How a 68-Year-Old Patient Overcame Stage T3N1M0 Disease With a Multimodal Approach

A 68-year-old man sought medical care after experiencing rectal bleeding for three days, which then resolved but led to narrowing of his stool. His medical history included an acute myocardial infarction, treated with percutaneous transluminal coronary angioplasty and stenting. Although his father had died of lung cancer, there was no family history of colorectal cancer.

Physical examination revealed a palpable mass at the rectum, located just 1 cm from the anal verge. The lesion occupied roughly one-third of the circumference, and laboratory tests showed a hemoglobin level of 11.2 gm/dL, hematocrit of 33.1%, and a carcinoembryonic antigen (CEA) level below 1 ng/mL. Colonoscopy identified an ulcerated rectal mass, and biopsy confirmed a moderately differentiated adenocarcinoma. Further evaluation with flexible sigmoidoscopy located the tumor at 1–6 cm from the anal verge, while rigid proctoscopy measured a 5 cm lesion extending through the dentate line.

Endoscopic ultrasound staged the disease as T3N0. Meanwhile, CT scans of the chest, abdomen, and pelvis excluded distant metastases. However, the pelvic CT showed slight wall thickening and small mesorectal and superior hemorrhoidal lymph nodes. Based on these findings, the tumor was characterized as T3N0 by ultrasound but T3N1M0 clinically.

Preoperative treatment involved radiation therapy to 45 Gy delivered to the pelvis plus a 5.4 Gy boost, for a total of 50.4 Gy, along with concurrent capecitabine. Five weeks after chemoradiotherapy, imaging no longer showed the original mass or lymph node involvement. Flexible sigmoidoscopy confirmed a clinical complete response.

The patient proceeded to an abdominoperineal resection. Pathology revealed no residual adenocarcinoma in the resected specimen and no metastatic involvement in any of the 20 lymph nodes examined. Finally, he received adjuvant chemotherapy with FOLFOX (5-FU/folinic acid plus oxaliplatin), completing an aggressive but highly effective treatment course.