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Year 3 > Colorectal tumours (GI) > Flashcards

Colorectal tumours (GI) Flashcards

1
Q

What type of cancer are most colorectal tumours?

A

Adenocarcinomas of epithelial cells

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2
Q

What are the types of colorectal tumours? (3)

A
  • sporadic (95%)
  • hereditary non-polyposis colorectal carcinoma (HNPCC AKA Lynch syndrome, 5%) - most common inheritable form
  • familial adenomatous polyposis (FAP, <1%)
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3
Q

Which parts of the colon do colorectal tumours occur in most?

A
  • 43% proximal colon
  • 23% distal colon
  • 30% rectum
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4
Q

Which age group do colorectal tumours tend to affect?

A

65-74 years old

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5
Q

Describe the progression of colorectal tumours.

A

Normal colonic epithelium –> dysplastic adenomatous polyps –> invasive colorectal cancer

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6
Q

Describe the pathophysiology of colorectal tumours.

A
  • inactivation of tumour suppressor genes –> DNA repair genes –> activation of oncogenes
  • mostly sporadic mutations
  • some due to mutation in adenomatous polyposis coli gene (APC) –> tumour suppressor gene inactivation –> uncontrolled division –> polyp
  • single germline mutation in APC responsible for dominantly inherited syndrome (FAP)
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7
Q

How can metastatic spread of colorectal tumours to local lymph nodes occur? (3)

A
  • enteric venous drainage to liver
  • systemic blood to lungs
  • less commonly to brain and bone
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8
Q

What are the (general) clinical features of colorectal tumours? (8)

A
  • rectal bleeding
  • change in bowel habit (increased frequency or looser stool)
  • rectal mass
  • iron deficiency anaemia signs e.g. fatigue, SOB, pallor
  • abdominal pain (relieved on emptying bowels, pain when defecating)
  • tenesmus
  • FLAWS
  • hepatomegaly (if liver mets)
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9
Q

What might you see on examination in colorectal tumours? (3)

A
  • rectal mass
  • palpable lymph nodes - advanced disease
  • abdominal distension - advanced disease due to ascites/obstruction/hepatomegaly
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10
Q

What are the signs of right-sided colorectal tumours (caecum, ascending and transverse colon)? (3)

A
  • melaena - dark blood in stool, may be occult
  • IDA signs e.g. lethargy
  • diarrhoea
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11
Q

What are the signs of left-sided colorectal tumours (splenic flexure, descending and sigmoid colon)? (3)

A
  • changes in bowel habit (size, consistency, frequency)
  • blood-streaked stools (mixed in)
  • colicky abdominal pain (due to obstruction because of narrower lumen)
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12
Q

What are the signs of rectal tumours? (5)

A
  • haematochezia (fresh, bright blood in stool)
  • rectal pain
  • tenesmus (urge to empty rectum/bladder)
  • flatulence
  • faecal incontinence
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13
Q

What are some risk factors for colorectal tumours? (10)

A
  • age
  • Fx
  • FAP (adenomatous polyposis coli mutation) - inevitably develop colorectal tumours
  • Lynch syndrome (AKA HNPCC)
  • MYH-associated polyposis
  • hamartomatous polyposis syndromes
  • IBD (UC) - related to extent and duration
  • obesity
  • smoking
  • alcohol
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14
Q

What are the first-line investigations for colorectal tumours? (4)

A
  • FBC
  • liver biochemistry/LFTs (liver mets)
  • renal function
  • colonoscopy
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15
Q

What test is gold-standard and diagnostic for colorectal tumours?

A

Colonoscopy (requiring laxatives day before surgery) and biopsy

(Can use flexible sigmoidoscopy/CT colonography if not available/suitable)

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16
Q

What does colonoscopy of colorectal tumours show?

A

Ulcerating or exophytic mucosal lesion that may narrow the bowel lumen

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17
Q

What would FBC show in colorectal tumours? (2)

A
  • IDA - microcytic anaemia
  • low ferritin in IDA
18
Q

What other blood test can we do for colorectal tumours?

A

Tumour markers (CEA) to monitor disease progression

19
Q

What is now being used more as a first-line investigation for colorectal tumours (NICE 2023 guidance change)?

A

Increased use of FIT testing, instead of always doing a colonoscopy first-line

20
Q

What scan can we do in colorectal tumours?

A

CT CAP (CT chest, abdomen, pelvis) to look for metastases and carry out Dukes’ staging/classification

21
Q

What is Dukes’ classification/staging of colorectal tumours (and 5-year survivial)?

