Detailed Treatment Process
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Male, 64 years old On April 14, the patient was admitted to the hepatobiliary and pancreatic surgery department of Hospital A with a chief complaint of altered bowel habits for more than two months. Pelvic CT plain scan showed abnormal thickening of the intestinal wall in the middle and lower rectum, suggestive of rectal cancer, with possible multiple lymph node metastases around the intestine, pelvic wall, and bilateral inguinal regions. Some small bowel loops showed marked fluid accumulation. Upper abdominal CT revealed a left renal cyst and fibrotic strands at the right lung base. Pelvic MRI plain scan plus contrast showed abnormal thickening of the intestinal wall in the middle and lower rectum, suggestive of rectal cancer with possible multiple lymph node metastases around the intestine, pelvic wall, and bilateral inguinal regions. Colonoscopy suggested possible rectal malignancy, and pathology confirmed (rectal) adenocarcinoma. Discharge diagnoses included rectal adenocarcinoma, perirectal lymph node metastasis, pelvic wall lymph node metastasis, and multiple bilateral inguinal lymph node metastases. Carcinoembryonic antigen (CEA) was 53.56 ng/ml. After discussion by the department, chemotherapy was recommended, with surgery planned for a later date. On April 24, the patient received his first cycle of chemotherapy at Hospital A with the regimen: fluorouracil 0.5 g + oxaliplatin 150 mg + calcium folinate 0.3 g + fluorouracil 1.5 g via micro-pump for 48 hours. He was discharged on April 27. On May 13, he received a second cycle of chemotherapy; CEA was 64.40 ng/ml. He was discharged on May 15. On May 29, the patient received a third cycle of chemotherapy; CEA was 50.35 ng/ml. On June 16, he received a fourth cycle of chemotherapy; CEA was 40.95 ng/ml. On July 9, pelvic CT plain scan and contrast-enhanced imaging showed rectal cancer invading the serosa, with multiple enlarged lymph nodes around the intestine and pelvic wall. From July 11 to August 7, the patient underwent preoperative radiotherapy for rectal cancer, receiving 20 fractions with a dose of PTV DT: 36 Gy/20 fx/28 d. The radiotherapy was not completed as planned at the patient's request. On August 4, outpatient CEA was 96.1 ng/ml. On September 10, the patient was readmitted to the hepatobiliary and pancreatic surgery department of Hospital A. Whole-body bone scintigraphy plus local SPECT/CT fusion imaging showed osteolytic bone metastasis at L4. Chest radiograph showed no obvious active lesions in either lung. Pelvic MRI plain scan plus contrast showed: 1. Irregular thickening of the rectal wall, consistent with rectal cancer based on clinical findings. 2. Moderate pelvic fluid collection. 3. Enhancing nodule at the posterior margin of the L4 vertebral body, highly suggestive of metastasis. Bone scan confirmed osteolytic metastasis at L4. CEA was 695.10 ng/ml. The patient was discharged on September 17. In the same month, PET-CT at Hospital C showed: post-radiotherapy changes in “rectal cancer,” with thickening of the local rectal wall and slight luminal narrowing, increased FDG uptake suggestive of mild residual tumor activity; multiple lymph node metastases around the iliac vessels, retroperitoneum, mediastinum, left axilla, bilateral supraclavicular fossae, and bilateral neck roots, along with extensive peritoneal and pelvic seeding, and L4 vertebral bone metastasis. From September 24 to February 14 of the following year, the patient received eight cycles of palliative FOLFIRI ± cetuximab chemotherapy at Hospital B. On admission to Hospital B, physical examination revealed beaded enlargement of supraclavicular lymph nodes and abdominal distension. On December 21, follow-up abdominal and pelvic plain and contrast-enhanced CT showed rectal malignancy with extensive lymph node metastases in the abdominal cavity and retroperitoneum; low-density lesions in the lumbar vertebrae, likely metastatic. Chest plain and contrast-enhanced CT showed multiple lymph node metastases in the mediastinum, neck root, and left axillary region. The patient died in April of the following year.