Colorectal surgery: Colorectal cancer.

Question 1

Which is the most common form of colorectal cancer? [1]

Answer 1

Adenocarcioma

Question 2

Which location is the most common place for colorectal cancer? [1]

Which is the second most? [1]

Answer 2

rectal: 40%
sigmoid: 30%
descending colon: 5%
transverse colon: 10%
ascending colon and caecum: 15%

Question 3

Name a therapeutic drug that is protective for colorectal cancer [1]

Answer 3

Aspirin

Question 4

Describe the clincical presentation of colorectal cancer [5]

Answer 4

Change in bowel habits:
- Constipation
- Diarrhoea
- Constipation & Diarrhoea alternating
- Frequency
- Tenesmus

PR Bleeding (melena or bright red)

Abdominal pain
- tumour obstructing bowel

Unexplained weight loss

Anaemia:
- Chronic bleeding from tumour

Question 5

What are the three type of colon cancer? [3]

Answer 5

Sporadic (95%)
Hereditary non-polyposis colorectal carcinoma (5%)
Familial adenomatous polyposis (<1%)

Question 6

Describe the genetic influence of developing colorectal cancer [2]

Answer 6

Hereditary non-polyposis colorectal carcinoma (aka Lynch syndrome; HNPCC, 5%):
- Autosomal dominant
- DNA mismatch repair, effecting MSH2, MLH1, MHSH6, PMS2 genes
- Does not cause adenomas
- Tumours develop in isolation

Familiar adenomatous polyposis (FAP):
- autosomal dominant
- malfunction of tumour suppressor gene adenomatous polyposis coli (APC)
- causes many polyps in the large intestine

Question 7

Why is IDA without any explanation a two week cancer referral? [1]

Answer 7

{{c1::GI malignancies such as bowel cancer can cause microscopic bleeding (not visible in bowel movements) that eventually lead to iron deficiency anaemia.}}

Question 8

Describe the test used to screen colorectal cancer? [1]
Which age demographic is the screening for? [1]
If results come back positive, what is the next step? [1]

Answer 8

Faecal immunochemical tests (FIT):
- ID Hb in stool
- 60-74 year olds
- Positive tests sent for colonscopy

Question 9

What is the investigation of choice for colorectal cancer? [1]
State three other investigations [3]

Answer 9

Colonoscopy:
- can biopsy
Sigmoidscopy
CT colonography
Staging CT: looks for metastasis of other cancers (CT thorax, abdomen, pelvis)

Question 10

Describe typical features of colorectal in colonscopy [2]

Answer 10

Shouldering
Mucosal obstruction

Question 11

What is the name for the staging criteria of colorectal cancer? [1]
Describe each stage [4]

Answer 11

Duke’s classification

Question 12

Describe how colorectal tumours can present via colonoscopy [3]

Answer 12

Ulcerating
Stenosing
Polypoidal

Question 13

What does this colonoscopy of colorectal cancer depict?

Ulcerating
Stenosing
Polypoidal

Answer 13

Ulcerating
Stenosing
Polypoidal

Question 14

What does this colonoscopy of colorectal cancer depict?

Ulcerating
Stenosing
Polypoidal

Answer 14

What does this colonoscopy of colorectal cancer depict?

Ulcerating
Stenosing
Polypoidal

Question 15

What does this colonoscopy of colorectal cancer depict?

Ulcerating
Stenosing
Polypoidal

Answer 15

What does this colonoscopy of colorectal cancer depict?

Ulcerating
Stenosing
Polypoidal

Question 16

Options for managing bowel cancer (in any combination) are? [4]

Answer 16

Surgical resection
Chemotherapy
Radiotherapy
Palliative care

Question 17

Describe how surgical resection of colorectal cancer occurs [4]

Answer 17

• Laparoscopic or robotic surgery
• Resection of tumour
• Most tumours are tailored around the resection of particular lymphatic chains
• Anastamose remaining remaining bowel OR stoma

Question 18

Describe the different types of colorectal cancer surgery that are used, depending on the location of the cancer [6]

Answer 18

Right hemicolectomy:
- involves removal of the caecum, ascending and proximal transverse colon.

Left hemicolectomy:
- involves removal of the distal transverse and descending colon.

High anterior resection:
- involves removing the sigmoid colon (may be called a sigmoid colectomy).

Low anterior resection:
- involves removing the sigmoid colon and upper rectum but sparing the lower rectum and anus.

Abdomino-perineal resection (APR):
- involves removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy.

Hartmann’s procedure:
- is usually an emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date. Common indications are acute obstruction by a tumour, or significant diverticular disease.

Question 19

make sure you know about blood supply for colon bits (its different)

Question 20

All patients with newly diagnosed colorectal cancer should have which tests for staging? [3]

Answer 20

Entire colon evaluated with colonscopy or CT colonography

Carcinoembryonic antigen (CEA)

CT of the chest, abdomen and pelvis

Question 21

Name the surgical procedure is used for obstructed right sided tumours cancer? [1]

Name and describe the surgical procedure is used for obstructed rectosigmoidal cancer? [2]

Answer 21

Right hemicolectomy

Hartmann’s procedure:
- remove recosigmoidal colon & rectal stump suture closed (permenantly or reversed)
- create colostomy

Question 22

Describe the adjuvant chemotherapy given for colorectal cancer: [2]

Describe the biologicals used [3]

Answer 22

Dukes B if poor prognositic factors

Dukes C:
- Fluorouracil (5-FU)
- Capecitabine (first line)

Biologicals:
- Cetuximab (anti-EGFR)
- Panitumubab (anti-EGFR)
- Bevacizumab (anti-VEGF)

Question 23

What is the FOLFOX regime of treating colorectal cancer? [3]

Answer 23

Chemotherapy regime of:
* 5-FU
* Folinic acid
* Oxaliplatin

Question 24

Radiotherapy is used for pre-op. treatment of which specific type of colorectal cancer? [1]

Answer 24

Rectal cancer

Question 25

State 4 reasons why get referred to the two week cancer pathway for colorectal cancers [5]

Answer 25

Positive FIT test
Over 40 years with abdominal pain and unexplained weight loss
Over 50 years with unexplained rectal bleeding
Over 60 years with a change in bowel habit or iron deficiency anaemia
Any age with rectal or abdominal mass

Question 26

What type of treatment is radiotherapy generally used for in colorectal cancer? [2]

Answer 26

Palliative care
Rectal cancers with high risk of local reoccurence