A 72-year-old woman from Mumbai undergoes colonoscopy for iron-deficiency anaemia and is found to have a 4 cm mass in the caecum with biopsy-proven adenocarcinoma. CT staging shows T2N0M0 disease with no distant metastases. She has a history of hypertension and mild chronic kidney disease (eGFR 55 mL/min). She is otherwise fit and willing for surgery. What is the most appropriate next step in management?

Explanation

## Clinical Context This patient has early-stage colon cancer (T2N0M0) of the caecum. Unlike rectal cancer, colon cancer does not routinely benefit from neoadjuvant therapy. The goal is prompt surgical resection with adequate lymph node harvest. ## Why Right Hemicolectomy Is Correct **Key Point:** For colon cancer (not rectal), the primary treatment is surgical resection. Neoadjuvant therapy is NOT standard for T2N0 disease. **High-Yield:** Colon cancer management differs fundamentally from rectal cancer: | Feature | Colon Cancer | Rectal Cancer | |---------|-------------|---------------| | **Neoadjuvant CRT** | Not routine; reserved for T4b or emergency obstruction | Standard for T3–T4 or N+ | | **Primary treatment** | Upfront surgery | nCRT → surgery | | **Lymph node harvest** | ≥12 nodes required | ≥12 nodes required (post-nCRT) | | **Adjuvant chemo** | Stage III (N+); consider Stage II high-risk | Stage III; consider Stage II high-risk | **Clinical Pearl:** The caecum is part of the right colon, supplied by the ileocolic vessels. Right hemicolectomy includes resection of the terminal ileum, caecum, ascending colon, and hepatic flexure with en bloc resection of the ileocolic and right colic lymph nodes. ## Surgical Approach ```mermaid flowchart TD A[Colon cancer T2N0M0]:::outcome --> B{Emergency presentation?}:::decision B -->|Yes: obstruction/perforation| C[Staged approach or primary resection]:::action B -->|No: elective| D[Direct surgical resection]:::action D --> E[Right hemicolectomy for caecal tumour]:::action E --> F[Primary anastomosis]:::action F --> G[Pathology: assess margins & lymph nodes]:::outcome G --> H{Adjuvant chemo indicated?}:::decision H -->|N0, no high-risk features| I[Observation]:::action H -->|High-risk Stage II or Stage III| J[Adjuvant FOLFOX or capecitabine]:::action ``` ## Rationale for Immediate Surgery 1. **T2N0 is early-stage:** No nodal involvement; neoadjuvant therapy does not improve outcomes 2. **Fit for surgery:** Age alone is not a contraindication; mild CKD does not preclude surgery 3. **Adequate time for assessment:** No acute obstruction or perforation requiring emergency intervention 4. **Lymph node harvest:** Adequate nodal staging requires surgical resection; endoscopic resection cannot provide this ## Extent of Resection - **Caecal tumour:** Right hemicolectomy with ileocolic and right colic lymphadenectomy - **Anastomosis:** Ileocolic primary anastomosis (safe in this patient; no contraindications) - **Margins:** Proximal and distal margins ≥5 cm from tumour [cite:Harrison 21e Ch 297]