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Questions and Answers
What is the primary aim of treatment in cancer management?
Which surgical procedure is generally performed for cancers of the right colon?
What is the purpose of administering neoadjuvant chemoradiotherapy before surgery?
In which scenario would palliative treatment be considered as the main approach?
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For rectal cancer that is located in the middle and lower third, which surgical option is typically used?
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What is the primary purpose of endoscopy in diagnosing colorectal issues?
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Which of the following statements is true regarding TNM staging?
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In the context of colorectal cancer, what does a raised CEA level indicate?
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Which imaging study is essential for staging colorectal cancer after a biopsy confirms cancer?
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What is the survival rate for Dukes A classification in colorectal cancer?
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What is the most common type of colorectal cancer?
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Which age group has the highest incidence of colorectal cancer?
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Which of the following is NOT a risk factor for colorectal cancer?
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What symptom is more likely associated with left sided lesions in colorectal cancer?
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What is the percentage of colorectal tumors located in the rectum?
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Which of these symptoms is considered an emergency presentation of colorectal cancer?
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What classification system is used for tumor staging in colorectal cancer?
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Which factor contributes to a lifetime risk of 1/6 for colorectal cancer?
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Which of the following statements about the endoscopic procedures is accurate?
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What information can be obtained from a CT TAP scan in colorectal cancer cases?
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In the context of TNM staging, what does the 'N' represent?
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Which Dukes classification corresponds to a 75% 5-year survival rate?
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What is the primary purpose of conducting a digital rectal exam in colorectal assessments?
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What is a potential outcome of chemoradiotherapy before surgery in colorectal cancer treatment?
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Which surgical procedure is primarily indicated for tumors located in the low rectum?
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In the context of treatment for colon cancer, what does downstaging typically refer to?
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What defines a palliative approach in colorectal cancer treatment?
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In the management of rectal cancers, which statement about neoadjuvant treatment is accurate?
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What is the male to female ratio for colorectal cancer incidence?
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Which age range shows the peak incidence of colorectal cancer?
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Which of the following is considered a greater risk factor for colorectal cancer?
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What percentage of colorectal tumors are located in the descending and sigmoid colon?
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Which symptom is typically associated with rectal lesions in colorectal cancer?
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Which condition contributes to a 1 in 6 lifetime risk of colorectal cancer?
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What type of stool is most likely to present with left sided lesions in colorectal cancer?
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What is the most common histological type of colorectal cancer?
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Study Notes
Treatment
- Aims to control symptoms and may require urgent intervention for obstruction or bleeding
- Disease downstaging may be achieved with chemotherapy and radiotherapy
- Surgery is often necessary
- Chemo-radiotherapy can be used to downstage to stage 0 eliminating the need for resection
- Palliative treatment is an option if disease modifying treatment fails
Surgical Options
- Right Colon: Right hemicolectomy
- Left Colon: Left hemicolectomy
- Sigmoid/Upper Rectum: Anterior resection
- Low Rectum: Abdomino-perineal (AP) resection
Additional Treatment
- Pre-operative (Neoadjuvant) chemoradiotherapy: Reduces local recurrence
- Post-operative (Adjuvant) chemotherapy: For tumors with positive lymph nodes or vascular invasion
Preoperative chemoradiotherapy for rectal cancer:
- Improves response to surgery and reduces local recurrence
Treatment of Rectal Cancer
- Upper 1/3 cancers: High anterior resection, no J pouch
- Middle and Lower 1/3 cancers: Abdomino-perineal resection
Learning Outcomes
- Understanding the aetiology of colorectal cancer
- Describing the presentation of colorectal cancer
- Listing chief investigations for staging colorectal cancer
- Describing tumour staging with TNM/Duke’s classification
- Illustrating the different types of colonic resections
- Demonstrating an understanding of screening for colorectal cancer
Introduction
- Second most common cause of cancer death in the UK and Ireland.
- Highest incidence in the Western world.
- Male to female ratio is 3:1.
- Peak incidence is between 55-75 years.
- Most cases are adenocarcinoma
Risk Factors
- Family History (HNPCC 5%, FAP 1%, Juvenile polyposis)
- Colonic polyps
- Low fiber diet
- Obesity
- Age (highest incidence at age 55-75)
- Smoking
- Chronic ulcerative colitis or colonic Crohns disease
Presentation - Symptoms
- Right sided lesions: Liquid stools, Iron deficiency anemia, Lower abdominal pain
- Left sided lesions: Semi-solid stools, PR bleeding
- Rectal lesions: Solid stools, Blood on stool surface, Tenesmus
Presentation - Signs
- Majority have none
- 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
- Bedside Investigations: History & Examination, Digital Rectal Exam & Fecal Occult Blood (FOB), Vitals (02 sats, BP, HR, RR, Temperature), Urine dipstick +/- beta hCG, Glucose check
- Imaging Investigations: Erect CXR, Abdominal X-ray, CT Abdomen & Pelvis, CT Thorax, Abdomen, Pelvis (TAP), ECG
- Laboratory Investigations: FBC, U&E, Coagulation profile, CRP, LFT's, CEA, VBG/ABG (lactate)
Endoscopy
- Essential for diagnosis - Requires biopsy
- Rigid sigmoidoscopy
- Flexible sigmoidoscopy
- Colonoscopy is essential to examine the entire colon
Imaging
- CT TAP is essential for staging
- Used to assess spread of the disease
- Based on TNM classification: T = Tumour, N = Lymph Nodes, M = Metastases
CT Findings - Example
- Caecal carcinoma with circumferential involvement of the caecal wall. Contrast-enhanced CT showing liver metastases. Several low-density metastases from the colonic primary tumor involve both lobes of the liver.
