Colorectal Flashcards
Treatment of Haemorrhoids
Conservative - Stool softness and anasol to reduce pain - likely ineffective
Grade 1-2 - Injection sclerotherapy, laser, RFA (Rafaelo), banding
Grade 2-3 - Banding vs HALO / THD - Hubble trial showed banding cheaper and equally effective but less pain
Grade 3-4 Stapled vs Open - eTHOS trial - open better quality of life
Risks of open haemorrhoidectomy
Pain - analgesia and laxatives as well as 5/7 metronidazole
Bleeding - around 7-14/7 (wound infection)
Infection - unusual
Urinary retention (more common in men)
Stenosis - Late complication - may require dilatation
Faecal incontinence - minor seepage common in early post-operative period
Treatment of fissure
Conservative, fibre, fluids, laxatives, sitz baths
Medication - 2% Diltiazem cream or GTN - twice a day for -8 weeks
Surgical - EUA and Botox
Shown to be effective in 80% of patients
Need to organise Flexi to rule out lesion when fissure healed
Chronic non- healing fissure post Botox
Reassess and confirm diagnosis - rule out underling anal SCC, infection (herpes, syphilis, TB.
Investigate - Physiology studies inc ends-anal ultrasound
Can consider repeat botox or lateral sphincterotomy if fissure confirmed (men initially - females need study)
Lateral Sphincertotomy
GA, Lithotomy
Intersphincteric groove identified and small incision made (11 blade).
Intersphincteric and submucosal planes developed and internal sphincter divided to length of fissure
85% change of healing - 5%risk of faecal seepage or soiling
Non - healing post Lateral Sphinctertomy
Anal manometry studies to assess high vs low pressure
Low presuure - advancement (VY) flap)
High pressure -biofeedback, botox and repeat lateral/opposite side
Rectal cancer found at colonoscopy
Complete Colon, take biospies, rule out synchronous disease. Note size, location, distance from anal verge, fixity and if obstruction. Also anal tone
CT, Chest, abdo, pelvis and MRI rectum
Bloods including baseline and CEA
Use of endoanal US
Consider if early cancer and considering TAMIS, TEMS, TEO
ACPGBI - early rectal cancer T1 - diameter <3cm, no Lymphovascualr invasion and well or moderately differentiated
Low rectal tumour
MRI based - Tumour with lower edge at or below origin of levators at pelvic side wall.
Approx <6cm of anal vegetables
When to use Neoadjuvant Tx in rectal cancer
Not required in resectable cancers no involving CRM (T1-3, N0-2 M)
Needed if high risk of local recurrence (T3c (5-15mminto mesorectum), EMVI or mesolectal LN), tumour involving or beyond the mesolectal fascia
What is long course Chemo-rad for rectal Ca and Short course
45Grays in 25 fractions with synchronous 5FU or oral capecitabine - normally over 6weeks
Restage in 8-12 weeks if patient Fit - PET-CT and MRIcould be considered
Short course is 25Gry over 5 days
TME
Total mesorectal Excision
Optimal surgery - popularised by Prof Heald
Reduces local recurrence and rates of APER
Bowel Prep for L sided resections?
Reduced stool burden and makes stapling easier
Difficult for patients and risk of dehydration or liquid stool if timed poorly
GRECCAR3 2010 showed reduced septic complications with prep, ESCP 2017 showed reduced leak rates with Prep and antibiotics.
