39 Treatment of Colorectal Cancer Overview

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Questions and Answers

What is the primary aim of treatment for cancer as indicated?

Prevention of tumor recurrence

Complete eradication of the disease

Symptom control initially (correct)

Disease downstaging

Which surgical procedure is typically performed for tumors located in the right colon?

Abdomino-perineal resection

Left Hemicolectomy

Anterior resection

Right Hemicolectomy (correct)

What treatment is administered before surgery to reduce local recurrence?

Supportive care

Palliative chemotherapy

Neoadjuvant chemoradiotherapy (correct)

Adjuvant chemotherapy

Which procedure is essential for obtaining a tissue diagnosis in suspected colorectal issues?

Endoscopic Biopsy Signup and view all the answers

What is the significant prognostic indicator associated with colorectal cancer monitoring?

CEA Signup and view all the answers

In which scenario is palliative care typically indicated?

Unresectable metastases Signup and view all the answers

What is the surgical approach for cancers located in the upper third of the rectum?

High anterior resection Signup and view all the answers

In the TNM staging classification, what does 'N' represent?

Lymph Nodes Signup and view all the answers

Which Dukes classification stage has the highest 5-year survival rate?

Dukes A Signup and view all the answers

What is the purpose of conducting a CT TAP in the context of cancer diagnosis?

For staging the spread of disease Signup and view all the answers

What is the male to female ratio for colorectal cancer incidence?

3:1 Signup and view all the answers

Which age group has the highest incidence of colorectal cancer?

55-75 years Signup and view all the answers

Which of the following is a common symptom of left sided colorectal lesions?

PR Bleeding Signup and view all the answers

Which of these is NOT considered a risk factor for colorectal cancer?

Regular physical activity Signup and view all the answers

Which type of adenocarcinoma is most commonly associated with familial syndromes such as HNPCC and FAP?

Colorectal adenocarcinoma Signup and view all the answers

Which of the following presentations is associated with right-sided colorectal lesions?

Stools liquid Signup and view all the answers

What percentage of colorectal cancer cases are located in the rectum?

30% Signup and view all the answers

What is the primary investigative approach for staging colorectal cancer?

Combination of imaging and laboratory investigations Signup and view all the answers

Study Notes

Treatment of Colorectal Cancer

Treatment depends on the TNM staging and the presentation of the cancer.
The aim of treatment is to control symptoms, downstage the disease, and potentially perform surgery.
Urgent intervention may be needed in cases of obstruction or bleeding.
Chemotherapy and radiotherapy can be used to downstage the disease, sometimes eliminating the need for resection.
Surgery is typically necessary, and different types of surgery are performed depending on the location of the cancer.
- Right colon: Right hemicolectomy
- Left colon: Left hemicolectomy
- Sigmoid/upper rectum: Anterior resection
- Low rectum: Abdomino-perineal (AP) resection
Palliative treatment is used if disease-modifying treatment fails.

Additional Treatment

Pre-operative (neoadjuvant) chemoradiotherapy may be used to reduce local recurrence.
Post-operative (adjuvant) chemotherapy is used for tumors with positive lymph nodes or vascular invasion.
Pre-operative chemoradiotherapy is specifically used for rectal cancer.
Palliative treatment options are used for unresectable metastases or tumors.
- Chemotherapy
- Stents for obstructing colon tumors
- Surgery for obstruction or bleeding

Treatment of Rectal Cancer

Upper 1/3 cancers are treated with a high anterior resection. No J pouch is needed.
Middle and lower 1/3 cancers are treated with an abdomino-perineal resection (APR).

Learning Outcomes for Colorectal Cancer

Understand the causes of colorectal cancer.
Describe the presentation of colorectal cancer.
Be familiar with the chief investigations used for staging colorectal cancer.
Understand the TNM/Duke’s classification for tumor staging.
Illustrate the different types of colonic resections.
Demonstrate understanding of colorectal cancer screening.

Colorectal Cancer Introduction

The second most common cause of cancer death in the UK, Ireland, and Bahrain.
Highest incidence in the Western world.
Male to female ratio is 3:1.
Peak incidence is between 55-75 years.
The most common type is adenocarcinoma.

Risk Factors for Colorectal Cancer

Family history:
- HNPCC (5%)
- FAP (1%)
- Juvenile polyposis
- Having two first-degree relatives with colorectal cancer increases lifetime risk by 1/6.
Colonic polyps
Low fiber/fruit/vegetable diet.
Obesity.
Male gender.
Age (highest incidence between 55-75 years).
Smoking.
Chronic ulcerative colitis or colonic Crohn’s disease (UC is a greater risk factor than Crohn’s).
Gardner’s Syndrome.
Peutz-Jeghers Syndrome.

Presentation of Colorectal Cancer: Symptoms

Right-sided lesions
- Liquid stools
- Symptoms of iron deficiency anemia
- Lower abdominal pain
- Constitutional symptoms (weight loss)
Left-sided lesions
- Semi-solid stools
- PR bleeding (blood mixed with stool)
- Change in bowel habit
- Emergency presentation (40% as emergencies)
- Large bowel obstruction
- Perforation/peritonitis
- Acute PR bleed
Rectal lesions
- Solid stools
- Blood on stool surface
- Tenesmus

Presentation of Colorectal Cancer: Signs

Majority of patients present with no signs.
Anemia
Blood per rectum or on stools.
Abdominal mass.
Rectal lesion on PR exam (within 10 cm of anal verge).
Hepatomegaly (metastatic).
Cachexia.

Tumor Sites

Rectum: 30%
Descending and Sigmoid: 45%
Right-sided: 20%
Transverse: 5%

Workup for Colorectal Cancer

Bedside Investigations
- History and examination
- Digital rectal exam and fecal occult blood (FOB)
- Vitals (O2 sats, BP, HR, RR, temperature)
- ECG
- Urine dipstick +/- beta hCG
- Glucose check
Imaging Investigations
- Erect CXR (? perforation)
- Abdominal X-ray (erect and supine if obstructed)
- CT abdomen & pelvis
- CT thorax, abdomen, pelvis (TAP) to check for spread of disease
Laboratory Investigations
- FBC, U&E, Coagulation profile
- CRP
- LFT’s (? mets)
- CEA (raised in 60% with colorectal cancer, useful for monitoring disease)
- VBG/ABG (lactate)

Endoscopy

Essential for diagnosis.
Tissue diagnosis must be obtained via biopsy.
Endoscopic biopsy access:
- Rigid sigmoidoscopy
- Flexible sigmoidoscopy
- Colonoscopy (essential to examine the entire colon).

Imaging

CT TAP is Essential for Staging
If biopsy confirms cancer, a CT TAP should be performed to stage disease.
The TNM classification is used for staging:
- T = Tumor
- N = Lymph Nodes
- M = Metastases

CT Findings

An example includes a caecal carcinoma with circumferential involvement of the caecal wall. Contrast-enhanced CT may demonstrate liver metastases, with low-density metastases from the colonic primary tumor involving both lobes of the liver.

Older Staging Classification: Dukes’ Classification

Dukes A – confined to bowel wall (90% 5-year survival)
Dukes B – through muscularis propria (75%)
Dukes C – regional lymph nodes (30-60%)
Dukes D – distant metastasis (5%)
TNM staging is more comprehensive than the Dukes’ classification.

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Description

This quiz covers the essential treatments for colorectal cancer based on TNM staging and disease presentation. It explores surgical options, chemotherapy, and palliative care, highlighting the importance of tailored interventions for different cancer locations. Test your knowledge on the mechanisms and aims of these treatments.