Older Staging Classification (Dukes’ Classification)
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Dukes A: Confined to bowel wall (90% 5-year survival)
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Dukes B: Through muscularis propria (75%)
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Dukes C: Regional lymph nodes (30-60%)
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Dukes D: Distant metastasis (5%)
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TNM staging is more comprehensive.
Colorectal Cancer
- Second most common cause of cancer death in the UK, Ireland, and Bahrain.
- Highest incidence in the Western world.
- Male to female ratio of 3:1.
- Peak incidence between the ages of 55 and 75.
- Most commonly adenocarcinoma.
Risk Factors
- Family history of colorectal cancer
- Hereditary nonpolyposis colorectal cancer (HNPCC) (5%): Increases lifetime risk by 6 times for those with 2 first-degree relatives with the condition.
- Familial adenomatous polyposis (FAP) (1%)
- Juvenile polyposis
- Colonic polyps
- Low fiber, fruit, and vegetable diet
- Obesity
- Male gender
- Age (highest incidence at 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 - Symptoms
- Right-sided lesions
- Liquid stools
- Symptoms of iron deficiency anemia
- Lower abdominal pain
- Left-sided lesions
- Semi-solid stools
- Rectal bleeding (blood mixed with stool)
- Change in bowel habit
- Rectal lesions
- Solid stools
- Blood on stool surface
- Tenesmus
Emergency Presentations (40% of cases)
- Large bowel obstruction
- Perforation/peritonitis
- Acute rectal bleeding
Presentation - Signs
- Majority of patients have no signs.
- Anemia
- Blood per rectum or on stools
- Abdominal mass
- Rectal lesion on rectal exam (within 10 cm of anal verge)
- Hepatomegaly (metastatic)
- Cachexia
Tumor Sites
- Rectum (30%)
- Descending and sigmoid colon (45%)
- Right-sided colon (20%)
- Transverse colon (5%)
Workup
-
Bedside Investigations*
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History and Examination
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Digital rectal exam
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Fecal occult blood test (FOB)
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Vital signs (oxygen saturation, blood pressure, heart rate, respiratory rate, temperature)
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ECG
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Urine dipstick +/- beta-hCG
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Glucose check
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Imaging Investigations*
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Erect chest X-ray (to rule out perforation)
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Abdominal X-ray (erect and supine if obstructed)
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CT abdomen and pelvis
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Laboratory Investigations*
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Full blood count (FBC)
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Urea and electrolytes (U&E)
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Coagulation profile
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C-reactive protein (CRP)
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Liver function tests (LFTs) (to check for metastases)
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Carcinoembryonic antigen (CEA) (elevated in 60% with colorectal cancer, useful for monitoring disease)
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Venous blood gas/arterial blood gas (VBG/ABG) (lactate)
Endoscopy
- Essential for diagnosis
- Biopsy required for tissue diagnosis
- Rigid sigmoidoscopy
- Flexible sigmoidoscopy
- Colonoscopy essential to examine the entire colon
Imaging
- CT Thorax, Abdomen, Pelvis (TAP) essential for staging
- Performed if biopsy confirms cancer
- Used to check for spread of disease
- Staging based on TNM classification
- T: Tumor
- N: Lymph Nodes
- M: Metastases
CT Findings - Examples
- Caecal carcinoma with circumferential involvement of the caecal wall.
- Contrast-enhanced CT showing liver metastases
- Several low-density metastases from a colonic primary tumor involving both lobes of the liver.
Older Staging Classification: Dukes' Classification
-
Dukes A: Confined to bowel wall (survival rate 90% at 5 years)
-
Dukes B: Through muscularis propria (survival rate 75% at 5 years)
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Dukes C: Regional lymph nodes (survival rate 30-60% at 5 years)
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Dukes D: Distant metastasis (survival rate 5% at 5 years)
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TNM staging is more comprehensive than Dukes' classification.
Treatment
- Depends on TNM staging and presentation
- Initial goal: Symptom control
- May need urgent intervention: Obstruction, bleeding
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Disease downstaging:
- Chemotherapy
- Radiotherapy
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Surgery: Usually necessary
- Chemo-radiotherapy can downstage to stage 0, and no resection is necessary
- Palliative treatment: If disease modifying fails
Surgical Options
- Right colon: Right hemicolectomy
- Left colon: Left hemicolectomy
- Sigmoid/upper rectum: Anterior resection
- Low rectum: Abdomino-perineal (AP) resection
Additional Treatment
- Pre-operative (neoadjuvant) chemoradiotherapy: Chemotherapy prior to surgery reduces local recurrence
- Post-operative (adjuvant) chemotherapy: For tumors with positive lymph nodes or evidence of vascular invasion
- Preoperative chemoradiotherapy for rectal cancer
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Palliative treatment: Unresectable metastases or unresectable tumors
- Chemotherapy
- Stents for obstructing colon tumors
- Surgery for obstruction or bleeding
Treatment of Rectal Cancer
- Upper 1/3 cancers: High anterior resection (no J-pouch)
- Middle and lower 1/3 cancers: Abdomino-perineal resection (APR) (usually for lesions involving the lower third of the rectum)
Screening for Colorectal Cancer
- Aim: Early detection and prevention of colorectal cancer
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Methods:
- Fecal occult blood testing (FOB)
- Colonoscopy
- Flexible sigmoidoscopy
- Stool DNA testing
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Description
This quiz explores various treatment strategies for rectal cancer, including surgical options, chemotherapy, and radiotherapy. You'll learn about palliative care, neoadjuvant and adjuvant treatments, and the specific surgical procedures for different parts of the colon. Test your knowledge on effective interventions and management of rectal cancer.
