Case senerio
Completion requirements
A 58-year-old man presents with a 4-month history of hematochezia, tenesmus, incomplete evacuation, and weight loss. Digital rectal examination (DRE) reveals a semi-circumferential mass located 4 cm from the anal verge.
Biopsy confirms moderately differentiated rectal adenocarcinoma. Haemoglobin (Hb) is 10.2 g/dL and carcinoembryonic antigen (CEA) is 24.5 ng/mL.
High-resolution pelvic magnetic resonance imaging (MRI) shows:
- Clinical tumour stage T3c, nodal stage N2a, and no distant metastasis (M0)
- Circumferential resection margin (CRM) threatened, with tumour within 1 mm of the mesorectal fascia (MRF)
- Positive extramural vascular invasion (EMVI)
Molecular testing shows proficient mismatch repair (pMMR), microsatellite stable (MSS), and KRAS, NRAS, and BRAF wild-type status.
Fellow Discussion Questions
- Staging and Risk Stratification
- What is the role of high-resolution pelvic MRI?
- What is the significance of threatened CRM/MRF and positive EMVI?
- Neoadjuvant Treatment
- Total neoadjuvant therapy (TNT) versus conventional chemoradiotherapy followed by surgery.
- Short-course radiotherapy (RT) (5 × 5 Gy) versus long-course chemoradiotherapy.
- Impact on pathological complete response (pCR), distant disease control, and organ preservation.
- Surgery and Organ Preservation
- Is sphincter preservation feasible for a tumour 4 cm from the anal verge?
- Low anterior resection (LAR) or abdominoperineal resection (APR)?
- When is a Watch-and-Wait strategy appropriate after a clinical complete response (cCR)?
- Resource-Constrained Setting
- How can short-course RT or TNT reduce treatment time, cost, and logistical barriers?
- What practical adaptations are needed in an out-of-pocket healthcare system?
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