Assit. Univ.

Dr George Dejeu

A RECTAL MASS

History
A 70-year-old man was seen in the surgical outpatient clinic complaining of a 3-month history
of loose stools. He normally opens his bowels once a day, but has recently been passing loose
motions up to four times a day. The motions have been associated with the passage of blood
clots and fresh blood mixed within the stools. His appetite has been normal, but he reports a
12 kg weight loss. The past history was otherwise unremarkable. His father had died from
cancer at the age of 45 years, but he is unsure of the origin.

Examination
No pallor or lymphadenopathy is present. The abdomen is soft and non-tender with no
palpable masses. Digital rectal examination (DRE) is normal. Noted that no blood is revealed
at DRE.

INVESTIGATIONS
Rigid sigmoidoscopy reveals a mass located approximately 11 cm from the anal verge

Lesion on sigmoidoscopy.

Questions
• What is the likely diagnosis?
• How should the patient be investigated?
• What are the options for treatment?
• Which are the worrying symptoms in the patient’s history?
 Assit. Univ. Dr George Dejeu

ANSWER
A sessile mass is seen occupying approximately half of the bowel wall circumference. A biopsy
of the lesion should be taken at the time of sigmoidoscopy to confirm the diagnosis of rectal
cancer.

Blood tests including full blood count, liver function tests and tumor markers (e.g.
carcinoembryonic antigen [CEA]) should be arranged.

An urgent colonoscopy is required to determine whether there are any synchronous cancers
(5 per cent) or synchronous polyps (75 per cent) in the rest of the large bowel.

The patient should be staged using computerized tomography (CT) of the chest and abdomen
to check for chest, mediastinal and intra-abdominal metastases.
Magnetic resonance imaging (MRI) of the pelvis is used to ascertain the depth of tumor
invasion through the rectal wall and any regional nodal metastases. For tumors located above
approximately 5 cm from the anal verge, an anterior resection is carried out with or without
a temporary defunctioning colostomy. If the tumor is less than 5 cm from the anal verge, then
abdomino-perineal resection of the anus and rectum may be required with a permanent end
colostomy. The 5 cm depth is not a rule, the decision is taken after the MRI and DRE and
depends on the relation of the tumor inferior margin to the external anal sphincter. In the last
few years the inferior margin has been going down, and more and more research is being
done, and it seems that short- and long-term results are good as long as oncological principles
are being obeyed (CRM – Circumferential Resection Margin).

For tumors penetrating the rectal wall preoperative radiotherapy is beneficial, and more
recently a combination of chemotherapy and radiotherapy has been advocated for some
tumors.

KEY POINTS
The following symptoms should prompt urgent colorectal assessment:

• rectal bleeding with a change in bowel habit to looser stools and/or frequency of
defecation persistent for 6 weeks
• patients aged over 60 years with a change in bowel habit as above without rectal
bleeding and persistent for 6 weeks
• patients aged over 60 years with rectal bleeding persistently without anal symptoms
• a definite palpable right-sided abdominal mass
• a definite palpable rectal mass (not pelvic)
• iron-deficiency anemia without an obvious cause below 10g/dL in postmenopausal
women and below 11g/dL in all men.