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.