American society of colon and rectal surgeons recommends Abx and prep
Nerve injury in pelvic surgery
Ligation of IMA and rectrorectal space - Superior hypogastric plexus or hypogastric nerves
Disection of lateral rectal ligament - Nervi erigentes
Division of Denonvilliers fascia - inferior hypogastric plexus
Perineal dissection - pudendal nerve
Functional outcomes - difficulties in bladder emptying, erectile dysfunction and an-orgasmia
Risk factor for leaks
Male, bulky tumour, DM, pulmonary disease, vascular disease, smoker, obesity, malnutrition, immunocompromised, difficult procedure (Contamination, blood loss, transfusion, use of inotropes, >4hrs)
Anal Cancer Hx
Symptoms - pain, bleeding, pruritus, faecal incontinacne, Anal receptive inercourse, STD, HIV, Cervical or vulval intraepithelial neoplasia in women
Examination - inguinal lymphadenopathy, DRE
Differentials for Anal Cancer
Cancer, fissure, Crohns, Excoriation associated with pruritus Ani, Chancroid, Nicorandil induced anal ulcer
Staging Anal Cancer Ix
Ct chest, abdo, pelvis
MRI pelvis
CT PET - improves loco-regional LN staging and helps planning for radiotherapy - used in high risk (T2–>)
LN Anal SCC
14% of cancers have LN at presentation
>40% not clinically decidable as <5mm
CLN can be reactive or mets
If high uptake on PETCT or MRI then FNA not required
Should be included in Radio unless small T1 lesion
Treatment Anal SCC
Local resection small and T1
All others
Nigro Protocol 50.4Gray radiotherapy with mitomycin -c and 5FU or capecitabine
Possible need for defunctioning stoma
Follow Up Anal SCC
Primary aim to detect disease for surgery Secondary aim is to assess symptoms
Initial Clinical assessment at 6-8 weeks then every 4-8 weeks until clinical and radilogical complete response (can take 6 months)
After complete response - ACT 2 trial
Every 2 months for first year
Every 3 months for second year
Every 6 months 3-5yrs
CT C/A/P first at 12-18months then 24-36 months.
Most failures (Round 80%) occur within 2 years
Recurrent Anal SCC
Reassess, EUA, CT and MRI
Can consider for salvage surgery (50-75%) conversion for persistent or recurrent.
May need radical ischia-anal APER or Exenteration
Distant Mets in Anal SCC
Usually considered palliative
Palliative Chemo - Cisplatib with 5FU or capecitabine
IF small and resectable can occasionally consider resection
FOxTROT trial
Investigate neoadjuvant vs standart post Op Chemo for locally advanced operable colon cancer
6weeks pre-op Oxaliplatin and fluropyrimidine chemo plus post op tx
or
only 24 weeks post op Chemo
Outcomes
Neoadj led to significant down staging, improved Ro reaction, reduced 2yr recurrence rated also less serious post-op complications
Addition of panitumumab offered no extra benefit.
Survival Rates for Colon cancer
Overall 5yr survival rate is 60%
Stage 1 approx 95%
Stage 2 85%
Stage 3 65%
Metastatic or stage 4 colon cancer approx 10%
CME - Complete mesocolic excision
Described by Hohenberger 2009
3 main principles
1)Disection along embryological planes (keeping visceral fascial layer intact)
2)Transection of vascular pedicles (SMV -right, IMA - Left)
3) Appropriate longitudinal resection margins
FAP
Autosomal dominant
Germline mutation of APC on 5q
20% occur due to new mutation
If left untreated have CRC by 40
Extra-colonic manifestations of FAP
Congenital hypertrophy of retinal pigment epithelium
Osteomas of skull and mandible
Dental abnormalities
Epidermoid cysts and firbomas
Desmoid tumours
Fundic glad polyps
Duodenal and periampullary polyps - duodenal cancers
Associated with other cancers - medulloblastoma, hepatoblastoma, thyroid cancer, gastric cancer, pancreatic cancer and adrenal caner
Turcot syndrome - colonic polyps and brain tumour
Gardner syndrome - dermoid, thyroid and oestomas wit colonic polyposis
APC surveillance
Annual Colonoscopy and polypectomy till surgery starting at 12-15
OGD (side viewing scope) from 25 to 30 depending of spigelman stage
-Stage 0-1 5yrs
-stage 2 -3yrs
-stage3 - 2yrs
-stage4 - consider surgery
Treatment of dermoid tumours
Occur in approx 15% of patients
Benign and rarely Met but can cause compression
Sulindac with Tamoxifen with intra-abdominal and abdominal call desmoid
Chemo/radio for larger or rapidly growth tumours
Surgery is controversial and risky
Timings for surgery in FAP
No guidelines
Consider when large number of larger adenomas (>5mm) or adenomas with high degree of dysplasia
Usually between 15-25 to avoid major disruption to life
Counselling for a pouch
Get to meet Pouch patient and specialist nurse
Good function is 4-6 motions and day and 2 at night - 50% need loperamide to achieve
Complications
20% have complications
25% need readmitting within 30days
1in17 need re-operatio
10-15% rate of failure at 10-25yrs
Anastomotic leak 5%
Pelvic sepsis 15-20%
Pouchitis 10%
Adhesions, strictures and SBO approx 20% (half need surgery)
Reduced fertility, impotence and ED
Mortality is low at <0.5%
Investigations of Faecal incontinence
Colonoscopy, anal manometry and endoanal ultrasound
Mangement for low pressure incontinence and no defects
Initially - dietary modification, bulking agents and loperamide.
