lymph node
• 2x2 cm, hard swelling in left inguinal region. No
overlying skin changes. Overlying skin is
pinchable.
• Adherent to underlying structures
• Abdomen- SNT
• Chest- NVB
• B/L breast and axilla- normal.(No lump found)

31. • Before picture of
swelling
• Recent picture of
wound

32. INVESTIGATIONS

33. Histopathology
(9/2/2024)
• The tissue reveals a neoplastic process showing nests
of atypical cells with moderate nuclear
pleomorphism, few showing prominent nucleoli.
• Suggestive of a malignant epithelial neoplasm

35. CT CAP
(12/2/2024)
• Right inguinal region shows a heterogenously enhancing
predominantly solid looking mass lesion
• Multiple enlarged necrotic lymph nodes in B/L inguinal region,
largest 24x25 mm on right and 40x25mm on left side.
• Left kidney shows a simple cortical cyst, measuring 11.4mm.
However, both kidneys secreting contrast normally
• An intra-pulmonary spiculated soft tissue density mass
measuring 22x17mmis noted in apicoposterior segment of
left upper lobe.
• B/L areas of focal pleural thickening
• Rest of the scan is normal.

37. LABS:
• CBC- Hb 9.3, TLC .4, PLT 341
• RFTs: Normal
• LFTs: Normal
• S/E: Normal

38. DISCUSSION