7/31/2019 Oncology - Colorectal Cancer Briefly
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Colorectal Cancer
Typical HPI Past History
Examination
Laboratory Investigations
Staging
Management Strategies
Dukes A
Dukes B
Dukes C
Dukes D
Palliative
Follow-Up
Chemotherapy RadiotherapySurgery
Over 40 y. o.MaleWestern
Rectal BleedingChange in bowel habitIncomplete emptyingpencil
stoolsWei ht Loss
FeverAbdominal PainConstipationDistension + colicBone ain
Smoking, Alcohol, Dietary excess of animal protein and fatFamily
history of early onset bowel cancer, polyps, other cancersSedentary
lifestyle / lack of exercise / fluctuating weight + Obesity
LOOK FOR:JaundicePallor
CachexiaPrevious surgery
PALPATE FORMass
Abdo distensionAbdo tenderness
Liver + SpleenLymph nodesHernia orificesBony tenderness
AUSCULTATEHeart soundsLung fieldsBowel sounds
PELVIC EXAM- 10% are palpableExamine anus, rectum, perineumLook
for ballooning + anal toneBlood on the glove? Haemorrhoids?
NEURO EXAMFocal signsIncreased ICPMMSE
Faecal Occult Blood Test (FOBT)Must be performed 3 times
Carcinoembrionic Antigen (CEA)To have a baseline before
surgeryBUT: 1) CEA is also elevated in hepatic and pancreatic
cancer
2) Low post-op CEA does not exclude recurrence
Full Blood Count, Electrolytes, BiochemistryPre-operative
assessment, Anaemia, hypercalcaemia,thrombocytopenia
Liver Function TestsMainly checking for metastasis
? PT + APTTreasons for blood in the stool may be haemostasis
disorder
Histopathology of biopsy sampleHistological subtype and degree
of differentiation are necessaryfor decision-making in
management.
Imaging Investigations
Abdomen X-rayLooking for distended small bowel loops with gas,
or bony disease
Chest X-rayLooking for lung opacities, for baseline
Barium EnemaLooking for site of obstruction, Apple Core
appearance
CT Scan of chest, abdomen & pelvis
Lymph node involvementextension into adjacent organsmetastasis
to liver, kidneys, lungs, etc
Proctoscopy, Sigmoidoscopy, ColonoscopyGold standard: visualise
lesion, take sample, snip polyps
Trans-rectal Ultrasound
Dukes:A-B-
C-D-
Which risk category?
Limited to mucosa + submucosa
extends into the muscularis (B1),into or through the serosa
(B2)
Involves nodesIs metastatic
Mainstay of treatmentTemporary colostomy unless FAP +ve( FAP =
remove whole bowel)
Limited use Limited use
Remove primary cancer+ whatevertissue it adheres to. + temp
colostomyPathology check margins clearance
Should be offered 5FU + leukovorin
Better rates of local control with 45/25(fewer recurrences over
5yr interval)esp. locally advanced disease
Remove bowel + any involved nodesColostomy or ileostomy
Should be encouraged;improves survival
Better rates of local control(fewer recurrences over 5yr
interval)esp. locally advanced disease
De-bulking surgery if appropriateUsually inoperable
Palliate symptoms of metastaticspread; occasionally
remission
Control of bony met painAlleviate effects of brain mets
Oral pain control with MS contin, oral morphine; battery of
analgesics (but dont superimpose opiates)Bony met pain + neuropathy
= controlled with tricyclics, Ketamine, anticonvulsants eg.
valproateKey words: Dignity, comfort, daily activity assistance and
counselling of end-of-life decisions
BioPsycho
Social
Stoma specialistCounselling (esp. regarding sexuality,
fertility)Psychiatrist
Occupational therapistGenetic counselling
Bowel Cancer Support network
DietitianLegal advice re. enduring
guardianship, will etc
DUKES A to CRegular and frequent occult blood orcolonoscopy of
remaining colon for 5 yearsYearly FOB thereafter
METASTATIC or HIGH-GRADE DISEASECT scans every 2 months while on
chemo,Regular follow-up until next recurrenceis identified
PALLIATIVERegular monitoring of pain status and QOL,with
relevant alterations to management strategy
Risk categories1
2
3
No Hx, or one 1st or 2nd degreerelative hand cancer after 55
y.o
One 1st degree rel. before 55 y.oor two 2nd degree rels of any
age
Identified mutation eg. FAP, HNPCCMultiple cancer Hx throughout
family
NHMRC doc cp64; eMedicine; Harrissons; NIH website, Cancer
Medicine 5th ed
Pattern of spreadLungs, Liver,Brain and Bone
Screening recommended for over 50sDigital Rectal exam + FOB
annuallyDouble-contrast barium enema every 5 10 yearsFlexible
sigmoidoscopy every 5 years
