Questions and Answers
What is the percentage of risk of cancer in ulcerative colitis at 30 years from diagnosis?
What is the minimum age of patients in which Amsterdam II criteria apply?
What is the presentation of left-sided colonic tumors?
What is the percentage of cases that present as an emergency with intestinal obstruction or peritonitis?
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What is the age range in which this type of cancer is most common?
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What is necessary for Amsterdam II criteria to be met?
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What is the primary therapy for non-metastatic colon cancer?
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What is the aim of surgery in colon cancer?
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What percentage of patients with colonic cancer will present as an emergency?
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What is the Tis stage in the TNM classification?
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What is the Stage C2 in the TNM classification?
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What is the most important determinant of prognosis for colorectal cancer?
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What is the approximate five-year survival rate for colorectal cancer?
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What is the surgical procedure for Familial Adenomatous Polyposis (FAP)?
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What is the main objective of surgery in colon cancer?
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What is the purpose of follow-up for patients with colorectal cancer?
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What surgical procedure may be advisable for a right-sided lesion with perforation and substantial contamination?
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What is the likelihood of cure in colon cancer?
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What chemotherapy combination is often used in the treatment of colorectal cancer?
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What is the five-year survival rate for a T1N0 colorectal cancer?
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What is the approximate length of the rectum?
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What is the main route of lymphatic drainage of the rectum?
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What is the most common histological type of rectal polyps?
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What is the purpose of colonoscopy in patients with rectal polyps?
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What is the purpose of CT of the chest and abdomen in rectal cancer?
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What is the accuracy of transrectal ultrasound (EUS) in tumor staging?
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What is the limitation of transrectal ultrasound (EUS) in assessing rectal cancer?
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What is the clinical importance of determining extension of disease into the anal canal in rectal cancer?
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What is the primary goal of radical excision of the rectum?
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What is usually possible for tumours whose lower margin is 2 cm above the anal canal?
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What is the administration of a course of neoadjuvant chemoradiotherapy intended to do?
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What is necessary before treatment can be planned for rectal cancer?
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What type of resection is usually performed for tumours whose lower margin is close to the anal canal?
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What is considered for patients who are unfit for radical surgery?
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Study Notes
Amsterdam II Criteria for HNPCC
- Three or more family members with an HNPCC-related cancer (colorectal, endometrial, small bowel, ureter, renal pelvis), one of whom is a first-degree relative of the other two
- Two successive affected generations
- At least one colorectal cancer diagnosed before the age of 50 years
- FAP excluded
- Tumours verified by pathological examination
IBD and Cancer Risk
- The risk of cancer in ulcerative colitis increases with duration of disease
- At ten years from diagnosis, the risk is around 1%
- The risk increases to 10-15% at 20 years and may be as high as 20% at 30 years
Clinical Features of Colonic Cancer
- Occurs in patients over 50 years of age and is most common in the eighth decade of life
- 20% of cases present as an emergency with intestinal obstruction or peritonitis
- Left-sided colonic tumors usually present with a change in bowel habit or rectal bleeding
- More proximal lesions typically present later with iron deficiency anaemia or a mass
- Patients may present for the first time with metastatic disease
Staging of Colonic Cancer
- Stage B2: Penetrating through muscularis propria; nodes not involved
- Stage C1: Extending into muscularis propria but not penetrating through it. Nodes involved
- Stage C2: Penetrating through muscularis propria. Nodes involved
- Stage D: Distant metastatic spread
TNM Classification
- TX: Primary tumor cannot be assessed
- T0: No evidence of primary tumor
- Tis: Carcinoma in situ: intraepithelial or invasion of lamina propria
- T1: Tumor invades submucosa
- T2: Tumor invades muscularis propria
- T3: Tumor invades through the muscularis propria into pericolorectal tissues
- T4a: Tumor penetrates to the surface of the visceral peritoneum
- T4b: Tumor directly invades or is adherent to other organs or structures
Surgery for Colonic Cancer
- Surgery is the gold standard and principal therapy of primary and non-metastatic ca colon
- Curative, palliative, and accurate disease staging
- Goal is to excise the primary lesion with adequate margin (~5 cm of normal bowel proximal and distal to the tumor)
- Reconstitute bowel continuity
Emergency Surgery
- 20% of patients with colonic cancer will present as an emergency, the majority with obstruction, but occasionally with haemorrhage or perforation
- Right hemicolectomy and anastomosis can be performed for right-sided lesions
- Left-sided lesions may require a Hartmann’s procedure or resection and anastomosis
Stage and Prognosis
- The most important determinant of prognosis is tumor stage and, in particular, lymph node status
- Overall five-year survival for colorectal cancer is approximately 50%
Chemotherapy
- 5Fu, Leucovorin, Oxaliplatin, Irinotecan, Bevacizumab, and Cetuximab are used in various combinations
- FOLFOX, FOLFIRI, and Capecitabine are common regimens
Rectum and Rectal Cancer
- The rectum measures approximately 15 cm in length
- Divided into lower, middle, and upper thirds
- Blood supply consists of superior, middle, and inferior rectal vessels
- Lymphatic drainage follows the blood supply, with the principal route being upwards along the superior rectal vessels to the para-aortic nodes
Symptoms of Rectal Disease
- Bleeding per rectum
- Altered bowel habit
- Mucus discharge
- Tenesmus
- Prolapse
Rectal Polyps
- Either single or multiple
- Adenomas are the most frequent histological type
- Villous adenomas may be extensive and undergo malignant changes
- All adenomas must be removed to avoid carcinomatous change
- All patients must undergo colonoscopy to determine whether further polyps are present
Workup
- CT of the chest and abdomen to exclude distant metastases
- PET scanning can be helpful in identifying metastases if imaging is otherwise equivocal
- Endoluminal ultrasound, performed using a probe placed in the rectal lumen, can be used to assess the local spread of the tumor
- MRI and Transrectal ultrasound (EUS) are used for clinical staging and to demonstrate layers of rectal wall
Management of Rectal Cancer
- Management has become increasingly complex due to various surgical, neoadjuvant, and adjuvant options
- Fitness of the patient and extent of spread must be assessed
- Radical excision of the rectum, together with the mesorectum and associated lymph nodes, should be the aim in most cases
- Neoadjuvant chemoradiotherapy can reduce tumor size and make curative surgery possible
- Local procedures such as transanal excision, laser destruction, or interstitial radiation should be considered for unfit patients or those with early tumors
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Description
This quiz covers the Amsterdam II criteria for Hereditary Non-Polyposis Colorectal Cancer (HNPCC) and the risk of cancer in ulcerative colitis.