Report from Victoria Hospital
Prince Albert, Saskatchewan, Canada
Attending Physician: Randy Friesen
Admission Date: 2003 October 8

INDICATION FOR PROCEDURE
Elevated serum CEA levels

FINAL DIAGNOSIS
Rectosigmoid carcinoma with hepatic metastases

PROCEDURE
Colonoscopy and biopsies

PREAMBLE
This 45-year-old gentleman is well known to me. About two and half years ago he had an obstructing splenic flexure carcinoma. He had an uneventful excision and has done well since then. I saw him July 2002 and performed a colonoscopy. Everything looked normal. CEA levels were normal at that time. Subsequent CEA levels last fall were also normal. However, in April of this year his CEA level rose to 10. He underwent abdominal ultrasound and abdominal CT scanning. No abnormalities were found. He was asymptomatic. Subsequent follow-up CEA level was much higher at 29. He was thus referred to me and he came in for urgent colonoscopy. he did advise that for the last several weeks he has noticed gradual difficulty evacuating hid stools. He is getting the occasional crampy abdominal pain and postprandial nausea. He is feeling weak. On examination I could find no abnormalities in the abdomen. Digital rectal examination was negative.

COLONOSCOPY FINDINGS
Some obvious fungating ulcerated tumor at 15 cm. from the anal verge. No other abnormalities were noted up to and including the cecum.

PROCEDURE
Routine video colonoscopy. Tolerated well. The tumor was biopsied.

The patient had previously been booked for a CT scan the same day. This revealed tow new findings, the first being that of a right hydroureter, and the second being that of hepatic metastases x4, one in the left lobe and three in the right lobe, all relatively small.

OPINION
I met Stephen and his new wife later that day and again in my office on Oct. 9 , 2003. We discussed the ramifications. Because of his significant symptoms. I have recommended urgent surgery. We booked him to come to the operating room on Tuesday, Oct. 14, 2003 for resection of the rectosigmoid lesion. We also advised that we would assess the presence of disease elsewhere because if there were, he would not be a good candidate for any hepatic treatment.

He and his wife phoned me later in the day to advise me that they have decided not to take any orthodox medical intervention at this time, but that they are going to try a fruit juice and vitamin therapy protocol instead. He was made aware that this was definitely in his best interest and that further delay might severely and irreversibly harm his chances at cure. However, he was quite persistent that is was just as important to him that his wife be happy, and that he live longer, if I might put it in those terms.

Thus, they have agreed to have a repeat CT scan in approximately 6 week's time to assess if there is any change either in the pelvis or in the liver. Obviously if he becomes totally obstructed at some point he is going to require some form of surgery anyway, and that would undoubtedly entail a colostomy.

Whether this represents a de novo tumor, or whether this represents a metastatic lesion in the pelvis from trans-abdominal spread I am not certain. Certainly, it appears to be extremely aggressive.

Dr. Randy Friesen

cc: Dr. R. Unsworth
cc: Saskatoon Cancer Center