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Surgery (Britney) > Bowel Cancer {AKA: Cancers of colon or rectum / Colorectal cancer} > Flashcards

Bowel Cancer {AKA: Cancers of colon or rectum / Colorectal cancer} Flashcards

1
Q

What are the risk factors of Colorectal cancer?

A
  • Familial Adenomatous Polyposis (FAP)
  • Hereditary Nonpolyposis Colorectal Cancer {AKA: Lynch syndrome}
  • Inflammatory bowel disease (i.e., Chron’s or Ulcerative colitis)
  • Family H/O bowel cancer
  • increased age
  • Diet high in red and processed meat and low in fibre
  • Smoking
  • Alcohol
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2
Q

What red flags would make you consider bowel cancer?

A
  • Change in bowel habit usually to more frequent and loose stools
  • Unexplained weight loss
  • Unexplained abdominal pain
  • Rectal bleeding
  • Abdominal or rectal mass on exam
  • Iron Deficiency Anemia (GI malignancies can cause microscopic bleeding)
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3
Q

what is Familial Adenomatous Polyposis (FAP)?

A

Familial Adenomatous Polyposis (FAP) is an autosomal dominant condition caused by a mutation in the tumor suppressor gene called Adenomatous Polyposis Coli (APC) on chromosome 5q22. It is clinically defined by the presence of more than 100 polyps (adenomas) growing in the large intestine

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4
Q

How do I diagnose Familial Adenomatous Polyposis?

A
  1. See more than 100 polyps growing in the large intestine under Sigmoidoscopy / Colonoscopy and histology
  2. Genetic testing for Adenomatous Polyposis Coli
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5
Q

What is Hereditary Nonpolyposis Colorectal Cancer (HNPCC)?

A

Hereditary Nonpolyposis Colorectal Cancer (HNPCC) is an autosomal dominant condition caused by mutations in the DNA mismatch repair genes called MLH2 & MSH2

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6
Q

Hereditary Nonpolyposis Colorectal Cancer (HNPCC) increase your risk of what other cancers?

A
  • Endometrial
  • Ovarian
  • Stomach
  • Small intestinal
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7
Q

who do l screen for bowel cancer?

A

Patients with the risk factors of:
* Familial Adenomatous Polyposis
* Hereditary Nonpolyposis Colorectal Cancer
* Inflammatory bowel disease

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8
Q

How do I screen for colorectal cancer in patients with FAP, HNPCC or IBD

A

Sigmoidoscopy / Colonoscopy q 1-2 years starting at 10-15 y.o.

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9
Q

What is? and Explain the diagnostic criteria for Hereditary Nonpolyposis Colorectal Cancer

A

The Amsterdam criteria states:
1. All 3 members in a family should have colorectal cancer- 2 of whom are 1st degree relatives

  1. In at least 2 consecutive generations
  2. At least 1 relative should have colorectal cancer under the age of 50
  3. FAP is excluded
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10
Q

What is Gardner’s syndrome?

A

Family Adenomatous Polyposis associated with:
* Desmoid tumor
* Osteomas
* Epidermoid cyst
* Congenital hypertrophy of the retinal pigment epithelium (CHRPE)

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11
Q

What is Turcot’syndrome?

A

Family Adenomatous Polyposis associated with:
* Central nervous system tumor
* Glioblastoma

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12
Q

What are the Treatment options for Family Adenomatous Polyposis ?

A
  1. Colectomy with ileorectal anastomosis (IRA)
                            OR
  2. Restorative protocoloectomy with J-pouch
                           OR
  3. Panproctocolectomy with End iloestomy
                             \+
    Sulindac 300mg BD + Aspirin 325mg OD
    (Decrease the size of polyps)
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13
Q

What is a Panproctocolectomy?

A

A Panproctocolectomy {AKA: Total Protocolectomy} is a total colectomy with removal of the large bowel, rectum and anus

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14
Q

What are the 4 Macroscopic types of Colon cancer?

A

1) Annular
2) Tubular
3) Ulcer
4) Cauliflower

Annular tends to give rise to obstructive symptoms, the others tend to bleed

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15
Q

Microscopically colon cancer is an?

A

Adenocarcinoma originating in the colonic epithelium

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16
Q

To check for local and distant metastasis, what tests do I order?

A
  • CT Chest, Abdomen & Pelvis with IV and oral contrast
  • Pelvic MRI with and without IV contrast: to determine T stage and N stage
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17
Q

Describe the CT Chest in the case of lung metastasis

A

In both lungs:

  • Green: multiple circumscribed nodules of varying sizes
  • Red: nodules with a small foci of air, may indicate small bronchioles or early cavitation
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18
Q

Describe the CT abdomen in case of Liver metastasis

A

Green: hypodense lesions throughout the liver

A: aorta
HV: hepatic vein
S: stomach
Sp: spleen
K: kidney
Pa: pancrease
IVC: inferior vena cava
SMV: superior mesenteric vein
VB: Vertebral body

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19
Q

What is the TNM classification of colorectal cancer?

