Cancer 2- Colo-rectal Cancer Flashcards
Anatomical Layers of the bowel, lumen the….6
Why do we stage? 2
Staging vs Grading Def
AJCC/ TNM Staging Tx T0 Tis T 1,2,3,4 Nx N0 N1, 2 Mx M1
Lumen, Mucosa, Muscularis Mucosae, Submucosa, Muscularis propria, Subserosa, Serosa
Why Stage? Prognosis and treatment
Stage= Spread Grade= Severity of the cancer
TNM Staging:
Tx- Primary tumour cannot be assessed
T0- No evidence of primary tumour
Tis- Carcinoma insitu (intraepithelial or invasion of lamina propria)
T1- Invades submucosa
T2- Invades muscularis propria
T3- Invades though musc prop, into subserosa or into non-peritonised pericolic or perirectal tissues
T4- Directly invades other organs or structures and perforates visceral peritoneum
Nx- Regional lymph nodes cannot be assessed
N0- No regional lymph node met
N1- Met 1-3 regional lymph nodes
N2- >4 regional lymph nodes met
Mx- Distant met cannot be assessed
M1- Distant met present
Stages 0,1,2,3,4 in respective of TNM (draw table)
Grading
Grade 1
Grade 2
Grade 3
3 pathologies leading to colorectal cancer
- (most common) - -
What else is given on the pathology report? Staging, Grading, - - - mutations such as 3egs - MMR or MSI
What is MMR or MSI
Name 3/4 MMR
Name of the Syndrome for hereditary cause of colorectal cancer aka….
Deficit in… therefore…
Another syndrome to be aware of
Stages T N M
0 Tis N0 M0
1 T1 or 2 N0 M0
2 T3 or 4 N0 M0
3 any T N1 or 2 M0
4 any t any 2 M1
- Adenocarcinoma (can be well or mod differenciated)
- Mucinous carcinoma
- Colloid carcinoma
What else? - Vascular or lymph invasion - R0, R1, R2 (Resection - Mutations such as BRAF, KRAS, NRAS MMR or MSI Micro-Satellite Instability (MSI) or DNA Mismatch Repair (MMR), essentially shows there reponse to chemo
MMR: MLH1, MSH2, MSH6, PMS2
If you care MMR proficient then you’re MSI stable/low
If you are MMR deficient then you’re MSI in stable/high
Lynch Syndrome eg Hereditary non-polyposis Colorectal cancer (HNPCC)
Deficit in MSH2 and/or MSH6 therefore increased risk of lots of cancers before the age of 50 eg. uterine, gastric,liver
FAP- Familial adenomatous polyposis, rare, inherited condition caused by a defect in the adenomatous polyposis coli (APC) gene. (think no destruction complex)
Surgical treatment depends on 4/5
5 types of surgery and anastomosies depending on location
Other procedures:
3
- Tumour location and spread
- Blood supply
- Lymphatic drainage
- Patient fitness eg. CPET cardio pul exercise testing for V02 and anaerobic threshold
- Patient choice!
Surgery:
- R hemicolectomy = caecum, ascd, prox trans (iliocolic anastomosis)
- Transverse colectomy (Anastomose ascending + desceding)
- Extened R hemicolectomy (iliocolic anastomosis)
- L hemicolectomy = distal trans, desc colon (anastomose sig + transverse)
- Sigmoid colectomy= just sig (anastomose rectum and descending)
Other:
- Endoscopic stent (emergency obstruction but still need elective surgery for met)
- Stoma not functioning/ leaky
- Met disease but not for surgery
Adjuvant=
Neoadjuvant =
Radiotherapy 1 Chemo - what stage to use? - FOLFOX regimen consists of 3 Biotherapies 2egs and target
Adjuvant= applied after initial treatment for cancer to decrease risk of secondary tumour Neoadjuvant = applied before main treatment (surgery) to reduce size for resection
Radiotherapy- usually used palliatively in colon cancer, occassionaly used pre-op for resection to occur
Chemo- If stage 3 (Any T, N1/2, M0) can reduce up to 30% recurrence, stage 2 more individual approach.
- Use FOLFOX regimen:
folinic acid (also called leucovorin, FA or calcium folinate)
fluorouracil (5FU)
oxaliplatin
Biotherapy
Bevacizumab= anti VEGF
Cetuximab or Panitumumab = anti EGFR
2 Types of stoma first type - location - looks like - temporary dysfunction of bowel by.... but why? - Then elective... - Reversed by....
second type
- location
- looks
- temp….