A
  • Dukes’ A: tumour confined to mucosA (95%)
  • Dukes’ B: tumour invading Bowel wall (80%)
  • Dukes’ C: lymph node metastases (65%)
  • Dukes’ D: Distant metastases (5%, 20% if resectable)
22
Q

What would a barium enema show in colorectal tumours?

A

Apple core lesion due to stricturing

23
Q

Who do we do DRE on for colorectal tumours?

A

All patients with lower GI bleeding or red flags for colorectal cancer

24
Q

How does screening for colorectal tumours work?

A

Faecal immunochemical test (FIT) screening every 2 years to all men and women ages 60-74 in England, 50-74 in Scotland

25
Q

Which patients do we do 2WW for bower cancer and which do we not?

A
  • 60+ years with iron-deficiency anaemia (low ferritin or Hb<110g/L in man) or change in bowel habit –> 2WW
  • 50+ with unexplained rectal bleeding
  • 40+ with unexplained weight loss and abdominal pain
  • patient with new Sx of possible colorectal cancer but does not meet 2WW criteria –> FIT test (occult blood in faeces –> 2WW)
26
Q

What are some differential diagnoses for colorectal tumours? (6)

A
  • IBS
  • UC (increased risk of CRC)
  • Crohn’s
  • haemorrhoids (bright red bleeding separate from stool)
  • anal fissure (severe pain, blood)
  • diverticular disease
27
Q

When do we do 2WW in suspected colorectal tumours? (4)

A
  • 40+ with unexplained weight loss and abdominal pain
  • 50+ with unexplained rectal bleeding
  • 60+ with IDA or change in bowel habit
  • occult blood in faeces (FIT)
28
Q

What do we do after 2WW in colorectal tumours? (3)

A
  • CT-CAP (look for metastases + local invasion)
  • MRI rectum/transrectal endoscopic ultrasound - for local staging of tumour invasion
  • TNM staging
29
Q

What is the main management for colorectal tumours?

A

Surgical excision + adjuvant or neoadjuvant chemotherapy/radiotherapy

30
Q

How do we do manage colon cancers?

A
  • surgical resection: metastases –> colectomy with removal of regional lymph nodes
  • pre + post-operative chemotherapy
  • stage IV: locally ablative procedures, VEGF inhibitor or EGFR inhibitor
31
Q

How do we manage rectal cancers?

A
  • excision - local/radical if higher stage
  • pre + post-operative radiotherapy +/- chemotherapy
  • total neoadjuvant therapy
  • locally ablative procedures - for patients with oligometastatic liver/lung disease who do not want surgery
  • stage 4 (M>0) - surgical resection of primary tumour and metastases
32
Q

How do we manage colorectal tumours not suitable for surgery? (3)

A
  • chemotherapy (oxaliplatin and fluorouracil and folinic acid)
  • VEGF inhibitor or EGFR inhibitor (bevacizumab) - metastatic
  • stenting - for obstructing tumours of rectum/sigmoid colon
33
Q

What type of resection do we do for cancer of the caecal, ascending or transverse colon, and where is the anastomosis?

A

Right hemicolectomy
Ileo-colic anastomosis

34
Q

What type of resection do we do for cancer of the distal transverse or descending colon, and where is the anastomosis?

A

Left hemicolectomy
Colo-colon anastomosis

35
Q

What type of resection do we do for cancer of the sigmoid colon, and where is the anastomosis?

A

High anterior resection
Colo-rectal anastomosis

36
Q

What type of resection do we do for cancer of the upper rectum, and where is the anastomosis?

A

Anterior resection (TME)
Colo-rectal anastomosis

37
Q

What type of resection do we do for cancer of the low rectum, and where is the anastomosis?

A

Anterior resection (low TME)
Colo-rectal anastomosis (+/- defunctioning stoma) - connect colon to anus

38
Q

What type of resection do we do for cancer of the anal verge, and where is the anastomosis?

A

Abdomino-perineal excision of rectum
No anastomosis

39
Q

What main complication of bowel surgery is there? (1+5)

A

Anastomotic leak 5-7 days post-op:

  • diffuse abdominal tenderness
  • guarding
  • rigidity
  • hypotensive
  • tachycardic
40
Q

What are some complications of colorectal tumours?

A
  • chemotherapy - bone marrow suppression, hepatotoxicity, GI toxicity, alopecia
  • radiotherapy - faecal incontinence
  • immunotherapy - Cetuximab-associated rash
  • rectal excision - bladder/erectile dysfunction
  • surgery - anastomotic leak
  • metastases - liver, lung, bone, brain
41
Q

Describe the prognosis of colorectal tumours.

A

Half of patients have advanced local or metastatic disease at diagnosis

Year 3 (203 decks)

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