Can consider glycerol suppositories to empty
If unsuccessful the refer to specialist nurse for pelvic floor exercise, biofeedback and consideration of rectal irrigation
Sacral Nerve stimulation
Cochrane review 2015 - supported use for faecal incontinence
Trail period - temp leads into S3 foramen each side (bellows from elevator and plantar flexion or toe). Connected to external stimulator for 5-7 days. Bowel diary is kept and compared to baseline. If >50% improvement is deemed success
Complications 10% (infection, bleeding, serum, pain, nerve injury, new defacectoy problems
Need to treat like a pacemaker - MRI and diathermy
Follow up - every 6-12months
Succesfull in around 80% of patients
Treatment options for incontinence
Posterior tibial nerve stimulation - NICE approved - 12 sessions leading to 50-70% success
Anal plugs
Sphincter repair if defect
Artificial Neo-sphincters (magnetic FENIX)
Buling agents
Evaluation of Prolpase
Hx - possible concomitant slow transit constipation, obstructive defaecation and faecal incontinence
Urinary incontience and vaginal prolapse
Examination - Abdo and PR. Inspect for apparent prolapse, perianal scars, deformity and evidence of soiling
Ask patient to bear down and look for rectal or mucosal prolapse and perineal decent
On DRE try to assess for rectal prolapse take-off (high or low) and note if anus is patulous
Assess anal tone at rest and squeezing or sphincter defects
Associated vaginal prolapse
Perform proctoscopic examination
Surgical repair of prolapse
Split into Abdominal or perineal approach
Cochraine review 2008 no difference in recurrence rate and PROPSPER trail in 2013 again showed no difference in rates
If young and healthy - Lap Ventral rectoplexi - Pelvic Floor Society in UK statement mesh lower risk than in transvaginal procedures
If old
<5cm Delormes
>5cm Altemeiers (Perineal proctosigmoidectomy)
Define Functional Constipation
Rome 4 Criteria (fulfilled for <3/12 with symptom onset at least 6/12 prior)
1) Two or more of the following in at least 25% of defecations: Straining during lumpy or hard stools; sensation of incomplete evacuation,; sensation of anorectal obstruction or blockage; manual manoeuvres to facilitate; Fewer than three delectations per week
2) Loose stools are rarely present without laxatives
3) Insufficient criteria for IBS
Constipation investigate
Bloods - FBC, UE, LFTs, Calcium, TSH
Colonoscopy
Colonic transit studies and defaecating proctogram (if indicated)
Chronic Conspitation Tratment
Initially - dietary fibre, fluid and laxatives
Then - Specialist nurses, biofeedback and rectrograde irrigation
Second line - NICE - prucalopride (failed 2 classes laxatives at highest tolerated dose for >6months and invasive tx being considered. Trial period of 4 weeks - if no better need to evaluate if to continue or if >3month period of use then need to evaluate at regular intervals
Prucalopride mechanism of action
Highly selective 5-HT4 receptor agonist - stimulates motility
Originally only approved in women as they made up approx 90% of the study population
RCT in 2015 confirmed safety and efficacy in men
Surgery for Constipation
ACE - Integrate colonic enema - appendix used as stoma with washout every 1-2 days
Ilestomy is an option (reversible)
Subtotal and ileorectal anastomosis
Classification of fistula in ano
Parks Classification
1) Intersphincteric (70%)
2) Transsphincteric (25%)
3)Suprasphincteric (5%)
4) Extrasphincteric (1%)
Colonic Stenting
Self expanding metal stent can be using as bridge to surgery or palliative measure
CREST trial showed reduced stoma formation with adverse impact on survival
SCOTIA trial
Subtotal colectomy (47) vs segmental and primary anastomosis (44) for left sided obstructing tumours.
No difference in mortality and complication rated. Bowel problems more common after segmental.
