1. Imaging Metastatic Rectal Cancer Jack Temple, MS3 June 2013 Christian Malalis, MD

2. JS is a 77 year old man with a history of sigmoid colon cancer (s/p sigmoid resection w/o adjuvant therapy in 2009) Surveillance colonoscopy at OSH on 4/17/13 revealed large rectal mass  referred to Rush GI and Colorectal surgery Rush GI performed: – Flexible Sigmoidoscopy (5/22/13) – Transrectal Ultrasound (5/22/13) Rush Radiology consulted for: – Staging purposes Clinical History / Physical Exam

3. Rush Endoscopy Images Flexible Sigmoidoscopy Images, Courtesy of David Shapiro, MD; 5/22/13

4. Transrectal Ultrasound Transrectal Ultrasound Images, Courtesy of David Shapiro, MD; 5/22/13

5. Colorectal Cancer Staging Image Source: http://www.hopkinscoloncancercenter.org/

6. Rectal Cancer Metastasis Image Source: http://www.elsevierimages.com/

7. For pre-treatment staging of colorectal cancer (large lesion): ACR Appropriateness Criteria ProcedureRatingRRL CT chest, abdomen, pelvis with contrast 8 FDG-PET/CT whole body 8 X-Ray chest 8 MRI pelvis with and without contrast 80 MRI abdomen with and without contrast 70 Source: ACR appropriateness criteria

8. Pelvis (normal) Axial CT (No MRN) Source: e-Anatomy (www.imaios.com)

9. Pelvis (our patient) Axial CT from PET/CT MRN-6557254

10. Pelvis (our patient) Axial Fused PET/CT MRN-6557254

11. Pelvis (normal) Axial CT (No MRN) Source: e-Anatomy (www.imaios.com)

12. Pelvis (our patient) Axial CT From PET/CT MRN-6557254

13. Pelvis (our patient) Axial Fused PET/CT MRN-6557254

14. Abdomen (normal) Axial CT (No MRN) Source: e-Anatomy (www.imaios.com)

15. Abdomen (our patient) Axial CT from PET/CT MRN-6557254

16. Abdomen (our patient) Axial Fused PET/CT MRN-6557254

17. Abdomen (our patient) Diagnostic CT post contrast MRN-6557254 Axial Coronal

18. Treatment: – Most cases, treatment is palliative 3 Prolong survival and maintain quality of life – Chemo options Old: 5-Fluorouracil New: Irinotecan, Oxaliplatin Monoclonal Abs: Cetuximab, Panitumumab, Aflibercept 4 – Surgical resection Follow up imaging: – Surveillance imaging Treatment and Follow Up Imaging

19. Images: www.hopkinscoloncancercenter.org/ www.elsevierimages.com www.imaios.com (e-Anatomy) www.gruntdoc.com References: 1.Bipat S, Glas AS, et al. Rectal Cancer: Local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging—a meta-analysis. Radiology 2004 Sep; 232(3): 773-83. 2.American College of Radiology Appropriateness Criteria: Pretreatment Staging of Colorectal Cancer, 2011. 3.Weeks JC, Catalano PJ, et. al. Patients’ expectations about effects of chemotherapy for advanced cancer. New England Journal of Medicine 2012; 367: 1616-25. 4.Clark JW, Grothey A. Systemic chemotherapy for nonoperable metastatic colorectal cancer: treatment recommendations. UpToDate 2013. 5.Flamen P, Hoekstra OS, et al. Unexplained rising carcinoembryonic antigen (CEA) in the postoperative surveillance of colorectal cancer: the utility of positron emission tomography (PET). European Journal of Cancer 2001; 37(7): 862. References

20. Christian Malalis, MD, PGY IV Rush Endoscopy David Shapiro, MD Thanks!

21. The End Source: www.gruntdoc.com