Colorectal Cancer & Diverticular Disease 2024 - RCSI PDF

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Title Colorectal Cancer Thomas N Walsh Class Year 2 Course Surgery Year 2024 LEARNING OU...

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Title Colorectal Cancer Thomas N Walsh Class Year 2 Course Surgery Year 2024 LEARNING OUTCOME Discuss the aetiology of colorectal cancer Describe the presentation of colorectal cancer List the chief investigations for staging colorectal cancer Describe tumour staging with TNM/Duke’s classification Illustrate the different types of colonic resections Demonstrate an understanding of screening for colorectal cancer INTRODUCTION Second commonest cause of cancer death in UK and Ireland and in third commonest in Bahrain Highest incidence in western world M:F = 3:1 Peak incidence = 55-75years Adenocarcinoma RISK FACTORS Family History (HNPCC 5%, FAP 1%, Juvenile polyposis). – 2 first degree relatives 1/6 lifetime risk Colonic polyps Low fibre / fruit / veg diet Obesity Male Age (highest incidence at age 55-75) Smoking Chronic ulcerative colitis or colonic Crohns disease (UC is a greater risk factor than Crohns) Gardners Syndrome Peutz-Jehger Syndrome  PRESENTATION - SYMPTOMS Right sided lesions Constitutional Symptoms Stools liquid Weight loss Symptoms of Iron deficiency anaemia Lower abdominal pain Left sided lesions Stools semi-solid PR Bleeding (blood mixed with stool) Emergency presentation Change in bowel habit (40% - as emergencies Rectal Lesions Large bowel obstruction Stools solid Perforation / peritonitis Blood on stool surface Acute PR Bleed Tenesmus  PRESENTATION - SIGNS Majority have none Anaemia Blood per rectum or on stools Abdominal mass Rectal lesion on PR exam (within 10 cm of anal verge) Hepatomegaly (metastatic) Cachexia  TUMOUR SITES Rectum 30% Descending and Sigmoid 45% Right sided 20% Transverse 5% WORKUP Bedside Imaging Laboratory Investigations Investigations History & Erect CXR (? FBC, U&E, Examination perforation) Coagulation profile Digital Rectal Exam & Abdominal X-ray CRP Fecal Occult Blood Erect and supine if (FOB) obstructed Vitals (02 sats, BP, CT Abdomen & Pelvis LFT’s (?mets) HR, RR, Temperature) ECG CEA (raised in 60% with colorectal cancer, useful for monitoring disease) Urine dipstick +/- VBG/ABG (lactate) beta hCG Glucose check  ENDOSCOPY ESSENTIAL FOR DIAGNOSIS Must get a tissue diagnosis!! (Biopsy) Endoscopic Biopsy Access Rigid sigmoidoscopy Flexible sigmoidoscopy Colonoscopy essential to examine the entire colon IMAGING CT TAP ESSENTIAL FOR STAGING If biopsy - cancer, CT Thorax, Abdomen, Pelvis (TAP) to check for spread of disease This is called Staging Staging based on TNM classification T = Tumour 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 the colonic primary tumor involve 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! TREATMENT Depends on TNM staging + Presentiation Aim of Treatment: Symptom control (initially) May need urgent intervention – obstruction, bleeding Disease downstaging – Chemotherapy – Radiotherapy Surgery usually necessary Chemo-radiotherapy may downstage to Stage 0 and no resection necessary Palliative - if disease modifying fails TREATMENT Anterior resection Surgery – Right colon – Right hemicolectomy – Left colon – Left Hemicolectomy – Sigmoid /upper rectum – Anterior resection – Low Rectum – Abdomino-perineal (AP) resection Abdomino-perineal resection + Colostomy ADDITIONAL TREATMENT Pre-operative (Neoadjuvant) chemoradiotherapy – Chemotherapy prior to surgery. This reduces local recurrence Post-operative (Adjuvant) chemotherapy – Tumors with positive lymph nodes or evidence of vascular invasion Preoperative chemoradiotherapy for rectal cancer Palliative - 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