Concluded that segmental resection following intra-operative irrigation is preferred option (exception of catcall perf or synchronous neoplasm)
Pouchitits
Aprox 50% of patients will develop acute pouchitis during first 10yrs
More common in Crohn’s vs UC vs FAP
Review histology (missed Crohn’s), confirm diagnosis with Endo examination - inflammation and biopsies for histology and CMV. Look for cuff-its, stricture or ischaemia
Stool sample to exclude infection
Stop smoking
Treat with 2/52 Cipro or metro, second line is budesonide enemas at bedtime (effective as metro)
Probiotic VSL #3 effective in mildly active pouchitis
Puch-itis scoring
Pouch-itis Disease activity index (PDAI) - based on clinical, end and hits.
Diagnosis suggested if >7
Chronic Pouch-itits
Symptoms lasting over 4 weeks - occurs in approx 10% of patients
Discuss case at IBD MDT
Remission induced in around 80% of patients with combination of 2 abxs
Oral budesonide (9mg OD 8/52), oral beclomethasone and topical tacrolimus are alternatives
If Chronic refractory can consider Imfliximab as effective Tx
IF still ongoing can consider further medical Tx (Budesonide or azathioprine) or excision of pouch)
Screening for at risk CRC family
Moderate risk - 1 first degree relative <50 or 2 first degree any age - 1 off colon at 55 then follow up as per BSG guidelines
High risk - cluster of at least 3 first degree relatives any age across 2 generations - 5yrly colon from 40-75
Good screening test
Screening - identifying at risk individual who may appear healthy
Wilson (WHO) criteria
1) Important health problem
2) Should be a treatment
3) Facilities for diagnosis and Tx should be available
4) Should be a latent stage
5) Should be a test or examination for disease which is acceptable
6) Natural history of the disease should be understood
7) Should be a policy on whom to treat
Bowel cancer screening
Launched 2006
2yrly to men and women 55-74
Based on faecal immunochemical test (FIT)
Uptake is approx 50-60%
2/100 doing test will get abnormal result - offered colonoscopy
5/10 Colons will be norma
4/10 Will have polyps
1/10 will have cancer
Evidence based on 4 RCTs - Cochrane review 2007 - 16% reduction in relative risk of CRC mortality
FOB - sensitivity of 50-80% and 88% specificity
FIT - 92% sensivitiy and 85% specificity
Causes of short gut
Anatomical - Surgery (<200cm SB) Crohns disease, mesenteric ischaemia, Neoplastic disease, radiation enteritis
Functional - Intra-abdoninal sepsis, enteritis, Intermittent bowel obstruction (strictures), bacterial overgrowth, recurrent disease (crohns), Medications.
Scoring system to assess need for surgery in IBD patient
Travis (Oxford) criteria
At day 3 of IV steroids
-Opening bowels >8x a day
-3-8 motions + CRP >45
Positive predictive valuue for colectomy is 85%
Treatment for Flare of acute colitis
Initially 100mg IV hydrocortisone QDS
If fails
Cyclosporin (2mg/Kg/day) - 80% will respond but approx 50% will need colectomy in 1yr at 8% at 7yrs - SE seizure, HTN, renal impairment
Infliximab (5mg/Kg) - repeated at 2 and 6 weeks. 3yr colectomy rate of 50% SE Severe infection, demyelination, non- Hodgkins lymphoma
UC/Colitis surveillance - retained rectal sump/pouch
BSG/ACPGBI
Annual endoscopic surveillance if high risk features (Previous dysplasia (rectal) or cancer at time of pouch surgery, PSC, Type C mucosa (permanent persistent atrophy and severe inflammation)
Otherwise 5yrly Surveillance
Large PR bleed
BSG 2019 Assess to stable vs unstable using Shock index (HR/systolic) <1 = stable
Catagorise to major or minor using Oaklands score
<10 safe to discharge and organise OP investigations.
