What is the management for a 67-year-old patient with a history of pilonidal cyst and a fungating rectal mass?

From the Guidelines

Management of a 67-year-old patient with a history of pilonidal cyst and a fungating rectal mass requires urgent colorectal surgical evaluation and a multidisciplinary approach, with the immediate priority being to obtain a tissue diagnosis through biopsy of the rectal mass, as this is highly concerning for rectal cancer. The patient should undergo a complete staging workup including colonoscopy (if not already done), CT scan of the chest, abdomen, and pelvis, and pelvic MRI to assess the local extent of the disease and potential metastases, as recommended by the ASCO guideline 1. Laboratory tests including CBC, comprehensive metabolic panel, and CEA tumor marker should be ordered. If rectal cancer is confirmed, treatment typically involves a combination of neoadjuvant chemoradiation (such as 5-fluorouracil or capecitabine with radiation therapy for 5-6 weeks) followed by surgical resection (low anterior resection or abdominoperineal resection depending on the tumor location), as outlined in the ESMO clinical practice guidelines 1. The prior history of pilonidal cyst is likely unrelated but should be noted for the surgeon.

• Pain management, nutritional support, and addressing any bleeding or discharge from the mass are important supportive measures.
• The patient should be evaluated for ostomy placement if the tumor is causing obstruction or if surgical resection will require temporary or permanent colostomy.
• Psychological support is also essential as the diagnosis and treatment can be emotionally challenging, and the patient's age and potential comorbidities should be taken into account when determining the treatment plan, as discussed in the SIOP expert recommendations 1. The NCCN Guidelines for Rectal Cancer, version 3.2024, also recommend a multidisciplinary approach and consideration of the patient's quality of life and functional outcomes when determining the treatment plan 1. Additionally, the guidelines suggest that patient participation in a clinical trial may be considered, especially for cases of advanced disease, as noted in the NCCN Clinical Practice Guidelines in Oncology for Rectal Cancer, version 2.2018 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Rectal Cancer

The management of a 67-year-old patient with a history of pilonidal cyst and a fungating rectal mass involves a multidisciplinary approach, with a focus on the stage of the disease.

• Restaging of rectal cancer after neoadjuvant therapy is crucial for treatment planning, and MRI is the current reference standard imaging modality for this purpose 2, 3, 4.
• The use of MRI in restaging rectal cancer allows for accurate evaluation of primary tumor staging, including the depth of invasion and involvement of adjacent organs 3.
• MRI can also be used to evaluate posttreatment morphologic components within the tumors, including fibrosis and mucinous changes, which correlate with the response to treatment 3.
• Functional assessment with diffusion-weighted MRI and perfusion MRI plays a role in predicting tumor aggressiveness and the likelihood of response to treatment, as well as the extent of residual tumor after therapy 3, 5.

Role of Imaging Modalities

• MRI, CT, and FDG-PET scan are commonly used imaging modalities for restaging rectal cancer after neoadjuvant therapy 6.
• The relative impact of each restaging modality on management varies, with FDG-PET scan having the most significant impact in changing management overall 6.
• Contrast-enhanced MRI has been shown to provide accurate differentiation of ypT0-1 from ypT2-4 tumors after neoadjuvant chemotherapy and radiation therapy 5.

Clinical Implications

• The management plan for a patient with rectal cancer should be individualized based on the stage of the disease and the response to neoadjuvant therapy 6, 3, 4.
• Accurate restaging of rectal cancer is crucial in the selection of candidates for local excision after neoadjuvant chemotherapy and radiation therapy 5.
• A multidisciplinary approach, including surgery, radiation therapy, and medical oncology, is essential for the optimal management of rectal cancer 2, 6, 3, 4, 5.