A

T for Tumor
Tx: can’t assess size
Tumor invades the:
T1- submucosa
T2- muscularis propria
T3- subserosa & serosa (but contained)
T4a- visceral peritonium
T4b- adjacent organs & tissues

N for Nodes
Nx: can’t assess nodes
Nodal spread to:
N0- 0 nodes
N1-1-3 nodes
N2a- 4-6 nodes
N2b-7 or more nodes

M for nodes
Mx: no metastasis
Metastasis to:
M1a: 1 organ or site
M1b: > 1organ or site
M1c: peritonium (regardless of metastasis to other organs)

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20
Q

What is the Dukes’ classification of colorectal cancer?

A

Dukes A: confined to mucosa & muscular propria
Dukes B: invades through muscular propria
Dukes C: lymph node involved
Dukes D: metastasis present

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21
Q

Embryologicaly the Midgut develops into the?

A
  • Distal Duodenum
  • Jejunum
  • Ileum
  • Cecum
  • Appendix
  • Ascending colon
  • Proximal 2/3 of the Transverse colon
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22
Q

Embryologicaly the Hindgut (Endoderm) develops into the?

A
  • Distal 1/3 of the Transverse colon
  • Descending colon
  • Sigmoid colon
  • Anal canal above the pectinate line
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23
Q

Embryologicaly the Protodeum (Ectoderm) develops into the?

A

Anal canal below the pectinate line

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24
Q

The branches of the Superior Mesenteric artery and vein supplies and drains which parts of the large intestine?

A
  • Cecum
  • Appendix
  • Ascending colon
  • Proximal 2/3 of the Transverse colon
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25
Q

The Superior rectal artery and vein,both supplies and drains from the?

A

Rectum and Anal canal above the pectinate line

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26
Q

The Middle rectal artery and vein. Plus Inferior rectal artery and vein, both supplies and drains from the?

A

Rectum and Anal canal below the pectinate line

27
Q

The Superior Mesenteric vein drains into the?

A

Portal vein

28
Q

The branches of the Inferior Mesenteric artery and vein supplies and drains which parts of the large intestine?

A
  • Distal 1/3 of the Transverse colon
  • Descending colon
  • Sigmoid colon
  • Anal canal above the pectinate line
29
Q

What’s the function of the Ascending and Transverse colon?

A
  • Absorbtion of NaCl and water
  • Solidification of stools
  • Excrete K+ and HCO3-
  • Lubrication for the passage of feces
  • Colonic bacteria synthesize Vitamin K and B
30
Q

What’s the function of the Descending colon, Rectum & Anal canal?

A

Storage, propulsion and expulsion of feces

31
Q

Where does the large intestine begin and end?

A

begins at the ileocecal junction and ends at the anus

32
Q

The large intestine is made up of the?

A
  • Cecum
  • Appendix
  • Colon
  • Rectum
  • Anal canal
33
Q

The colon is subdivided into 4 segments, which are the?

A
  • Ascending
  • Transverse
  • Descending
  • Sigmoid
34
Q

What 3 anatomical features distinguishes the large intestine from the rest of the GI tract?

A
  1. Omental appendices (epiploic appendages)
  2. Teniae coli
  3. Haustra coli
35
Q

What is the Hepatic flexure / Right colic felxure?

A

The Hepatic flexure is the curved part of the ascending that turns right into the Transverse colon

36
Q

What is the Splenic Flexure / Left colic flexure?

A

The Splenic flexure is the curved part of the Transverse colon that turns down into the Descending colon

37
Q

The Superior mesenteric lymph nodes drains from the?

A

Colon to Splenic flexure

38
Q

How does Colorectal cancer spread?

A

Colorectal cancer may spread:
1. Directly in a radial, longitudinal or transverse patern to adjacent tissues

  1. Hematogenous:
    * colon cancers spread to the liver fisrt via the portal vein
    * Rectal cancers spread to the lungs first via the Inferior vena cava vein
  2. Lymphatic spread
39
Q

if the cancer has spread to the liver, what symptoms would manifest?

A
  • Ascites
  • Abdominal distention
  • Hepatomegaly, RUQ pain
  • Jaundice
  • Anorexia
  • Early satiety
40
Q

if the cancer has spread to the lungs, what symptoms would manifest?

A
  • Dyspnea
  • Cough
  • Hemoptysis
  • Pleural effusion
41
Q

if the cancer has spread to the peritoneal surface, what symptoms would manifest?

A
  • Ascites
  • Abdominal distension
  • Diffuse Abdominal pain
  • Bowel obstruction
42
Q

If a patient presents with the red flags of colorectal cancer, what diagnostic test do l order?

A
  1. Digital rectal exam
  2. Colonoscopy (or CT Colonography if unfit for colonoscopy)
  3. CBC
  4. LFTs & Coags (maybe abnormal in liver metastasis)
43
Q

What would be some of my positive findings on DRE?