Causes of LGI bleeds
Diverticular
Vascular malformations (angiodysplasic)
ISchaemic coltiis
haemorrhoids
IBD
Neoplasia
Radation
Approx 15% will be UGI source - need OGD
Aspirin in LGI bleeds
BSG guidelines 2019
Primary prophylaxis - Permanently discontinued
Secondary previous should not be routinely stopped - if stopped should be re-commenced as soon as haemostats achieved
TXA in LGI bleeds
Not indicated
European society of Gastrointestinal Endoscopy 2021 guideline essay no
HALT-IT large multi-national RCT 2020 showed no reduction in deaths but increased VTE events
Options for parastomal hernia repair
1) Noting
2) Belt support
3)Restore continuity if possible and repair defect
4) Repair parastomal hernia (Suture - high recurrent risk, Mesh - Keyhole or sugar baker)
5) Relocate stoma
Histological features of solitary rectal ulcer syndrome
Obliteration of the lamina proprietor by fibrosis and smooth muscle fibre extension from the muscular mucosa to the lumen
Investigations for SRUS
Defaecting proctogram - Look for rectocele/intussusection
Colonic transit study. - slow transit constipation and obstructive patterns
Anorectal manometry and physiology studies - assess rectal sensation and inhibitory reflex and paradoxical contractions and animus
Endoanal US can demonstrate thickening of internal anal sphincter (limited significance)
Grading of rectal intussusception (prolapse)
Oxford grading system
Grade 1 - High rectal - descends no lower than proximal limit of rectocele
Grade 2 Low rectal - descends into level of the rectocele but not onto sphincter/canal
Grade 3 High anal - descends onto sphincter/anal canal
Grade 4 Low Anal - Descends into sphincter/anal canal
Grade 5 Overt rectal prolapse
Treatment for SRUS
1) Conservative treatment - Dietary modifications (high fibre, bulking laxatives), pelvic floor rehab, biofeedback
2) Mediations - Steroids, 5 ASA sucralfate
3) Surgery - STARR, LVMR - both have limited roles as correcting anatomy my not correct physiology. Only contemplate when failed all else, significant symptoms and high grade rectal intusseception with outlet obstructive pattern and animus ruled out.
Endoscopic findings of Radiation proctitis
3 main groups
1_ Inflammatory (mucosal oedema, erythema/pallor, ulceration)
2- Haemorrhagic (friable mucosa which bleeds spontaneously and/or telangiectasia
3- Mixture of both
Biopsy not required unless uncertain (then take from back wall) - risk of non-healing ulceration or fistula formation
Risk factors for radiation proctits
Radiation related - Volume of rectum irradiated, total dose and dose per fraction and technique (Spaces and balloons not routinely used)
Patient related - Vascular disease, DM, IBD, connective tissue disease, Chemo, smoking, anticoagulants/HTN/hormonal Tx, Previous CRC section
Treatment for radiation Proctitis
Conservative - mild symptoms (Do nothing, diet, loperamide)
Medical
Bleeding predominant - sucralfate enemas (2g Bd for up to 24/52)
Inflammatory - corticosteroids or metronidazole in combination oral mesalazine and betamethasone enemas for 4/52
Endoscopic - Argon plasma coagulation, topical formalin applications, laser, RFA bipolar
Sessile serrated polyps
Precursor lesions to serrated neoplasm resulting in cancers with B-RAF mutation, methylation of DNA repair genes, CpG island methylation phenotype and high levels of microsateliitle instability
Adenocarcinoma sequence can proceed after in them than APC mutation and higher risk of lymphatic invasion and mets
Can occur with our without dysplasia
Difficult to detect - may be related to failure of colonoscopy to reduced R sided cancers
Estimating size of endoscopy
Standard biopsy forceps 8mm open and 2.5mm closed
Definition of intestinal failure
Reduction of gut function to below the minimum level required to absorb macronutrients and/or water and electrolytes such that IV supplimentation is required
Classification of intestinal failure
European Society for clinical nutrition and metabolism
Type 1 - Acute and short term - usually self limiting (grade1 )short duration)- no intervention, Grade 2 - may require intervention)
