eP418 - Locally Advanced Cecal Cancer- a Complex Surgical Approach

Purpose/Background: Standard management for cecal adenocarcinoma includes colonoscopy, and subsequent staging computed tomography scan of Chest/Abdomen/Pelvis. Tumor resection can be performed in the setting of locoregional disease, and pending pathologic nodal involvement the patient can chemotherapy to prevent metastasis and recurrence. In this case report, we describe an adaptive stepwise approach for an atypical locally advanced cecal adenocarcinoma.Methods/Interventions: A 67-year-old female patient with history of COPD, HTN and tobacco use presented with a diagnosis of cecal adenocarcinoma identified on screening colonoscopy. CT scan of Chest/Abdominal/Pelvis demonstrated cecal mass with inflammation surrounding the soft tissues of the right inguinal region, multiple enlarged lymph nodes, and involvement of the abdominal wall without evidence of metastatic disease. Pathology confirmed invasive cecal adenocarcinoma. Given the abdominal wall involvement on physical examination and imaging neoadjuvant chemotherapy was recommended. After one round she developed an open wound tumor site. This wound prohibited administration of additional chemotherapy. She was admitted to the hospital as she was unable to care for her wound at home. A multi-disciplinary team was generated, consisting of colorectal, plastic, vascular, orthopedic-oncology, and urologic surgeons to manage to the invasion of her tumor on surrounding structures identified on planning scans. She was consented for an open right hemicolectomy, ureteral stenting, possible ureteral reconstruction, possible vascular reconstruction, possible abdominal wall reconstruction, possible flap reconstruction, possible hip disarticulation. Ultimately, the cecum, en bloc small, enbloc abdominal wall and skin wound were successfully resected. She underwent ileocolic side to side anastomosis. The right ureter and the inguinal blood vessels were encroached upon but not involved. Pedicled muscle flap reconstruction of the abdominal wall was performed with excision of anterior thigh muscles and skin. She remained hemodynamically stable postoperatively and transferred to surgical step down for monitoring of her flap.Results/Outcomes: Histopathologic analysis of the specimen was consistent with invasive colonic adenocarcinoma extending into small bowel and abdominal wall soft tissue with an inflamed fistula tract communicating with overlying skin, stage classification pT4N2M1. She was discharged after 7 days in the hospital to rehabilitation for her gait training. She was discharged able to ambulate and independent at home. She progressed as expected and no major complication at 30-day follow-up.Conclusion/

Discussion: Standard care pathways for cecal adenocarcinoma are less applicable for patients with locally advanced tumors encroaching on surrounding structures. The complexity of enbloc resection requires thoughtful interpretation of the imaging, and coordination amongst multiple subspecialist surgeons for safe execution. In conclusion, surgeons can use this adapted algorithm with a multidisciplinary team approach in patients with locoregional advanced colon adenocarcinoma who are not minimally invasive resection candidates.Complex Enbloc ResectionLaparotomy, groin defect, specimen and flap reconstruction