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Abstract: The patient came to the hospital with recurrent stomach pain and black stool. Outpatient colonoscopy was performed and a rectal mass was found, which was diagnosed as high-grade intraepithelial neoplasia of the rectum by pathological biopsy, which is a precancerous lesion or early carcinoma in situ, but after careful analysis of the colonoscopy results and abdominal CT examination, it was found that the rectal mass had invaded adjacent organs, so the diagnosis was revised to invasive rectal cancer with partial high-grade intraepithelial neoplasia. The patient was treated with surgery and followed by chemotherapy after the surgery, and the disease was controlled.
Basic information】Female, 77 years old
Disease Type】Invasive rectal cancer with partial high-grade intraepithelial neoplasia
Hospital】The Second Hospital of Guangzhou Medical University, Panyu Campus
Date of Consultation】February 2022
Treatment plan】Surgery (laparoscopic radical rectal cancer surgery) + drug therapy (oxaliplatin injection + capecitabine tablets)
Treatment cycle】Surgery was performed in 2 weeks of hospitalization, and chemotherapy was started 4 weeks after surgery, 21 days per cycle.
Treatment effect] The patient’s abdominal pain, black stool and other symptoms disappeared and the disease was controlled.
I. Initial consultation
The patient had recurrent abdominal pain for the past six months and thought it was because of poor bowel movement. In the past three months, she had been having black stools intermittently, and her abdominal pain had worsened, and she had diarrhea. Examination of the patient showed that there was pressure pain in the lower abdomen without rebound pain. Several lymph nodes the size of peanut rice could be felt in the groin. Based on the medical history and examination results, the outpatient doctor initially judged that it might be a malignant tumor of the gastrointestinal tract and suggested to admit the patient to the hospital for further examination. However, the patient refused to be hospitalized and requested to undergo colonoscopy in the outpatient clinic first. The colonoscopy revealed a rectal mass, and the pathological biopsy diagnosed high-grade intraepithelial neoplasia. The patient was then admitted to the hospital with the nature of rectal mass to be investigated: precancerous lesion possible.
II. Treatment history
After the patient was admitted to the hospital, the doctor gave a detailed account of the patient’s condition to the patient and family again. Although the pathological examination of colonoscopy was reported as precancerous lesion, considering that the biopsy of colonoscopy has certain limitations and cannot truly reflect the tumor condition, and that high-grade intraepithelial neoplasia and invasive cancer may coexist, in order not to miss the diagnosis, it was suggested to improve the CT enhancement examination of chest and abdomen. The patient’s family adopted the doctor’s suggestion, and the result of CT enhancement scan of chest and abdomen suggested that the rectal tumor involved the posterior wall of uterus. The patient’s final diagnosis was then revised to invasive rectal cancer with partial high-grade intraepithelial neoplasia. After 2 weeks of hospitalization, the patient was treated with laparoscopic radical rectal cancer surgery in surgery, and adjuvant chemotherapy with oxaliplatin injection + capecitabine tablets was administered at 4 weeks after surgery, and each cycle was 21 days.
III. Treatment results
The patient’s surgery was R0 resection (clean tumor resection and no malignant tumor cells were found at the cut edge), and the postoperative wound recovery was good. The patient’s abdominal pain, black stool, diarrhea and other symptoms disappeared, and the blood carcinoembryonic antigen concentration decreased to normal level. The patient is able to take care of himself completely, and his behavior ability score (KPS score) can reach 80. Patients are fully aware of and can fully accept their condition psychologically, and can also actively cooperate with the doctor to complete the follow-up treatment program every 21 days in one cycle.
IV. Notes
We are glad that the patient’s symptoms have improved after treatment, but since the patient is currently in the adjuvant chemotherapy period, the following precautions should be taken after discharge.
1. Must comply with medical advice and go to hospital for adjuvant chemotherapy regularly.
2. Since rectal cancer is a malignant tumor of the gastrointestinal tract, and surgery and chemotherapy can seriously damage the digestive function, the diet must be hygienic and clean, food should be cooked, and avoid raw, cold, greasy or overnight food. At the same time, advocate eating less and more meals and a balanced diet.
3. If you have fever, diarrhea and other uncomfortable symptoms, you must communicate with the doctor in charge and return to the hospital in time.
V. Personal insight
Although pathological biopsy is the gold standard for malignant tumor diagnosis, other than surgical biopsy, gastroscopic biopsy, general puncture biopsy and other methods have limitations and are likely to have false negative results, therefore, sometimes the diagnosis of tumor needs a combination of multiple methods, such as CT, MRI and other imaging examinations, which can make up for some shortcomings of pathological biopsy and improve the diagnostic accuracy. In addition, the accuracy of diagnosis is very important before formulating the treatment plan of tumor. Different diagnosis and treatment methods may be very different, therefore, patients must be convinced to undergo multiple examinations, and only when all the examination results point to the same diagnosis is the most reliable.