Type 2 Prolonged acute condition - often unstable patient requiring complex care and IV supplementation over months or years (reversible or irreversible)
Type 3 - Chronic condition, stable patient requires IV supplementation over months/years - may be reversible
Long term options for IF patietns
TPN
IV fluids and electrolytes
Surgery to correct fisulta or revese stoma
Type 3 patients may be appropriate for GLP2 drugs or experimental bowel lengthening procedures
Very selective patients may be eligible for SB transplant
Obstetric Sphincter injury
Full obsteritic history including prolonged second stage, instrumentation, episiotomy or tears
Onset of symptoms and nature and quality of incontinence
Relavent PMH and PSH
Incontinece score (St Marks or Wexner score) to classify severity
Conduct a perineal examination and PR to assess sphincter complex
Classification of obstetric injury
Sultan Classification system
1st Degree - skin or vaginal mucosa
2nd Degree - perineum involving muscles but not sphincters
3rd Degree - perineum involving sphincter complex -3a) <50% external anal sphincter form
3b) >50% external anal sphincter
3c Both external and internal torn
4th Degree Perineum involving sphincter complex and anal epithelium
Anal Physiology
Resting pressure and involuntary squeeze reflex - measure of function of internal anal sphincter
Peak Squeeze and 5 second squeeze - measure of external anal sphincter
When to avoid delayed sphincter repair
1- Asymptomatic
2 - Plans for further vaginal deliveries
3 - Late onset faecal incontinence
4- Non-contracting external anal sphincter
5- Partial external anal sphincter tear
6- Obese - risk of wound infection, breakdown and fistula formation
Pre-sacral venous anatomy
Result from anastomosis of the lateral and median sacral veins and courses into the pelvic fascia covering the anterior aspect of the body of the sacrum
The medial sacral vein drains into the Left common iliac
The lateral veins drain into the internal iliac veins
The plexus receives contributions from the lumbar veins of the posterior abdo wall and the base-verebral veins that pass through the sacral foramen
CRC - anastomotic leak
Sepsis 6
Investigate - CT with contrast +/- chest
Reassess with the imagine - if stable and subtle signs of possible early leak can attempt conservative management
Some units may have protocoled management where high inflammatory markers and suspension of CT would prompt operative re-intervention.
The ongoing Tentacle Study and IMARI trial will provide more detailed data on identifying which approach is best
UC patients with rectal stump - surgical options
1) Surveillance - may wish to retain rectum or avoid surgery - Stump surveillance in accordance with BSG and ACPGBI guidelines - low risk start 10yrs from start of symptoms and every 5 yrs or yearly if high risk
2) Completion proctectomy and end ileostomy
3) Ileoanal pouch
4) Ileorectal anastomosis - highly selective patients and careful counselling. Need to have minimal rectal disease and preserved complaint and capacity and good sphincter tome. Avoids pelvic dissection and risk of sexual and urinary dysfunction. Still has impact go fecundity. Will need ongoing surveillance of stump as per BSG . May still fail and need ileoanal pouch or end ileostomy
Management of IPAA fistula
Explain to patient
EUA and biopsy and seton
Future management depends of cause - leak, crypto glandular, Crohns or malignancy
At EUA - attempt to delineate anatomy, drain sepsis, take biopsy of anastomosis, body of pouch and pre-pouch ileum and place seton
Discuss at IBD MDT
If Crohns - may need anti-TNF biologic agent and Gastro input - ACCENT 2 trial - 50% closure
Surgical management of IPAA fistula
Need full clinical and radiological work up
Referral to tertiary centre with relevant expertise
Sphincter preserving approach desirable
Advancement flap or a LIFT (Ligation of intersphincteric fistula tract) proceedure
Need to council risk of failure to heal, prolonged healing, wound related issues, recurrence and worsening pouch function.
