EXAMPLE Ronald Yanagihara, M.D. CONSULTATION _________________________________ MEDICAL ONCOLOGY CONSULTATION REASON FOR CONSULTATION: I am kindly asked by Dr. G. Baldeon to evaluate this middle aged man with advanced rectal cancer, now admitted for RLE, DVT. HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old man whose pertinent history dates to 1/07/03, when colonoscopy to evaluate hematochezia described hemi-circumferential rectal mass biopsied as moderately to poorly differentiated adenocarcinoma. There was also a synchronous 1.5 cm sigmoid polyp; CEA was 9.2 ng/mL. He was discharged to DMC for further evaluation but was never compliant. Six months later he was evaluated at Stanford where CT staging reportedly documented seminal vesicle and pelvic lymph node involvement leading to clinical stage T4, N2. He was treated with concurrent 50 gray XRT plus capecitabine (7/22 to 8/29/03), but post-therapy CT (9/22/03) apparently documented increase in rectal wall mass associated with 4.7 cm sigmoid mass and multiple perirectal lymph nodes. He was recommended to proceed to surgery but was lost to follow up. He next came to medical attention in 11/04 when he was admitted here for evaluation of hematochezia. At that point, WBC was 9.7, HB 10.7, MCV 81, PLT 297, CEA 70.2 ng/mL. CT described 1.3 cm right lobe of liver hypodense lesion, 1.1 cm left pelvic sidewall and 1.7 cm left common iliac lymph nodes, all new since 9/03 imaging. I saw him at that point and strongly recommended initiation of first-line chemotherapy. However, he stated he wished a second opinion; was sent to UCSF GI Oncology Group where again recommendation was made for front-line chemotherapy. Patient however, was then lost to follow up. More recently he was again in hospital in early to mid 4/05 for nausea, vomiting, abdominal cramps. At admission, weight was 145 pounds. WBC 15.6, HB 10.0, MCV 74, PLT 720, CEA 119 ng/mL. CT studies described new bibasilar lung nodules, 1.0 cm on right and 1.1 cm on left, 2.2 cm right lobe of liver lesion and a new 1.1 cm medial left lobe of liver lesion, significant large bowel distension with presacral soft tissue mass effect and 1.8 cm left and 1.7 cm right inguinal lymph nodes as well as suggestion of a walled-off perirectal abscess. He was taken to surgery by Dr. Scott Benninghoven on 4/08/05 where frozen pelvis was documented with tumor fixation to both sidewalls completely encasing bladder. Four centimeter omental mass and several palpable right lateral lobe of liver lesions were noted. Diverting colostomy was done. Thereafter, he was begun on first line chemotherapy as FOLFOX 4 given, however, only for two cycles (4/20 and 5/04/05) complicated then by multiple missed appointments and noncompliance with further dosing. He was finally reevaluated in 7/01/05 and was found on CT to have radiographic progression including interval increase in size and number of ill-defined hypodense liver lesions, interval increase (compared to 5/18/05) in hypodense splenic lesions, interval increase in multiple mesenteric nodules, right inguinal and left obturator lymphadenopathy, and bladder wall thickening, as well as increase in number and size of multiple bilateral lung nodules and subcarinal lymphadenopathy. He was strongly advised consideration of continuing with chemotherapy and did receive a single cycle of second line bevacizumab irinotecan (7/13/05) after which he was again lost to follow-up. Despite multiple phone calls to patient and family, he has been resistant to returning for further evaluation. He has now been admitted on 11/07/05 via ED complaining of one week of right leg swelling. Pertinent findings at admission included right leg Doppler showing deep vein thrombosis, common femoral to popliteal vein. WBC was 14.4, RBC 3.1, HB 7.9, HCT 25, MCV 81, PLT 543, ProTime/INR 1.2, PTT 42 seconds, K 4.0, BUN 17, creatinine 0.8, albumin 3.1, globulin 5.6, total bilirubin 0.3, Normal AST and ALT, alkaline phosphatase 154. Since admission, patient and spouse have been insistent on being discharged to home and have refused recommended therapies. After my discussion with them tonight, however, they are agreeable to RBC transfusion and evaluation for potential IVC filter. PAST MEDICAL HISTORY: Remarkable for diabetes mellitus. Only previous surgery was diverting colostomy (4/05). ALLERGIES: He denies allergies. CURRENT MEDICATIONS: Unknown and apparently involve periodic courses of antibiotic for perirectal decubiti and discharge. SOCIAL HISTORY: He is married and lives in Gilroy and is a disabled machinist. He denies tobacco or ethanol use. PHYSICAL EXAMINATION: BP 130/80, T 92, R 20, T9 7.9. Weight 152 pounds. Performance status 60/70%. He is a chronically ill man who nevertheless is comfortable at rest. HEENT: Anicteric, pupils, 3 mm, equal, reactive, extraocular movements slow. Throat clear, tongue midline. NECK: Supple without goiter. There is small (sub-centimeter) right supraclavicular lymphadenopathy. LUNGS: Are clear without basilar flatness. HEART: Is regular without gallop. ABDOMEN: Is soft, there is firmness suggesting liver edge palpable up to 10 centimeter below the right costal margin at right midclavicular line. Scrotum and perirectal tissues are indurated and edematous. EXTREMITIES: There is asymmetric lower extremity edema, right greater than left. NEUROLOGIC: He is alert and conversant. There is no overt lateralizing motor deficit. ASSESSMENT: 1. Hypercoagulable state of cancer, RLE DVT in patient with chronic GI bleeding site. 2. Advanced rectal cancer (frozen pelvis, liver, lung) a. T4N2 at 7/03 Diagnosis; preoperative 50 Gy XRT plus capecitabine (7/03 to 8/03), then lost to follow-up. b. M1 (liver, local) at 11/04 reevaluation; then lost to follow up. c. Frozen pelvis/large bowel obstruction at 4/08/05 diverting colostomy; first line FOLFOX 4 (4/05 to 5/05), then multiple canceled visits. d. CEA/radiographic progression in liver and lung (7/05); second-line Bevacizumab plus irinotecan (7/05), then lost to follow up. PLAN: I again had a long discussion with patient and family about implications of progressive rectal cancer now complicated by hypercoagulable state and DVT. I explained that Heparin and warfarin were contraindicated in view of chronic bleeding sites; and that alternatives for management at this point would include hospice care versus palliative support as RBC transfusion and IVC filter. This entire course has been complicated by ambivalence and poor compliance, but he states tonight his willingness to have RBC transfusion and consideration of IVC filter. Will discuss in a.m. with a vascular surgery and potentially arrange for transfer.