Ung thư trực tràng giai đoạn T1

CT chest, abdomen, and pelvis.

Dynamically enhanced axial images have been obtained through the chest, abdomen, and pelvis following intravenous and oral contrast.

Within the chest, a 5mm nodule abuts the oblique fissure in the anterior aspect of the left lower lobe. Minimal atelectasis is seen in the base of the left lingula lobe.

No pleural or pericardial effusion.

No mediastinal, hilar, axillary, or retrocrural lymphadenopathy.

Within the abdomen and pelvis, the liver is of mildly decreased attenuation suggesting fatty infiltration. No focal liver lesion is seen.

The spleen, pancreas and adrenal glands have normal appearance.

Small bilateral low-attenuation renal lesions have CT features consistent with cysts. The largest lies in the mid pole of the right kidney measuring approximately 15 mm, with exophytic 13 mm cyst in the inferior pole of the left kidney. No hydronephrosis.

Multiple small and borderline in size and left para-aortic lymph nodes are demonstrated. None of which however has significantly enlarged on size criteria. There is no mesenteric or inguinal lymphadenopathy. No free fluid or focal collection is seen within the abdomen or pelvis.

Colonic diverticular disease is demonstrated. No evidence of bowel obstruction. The known rectal lesion is not clearly identified. The surrounding perirectal fat is preserved.

No suspicious bony lesion.

Conclusion:

A 5 mm left lower lobe pulmonary nodule is non-specific. Correlation, with an early follow-up study in 3 months time or comparison with any prior imaging is suggested.

There is no definite evidence of metastatic disease within the chest, abdomen or pelvis.

Gross pathological specimen showing the lesion in the rectum.

Multiplanar non-contrast small field of view MR imaging of the pelvis has been obtained. The high rectal tumor lies ~ 10 cm above the anal verge and 6 cm above the anorectal junction. The superior border lies below the peritoneal reflection. It measures ~ 2 cm in length and extends from 4 to 7 o'clock (clockwise). Tumor does not breach the muscularis propria and does not extend into the mesorectal fat.

The colorectal resection margin (CRM) is not at risk. There is no evidence of extramural venous invasion. The peritoneal reflection is not involved. There are no suspicious mesorectal lymph nodes. There are no pelvic side wall lymph nodes suspected of tumor involvement. There are no bone metastases evident. There is no extension into the presacral fat.

Right hip subchondral cysts.

The other polyps described in the requisition are not identified with certainty on this examination.

Conclusion: This is a high T1 (or early T2) N0 MX rectal tumor, 11.2 cm from the anal verge.

Clinical notes:

rectal cancer – ultra-low anterior resection

distal donut

Macroscopic description:

"Rectum" – A 275 mm-long anterior resection with a diameter of 20–30 mm. The anterior peritoneal reflection is 30 mm from the distal margin. The posterior perirectal fat is non-peritonealised from 170 mm from the distal margin. There is up to 100 mm of mesocolon, up to 29 mm of posterior perirectal fat, and up to 20 mm of anterior perirectal fat.

Within the rectum, at the level of the anterior peritoneal reflection (22 mm from the distal margin and 212 mm from the proximal margin), there is a pale brown, smooth, discoid tumor measuring 20 × 13 × 9 mm. The tumor causes puckering of the underlying mucosa but appears to be limited to the mucosa and submucosa, with an intact muscularis propria. The tumor is submitted in full.

The tumor is located on the posterior wall of the rectum, where there is up to 19 mm of posterior perirectal fat (the tumor is 30 mm from the posterior non-peritonealised surface).

The distal 120 mm of the rectum shows diffuse polypoid lesions measuring 2–5 mm in maximum dimension (approximately 45 in total). The polyps are present at the distal margin and 155 mm from the proximal margin.

The sigmoid mucosa contains a single polyp measuring 4 mm in diameter and is otherwise shiny and unremarkable. Representative sections of the largest polyps are submitted.

Inking notation:

proximal margin – black

distal margin – black

anterior circumferential margin – blue

posterior circumferential margin – green

Block designation:

1A – proximal margin

1B – distal margin

1C–1E – rectal tumor (submitted in full)

1F – largest rectal polyp (bisected)

1G – four rectal polyps

1H – seven whole nodes

1I – six whole nodes

P9

"Distal donut" – A mucosal donut measuring 22 × 10 mm with a length of 9 mm. Staples removed. Longitudinal sections of the mucosa submitted.

P1 (CH)

Microscopic description:

The sections show an invasive, moderately differentiated adenocarcinoma arising in a tubulovillous adenoma with high-grade dysplasia, involving the rectal mucosa. The tumor extends into the submucosa but does not appear to involve the muscularis propria. No evidence of vascular, lymphatic, or perineural invasion is seen.

Of the five other polypoid lesions sampled, one is a sessile serrated adenoma, and the remaining four are hyperplastic polyps. No evidence of metastatic tumor is seen in any of the 10 lymph nodes. All resection margins are clear of the tumor.

The section shows rectal mucosa and wall. A small hyperplastic polyp is noted within the rectal mucosa. No evidence of invasive tumor is seen.

Diagnosis:

Rectum:

site: rectum

type: moderately differentiated adenocarcinoma arising in a tubulovillous adenoma with high-grade dysplasia

size: 20 mm in maximum dimension

local invasion: tumor extends through the muscularis mucosae into the submucosa; no evidence of involvement of the muscularis propria

lymphovascular invasion: absent

perineural invasion: absent

resection margins: proximal, distal, and radial margins are all clear of the tumor

lymph nodes: no evidence of metastatic tumor in any of the 10 lymph nodes

additional pathology: five sampled polypoid lesions:

1 × sessile serrated adenoma

4 × hyperplastic polyps

AJCC (7th edition) stage: I (T1 N0 MX)

Identification and sectioning of further lymph nodes pending Carnoy's treatment of perirectal fat.

Distal donut:

Rectal mucosa with a small hyperplastic polyp; no evidence of invasive tumor seen.