- permanent end colostomy via 1) 2) 3)
Ileostomy:
- RIF
- Skin protrudes (spouted) and active enzymes present so skin needs protecting
- temporary dysfunction the colon a loop ileostomy can be performed just to control peri-anal Crohns
- End ileostomy follows/ subtotal colectomy
- Can be reversed by joining ileum to upper anal canal
Colostomy
- LIF
- Flush/ flat
- Temp loop colostomy as two stomas form and seperated by a bar, prox passes faeces and distal passes mucous
- End colostomy as bowel completely divided and distal end brought out 1) AP resection (abdo-perineal) 2) closed + left in abdo (Hartmann’s procedure) 3) exteriorized forming mucous fistulae
Name the 4 herreditory risk factors for CRC
1) FAP
Familial Adenomatous Polyposis
2) HNPCC/ aka Lynch Sydrome
Hereditery Non- Polyposis Colorectal Cancer
3) Juvinile Polyposis
4) Peutz- Jeghers syndrome
Staging in Colorectal cancer is called... and the survival percentages A 2 B 3 C 2 D 3
Dukes Staging:
Dukes A 90%
- Cancer grown into inner muscle layer of bowel wall (muscularis mucosae)
- Not spread to lymph nodes or other parts of the body
Dukes B 70%
- Grown through muscularis propria or serosa
- May be invading surrounding tissues
- Not spread to lymph nodes/ other parts of body
Dukes C 30%
- Cancer can be any size but SPREAD to near by lymph nodes
- not spread to other parts of body
Dukes D <5%
- Cancer any size
- May or may not have spread to nearby lymph nodes BUT has spread to distant parts of the body
CCR screening What test? How often? Who? From what ages?
CCR Screening Test: Faecal Immunochemical Test Every 2 years Men and Women 60- 74 yo
Investigations of CRC
First step and 3 positives
If cant do first line then 2 other options
What is CEA and what is used for?
First Line: Colonoscopy
- Visually see abnormalities
- Can take biopsy
- Can remove any polyps
2nd Line: Colonoscopy under CT but cant do biopsy
Pelvic MRI- better quality for invasion/ spread
- Carcinogen Embryonic Antigen
It is not diagnostic but it can show response to treatment
Management
What do stages I-III benefit best from?
Surgery
Cecum or Ascending colon
Distal transverse of descending
Sigmoid
Rectal Surgery:
When to do an anterior resection?
When to do an AP Resection (abdo-perineal resectnion?)
I-III benefit from surgery ad post-op chemo
Surgery:
Cecum or Ascending colon
- Right Hemicolectomy
Distal transverse or descending
- Left hemicolectomy
Sigmoid
- sigmoid colectomy
Rectal Surgery:
- If > 8cm from anal canal or involves 2/3 of proximal rectum then
Anterior resection
- If < 8cm from the anal canal or involves distal 1/3 of the rectum
Chemotherapy
What drugs are in the FOLFOX regimen?
Name a monclonal antibody used and what it does?
- FOLinic acid
- Flurouracil
- Oxilaplatin
Cetuximab- anti EGF
used in stage 4/ metastatic
Acute bowel obstruction?
In palliative patients?
- Do a Hartmanns procedure where they resect the rectosigmoid and form a temporary end colectomy and anorectal stump
Palliative- can stent open bowel
FAP Mutation of? Inheritance pattern What happens? What else are you at high risk of developing?
Extra- Gardners Syndrome
form 3 things
FAP
Mutation of?
APC
Inheritance pattern
Autosomal dominant
What happens?
Lots of adenomatous polyps form in teens and this means you will most likley develop CRC in 20s
What else are you at high risk of developing?
- Duodenal cancer
Extra- Gardners Syndrome
- Epidermal cysts
- Thyroid tumour
- Supernumary teeth
HNPCC Mutation of? Inheritance pattern Risk? What else are you at high risk of developing? - - - -
HNPCC
Mutation of?
MLH1/ MSH2 which are mismatch repair genes
Inheritance pattern
Autosomal dominant
Risk?
80% chance of CRC by 30s
What else are you at high risk of developing?
- Prostate cancer
- Breast cancer
- Gastric cancer
- Endometrial cancer
Peutz- Jeghers Syndrome
Mutation of?
Inheritance pattern
What happens?
Peutz- Jeghers Syndrome
Mutation of?
STK 11
Inheritance pattern
Autosomal dominant
What happens?
Present in teens with mucocutaneous pigmentation and hamartmous polyps
Hamartmous polyps have low risk of turning neoplastic but the sheer number of them leads to an increase risk.