Causes of rectovaginal fistula
Obstetric trauma
Pelvic surgery (hysterectomy, rectal surgery, stapling devices, anastomitic leak, mesh
Neoplasm
Crohns diseas
Radiation injury
Infection (cyrptoglandular)
Trauma, including sexual truma
Medications
Classification of rectovaginal fistula
Variety of systems exist
Ano-vaginal fistula - below dentate line
True recto-vaginal - proximal to dentate line (High, mid or low)
Low - occur through sphincter complex but proximal to dentate
Mid - lower 1/3 of vagina
high mid rectum to posterior fornix
Also classified based on complexity: Simple small, distal, caused by trauma or infection. Complex large , proximal caused by IBD, cancer, radiation
Radiological staging system for response
mrTRG (MR tumour regression Grade (MERCURY group and ESGAR)
Grade 1 - Complete response with linear/cresectric 1-2mm scar in mucosa or submucosa
Grade 2 - Good response. MRI - dense fibrosis without obvious residual tumour
Grade 3 - Moderal response >50% areas with fibrosis or mucin and visible intermediate tumour signal
Grade 4 - slight response.- few areas with fibrosis or mucin and mostly tumour derived signal
Grade 5 - No response to theatre. Similar to baseline or significant regrowth
Complete clinical response and complete pathological response
Clinical response - team find no clinical evidence of cancer (may still be residual disease microscopically 3 criteria:
Normal DRE
Endoscopic - Flat white scar, telangiectasia (no ulcer or modularity)
MR - mrTRG Grade1/2
Pathological response - Post neoadjuvent and surgery - pathologist cannot find evidence of cancer cells
Tx options for cCR in rectal Cancer
1) - Surgery - gold standard - risk of no cancer in specimen and 2% risk of mortality - 6vs12 trial - op traditionally 6 weeks post Chemorad but larger effect at 12
2) Watch and wait - ACPGBI support this
-Involves 3/12 follow up for 2yrs with clinical, end and MRI and CT imagine and CEA. Then 6/12 for 3yrs.
OnCoRE registry shows approx 1/3 with have local regrowth in first 3yrs with 88% undergoing successful salvage surgery. 8% will develop mets with no regrowth. 93.5% 3yr survival
Complete pathological response in Rectal Cancer
Absence of viable adenocarcinoma in surgical specimen or presence of lakes of mucus without tumour cells
Mansard TRG classification
TRG1- No viable cells - complete clinical response
TRG2 Fibrosis with scattered tumour cells
TRG3 - Fibrosis and tumour cells with a preponderance of fibrosis
TRG4 Fibrosis and tumour cells with preponderance of tumour cells
TRG5 - Tumour without changes of regression
Neoadjuvent Treatment for rectal cancer
LCRT with induction or consolidation Chemo - OPRA protocol
SCRT followed by consolidation chemotherapy - RAPIDO protocol
Rectal cancer with local invasion into structures
R0 resection key surgical objective and achieved in approx 70% with BeyondTME disease
PelvEx registry 3yr survival with R0 is approx 56%
R1 section
Royal college of Pathologists define positive R1 margin as presence of viable tumour cells within 1mm of any section margin
Adjuvant Chemo in complete pathological responce
Each case needs discussing with oncologist and MDT
Generally no evidence for adjuvant chemotherapy after complete pathological response
OnCoRE study
Propensity - score matched cohort analysis of watcha nd wait vs surgery for cCR after Chemorad
Showed substantial proportion of rectal cancer managed with watch and wait avoided major surgery and colostomy without loss of oncological safety at 3yrs
High proportion of local regrowths amenable to salvage surgery with high R0 resection rate and no evidence of pathological upward stage migration
Study looking at Colonoscopy vs CT colon
SIGGAR trials - no difference between pick ups
Rectal Tumours T3
Invasion beyond muscular proprietor - cutoff at 5mm
a<1mm
b 1-5mm invasion
c5-15mm
d>15
Anal marginal and anal canal
Anal cancel
- extends from the anorectal junction to the anal margin
- includes transition zone (some cancers can be adenoids)
Anal margin - extends from anal verge to pigmented area - approx 5cm
Proximal anal cana; - drains into perirectal and paravetebral
Tumours about the dentate-internal iliac and internal pudendal LN
Below the dentate and anal margin - inguinal, external iliac and femoral LN
Staging for anal marginal Cancer
T1 - <2cm
T2 - 2-5cm
T3 - >5cm
T4 - invading other structures
Common classification of Crohns disease
Montreal or Paris
