What is the plan for resection in a colon cancer patient with 50% wall circumference involvement and multiple linear deep ulcerations found on colonoscopy (Colonoscopy)?

Surgical Management of Colon Cancer with 50% Wall Circumference Involvement and Multiple Linear Deep Ulcerations

The appropriate plan is D: Resection of both primary tumor and secondary sites (if present) after proper staging.

Initial Assessment and Staging

Proper staging is essential before proceeding with definitive surgical management in this case. The presence of multiple linear deep ulcerations on colonoscopy suggests potential deep invasion, which requires formal oncologic resection 1.

• Complete staging workup should include:
  • CT scan of chest, abdomen, and pelvis 2
  • Complete blood count, platelets, chemistry profile
  • CEA determination 2
  • Complete colonoscopy (if not already done) 2

The 2017 WSES guidelines specifically state that "CT scan performs better than US in the abdomen and should be suggested for staging in the suspicion of cancer-related colorectal emergencies" 2.

Surgical Approach

Once staging is complete, the surgical plan should include:

1. Primary Tumor Resection:

   • Wide surgical resection with at least 5 cm margins on either side of the tumor 2, 1
   • En bloc removal of regional lymph nodes 2
   • Examination of a minimum of 12 lymph nodes to establish accurate staging 2

2. Management of Secondary Sites:

   • If metastases are identified during staging, simultaneous resection should be considered when feasible 2
   • For liver metastases, intraoperative ultrasound may help identify occult lesions 2

Specific Considerations for This Case

The 50% wall circumference involvement and multiple linear deep ulcerations indicate:

• Potential for locally advanced disease requiring careful assessment for invasion into adjacent structures 1
• Need for formal oncologic resection rather than local excision 1
• Possible consideration for laparoscopic approach if the surgeon is experienced and there is no evidence of locally advanced disease, obstruction, or perforation 2

Postoperative Management

Following resection, management will depend on final pathological staging:

• Stage I: No adjuvant chemotherapy recommended 2, 1
• Stage II: Consider adjuvant chemotherapy for high-risk features 2, 1
• Stage III: Standard adjuvant chemotherapy 2, 1

Common Pitfalls to Avoid

1. Inadequate lymph node assessment: Examining fewer than 12 lymph nodes can lead to understaging and inappropriate treatment decisions 2

2. Incomplete resection: The WSES guidelines emphasize that oncologic resection should be performed to obtain better oncologic outcomes 2

3. Overlooking synchronous lesions: Complete colonoscopy is essential to rule out other synchronous polyps or tumors 2

4. Delaying treatment of resectable metastases: When metastases are present and resectable, addressing both primary and secondary sites provides the best chance for improved outcomes 2

The evidence strongly supports a comprehensive approach that includes proper staging followed by resection of both primary tumor and any secondary sites when present, making option D the most appropriate choice for this patient.