MODULE 4

Abdominal Mass A 56-year old male farmer from Laguna is admitted because of an abdominal mass. History of the Present Illness: 5 months PTA, he noticed gradual abdominal enlargement and a palpable abdominal mass. This was accompanied by a feeling of abdominal fullness and early satiety. He also noticed weight loss of around 10 lbs. ROS: Unremarkable Personal History: The patient smokes around 10-15 sticks of cigarettes a day for the past 20 years. He drinks 2-3 bottles of beer every day. He has had no previous hospitalization. Physical Examination: BP 150/90; PR 78 bpm; RR 15 cpm; Temp 36.7; Weight: 130 lbs; Height: 5 ft 7 in HEENT - pinkish palpebral conjunctivae; no palpable cervical lymph nodes Heart and Lungs: essentially unremarkable Abdomen: palpable mass at the periumbilical area with a smooth surface, non-tender, with illdefined borders, measuring around 10 cm at its widest diameter. It is also not ballotable and does not move with respiration. Bowel sounds are normal. Rectal exam: Admission Work-ups: Blood tests Hemoglobin 130, Hematocrit 40, WBC 8000/cumm; PMN 70, lymphocytes 25, eosinophils 5 Total Protein 75, Albumin 55, Globulin 20 PT: 13 sec, Control 12 sec; APTT: 40 sec Chest x-ray normal CT scan of abdomen:

On the 2nd hospital day, he undergoes a diagnostic procedure. Histopath is shown below:

On the 4th hospital day, he undergoes surgery. Operative findings: A 15-cm encapsulated mass is found located at the retroperitoneum adherent to the ascending colon. The tumor does not involve the aorta nor the inferior vena cava. Liver is normal Resection of the tumor with R hemicolectomy is done. Histopathology of the resected tumor shows the following after special staining:

Post-operative course is uneventful. Eighteen months after surgery, he comes back complaining of persistent cough with weight loss. Chest x-ray and Chest CT scan are done and show the following:

Issues to be discussed: 1. Initial diagnostic evaluation Staging 2. Role of pre-operative biopsy 3. Role of neo-adjuvant therapy 4. Operative treatment Extent of surgery Role of frozen section 5. Surveillance after initial surgery 6. Assessment of extent of metastases 7. Treatment for recurrence