Looks at age of diagnosis, location of lesions, behaviour of disease (penetrating or stricturing)
Paris classification similar but loos at associated growth delay
Clinical assess Crohns activity
Crohns Disease Activity index (trials)
Harvey Bradshaw index (weighted towards diarrhoea
IBD tarted PROMS
Endoscopic assessment of Crohns activity
Crohns disease endoscopic index of severity
Simplified Endoscopic activity score for Crohns
Look at size of ulcers, surface Ulceration, Proportion of affected surface, presence of strictures
CREOLE trial
Medical management of Crohns stricture suceesful up to 12cm
Surgical management of stricutres
For stricutres small than 10cm - Heineken-Mikulicz procedure
Medium length strictures - Finney procedure
Entero-enterostomy for larger strictures
Lynch and Lynch likesyndrome
Lynch - autosomal dominant - Hereditary non-polyposis
Diagnosed using Amsterdam 2 criteria
Formal diagnosis mutation in MMR MLH1, MSH 2,6 PMS2
Average age of onset 42
Lynch like Syndrome -Patients who are MMR deficient without obvious genetic mutation
Amsterdam criteria
At lease 3 first degree relatives across 2 generations with an associated cancer
At lease 1 should be under 50yrs old
Screening for CRC based on risk
Average risk - no family HX
Moderate - 1 first degree relative under 50 or 2 first degree relative (any age)
High - at least 3 first degree relatives at any age across 2 generations
Average - 2yrly FIT(National screening)
Moderate risk - Colonsopy at 55 then following National guidelines depending on findins
High risk - 5yrly colons starting at 40
Reducing risk of cancer in Lynch
Lifestyle measures
BSG guidelines - aspirin - CAPP2 trial - reduced risk of cancer by 50% for 2yrs)
Aspirin thought to affect by reducing or inhibiting COX1 and 2 also affect Gut microbiome as well as aspirin metabolites which inhibit CDKs thus cell growth
Surveillance for Lynch
MLH1 and MSH2 (and no obvious mutation) - 2yrs COlon from 25-75
MSH6 and PMS 2 - 2yr colon from 35-75
H Pylori testing as increases risk of Gastric cancer
Hysterectomy (not PSM 2) 35-40 - first of endometrial caner
FAP
Familial adenomatous polyposis
Mutation in APC gene on 5q, 21/22 Chromosome
Autosomal dominant - near complete penetrance
25% de-novo mutation
Surveillance as per BSG guidelines -If mutation - Colon starting 12-14 ever 1-3yrs. OGD when 25 and surveillance depending on Spiegelman criteria
If no mutation 5yrly colon from 12-14. OGD not required unless polyps present on index colon
Spiegelman criteria
Score based on
Number of polyps
Size of polyps
histology
Degree of dysplasia
Interval of OGD based on score 6mnthly to 5yrly
Surgery for FAP
Absolute - presence or high suspicion of cancer or symptoms related to polyps
Relative - polyps >1cm, high grade dysplasia, significant increase in number of polyps
Other genetic polyp syndromes
Peutz Jeghers (STK11)
Juvenile Polyposis (SMAD4/BMPR1A mutation)
MUTYH- associated syndrome
Peutz Jeghers
Brown mucocutaneoux lesions with multiple hamartomas
Autosomal dominant
Mainly affects small bowel
Associated with STK11 gene mutation
Diagnosed - >1 GI hamartoma, mucocutaneuous lesion with family Hx or any hamartoma in someone with 1st degree PJS relative
Surveillance - BSG guidlines - commence at 8 - every 3 yrs
3yrly small bowel video capsule
Baseline OGD and colon - if normal surveillance of upper and lower postpones to 18yrs
Normally offer resection of Small bowel hamatoma as likely to lead to intersuspection
Juvenile Polyposis
Screening depends on mutation
SMAD4 only - OGD from 18 at 1-3yrs
BMPR!A mutation - OGD from 25 1-3yrs
Both should have Colonoscopy from 15 every 103yrs
MUTYH associated polyposis
Colonoscopy from 18 every year
OGD from 35 and interval based on Spiegelman criteria
Kudos Pit pattern classification
1- Round pits - Normal
2 - Asteroid or papillary pits - Hyperplasia
3 - Tubular - Adenoma (s - smaller , L larger)
4- Branch like or gyrus like - Adenoma
5 - Non structural - Carcinoma
Kikuchi levels
Classification of depth of invasion of T1 cancers SM1-3
1 - superficial 1/3 of submucosa (a-c) based on level of invasion into second 1/3
2 - intermediate 1/3 of submucosa
3extending into inner surface of musclaris proprietor
Related to likelihood of LN mets
Haggis classification
Level 0 - Carcinoma in situ
Level 1 - Invasion into head
Level 20 Invades into Neck
Level 3 - invades into stalk
Level 4 0 invaded the submucosa below level of mucosa - (all Kikuchi are level 4)