A
  • Distal rectal cancers maybe palpable
  • Blood on DRE may indicate CRC
44
Q

What would be some of my positive findings on colonoscopy?

A

Seeing a Ulceroproliferative friable mass

Optain a biopsy to confirm the diagnosis

45
Q

When would you do a Double - contrast barium enema?

A

When the patient either declines of is less fit for a CT Colonoscopy

46
Q

What is a Double - contrast barium enema?

A

x-rays of the colon and rectum are taken after rectal administration of a contrast agent

47
Q

What are some positive findings on a Double - contrast barium enema?

A

Apple core lesion (AKA: napkin ring sign) typically caused by colorectal cancer or esophageal cancer.

But in this case, it is the result of It is the result of annular constriction by a colorectal carcinoma

48
Q

What types of resection are available for Colon cancer

A
  • Right hemicolectomy
  • Extended right hemicolectomy
  • Left hemicolectomy
  • Extended left hemicolectomy
  • High anterior resection (AKA: Sigmoid colectomy)
49
Q

What types of resection are available for Rectal Cancer?

A
  • Low anterior resection
  • Abdomino-perineal resection
50
Q

What is a Right Hemicolectomy?

A

A Right Hemicolectomy involves removal of the:
* Distal ileum
* Ileocecal vale
* Caecum
* Ascending colon
* Hepatic flexure
* Proximal 1/3 Transverse colon

With ligation of the:
* ileocolic artery
* Right colic artery
* Right branch of the Middle colic artery

Then reconstruction via ileocolic anastomosis, that’s either:
* End-to-end
OR
* End-to-side
OR
* Side-to-side

51
Q

What are the indication for a Right Hemicolectomy?

A

Tumor in the Caecum & Ascending colon

52
Q

What is a Extended right hemicolectomy?

A

Right Hemicolectomy +
* Transverse colon resection
* Middle colic artery

With ligation of the:
* Ileocolic artery
* Ileal arteries
* Right & Middle colic arteries

Then reconstruction via ileocolic anastomosis, that’s either:
* End-to-end
OR
* End-to-side
OR
* Side-to-side

53
Q

What is the indication for a Extended right hemicolectomy

A

Tumor near the Hepatic flexure or in the **Proximal **or Middle Transverse colon

54
Q

What is a Left Hemicolectomy?

A

A Left hemicolectomy involes removal of the:
* Distal 1/3 of the Transverse colon
* Splenic flexure
* Descending colon
* Sigmoid colon

With ligation of the:
* Inferior Mesenteric artery
* Left branch of the middle colic artery

Then reconstruction via end-to-end colorectal anastomosis

55
Q

What is are the indications for a Left hemicolectomy?

A

Tumor in the Descendng colon

56
Q

What is an extended Left Hemicolectomy?

A
57
Q

What is a High anterior resection?

A

A High anterior resection involves removal of the:
* Sigmoid colon
* Sigmoid and superior rectal arteries

With ligation of the:
* Inferior mesenteric artery near its origin from the aorta or distal to the origin of the left colic artery

58
Q

What is the indication for a High Anterior Resection?

A

Tumor in the sigmoid colon

59
Q

What is a Low anterior resection?

A

A Low anterior resection involves removal of the:
* Sigmoid colon
* Upper rectum but spearing the Lower rectum and Anus

With ligation of the:
Inferior mesenteric artery either near its origin from the aorta or distal to the origin of the left colic artery.

Then reconstruction via:
* Transverse coloplasty
OR
* Colonic J-pouch
OR
* Coloanal atomosis that’s either:
- End to End (AKA : Straight)
OR
- Side to End

60
Q

What is an Abdomino-perineal resection?

A

An Abdomino-perineal resection involves removal of the:
* Rectum
* Anus
* Sigmoid colon

With ligation of the:
Inferior mesenteric artery either near its origin from the aorta or distal to the origin of the left colic artery.

Then reconstruction with:
* An End Colostomy
&
* Suturs are placed over the anus

61
Q

What is an indication for Abdomino-perineal resection?

A

Tumor in the rectum, close to the anal sphincter

62
Q

What are some Chemotherapy regimens after surgery?

A

FOL F OX:
Folinic acid (Leucovorin) +
5 Fluorouracil (5-FU) +
Oxaplatin

                              OR

FOL F IRI:
Folinic acid (Leucovorin) +
5-Fluorouracil (5-FU) +
Irinotecan

                              OR

CAPOX:
Capectiabine +
Oxaplatin

63
Q

If there’s metastasis, what do I add to the chemotherapy regimen?

A

Biologics:
An:

  • Anti-VEGF antibody (eg, Bevacizumab)

OR
* EGFR antibody (eg, Cetuximab)

64
Q

Who gets chemotherapy in Colonrectal cancer?

A

Surgery (Britney) (6 decks)

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