CRC TREATMENT

Question 1

Right hemicolectomy

Answer 1

if lesion involve the cecum, ascending colon, and hepatic flexure. It involves a removal
of the bowel from 4-6 cm proximal to the ileocecal valve to the portion of the transverse colon supplied by the right branch
of the middle colic artery. An anastomosis is fashioned between the terminal ileum and transverse colon.

Question 2

Left hemicolectomy

Answer 2

can be done if lesion involve the descending colon. It involves resection
from the splenic flexure to the rectosigmoid junction.

Question 2

Extended right hemicolectomy

Answer 2

if lesion involve the transverse colon. It involves a removal of the right and
transverse colon supplied by division of the right and middle colic arteries. The anastomosis is fashioned between the
terminal ileum and proximal left colon.

Question 2

Sigmoidectomy

Answer 2

can be done if lesion involve the sigmoid colon

Question 3

o Goals of the resection can be:

Answer 3

Curative: wide resection of lesion (>5 cm margins) with nodes and mesentery
¨ In some cases, liver metastasis can be resected for curative purposes
§ Palliative: if distant spread, local control for hemorrhage or obstruction
§ care is taken to not spread tumour by unnecessary palpation

Question 4

Adjuvant chemotherapy (5-FU or oral capecitabine with oxaliplatin)

Answer 4

for stage III and is considered in select stage II
patients

Question 5

Stage II (with at least one poor prognostic factor)

insufficient lymph node sampling (<12), T4 lesion, poorly differentiated, bowel perforation.

Answer 5

5 fluorouracil adjuvant chemotherapy

Question 6

Stage III

Answer 6

Oxaliplatin + 5 FU leucovorin. Capecitabine (oral fluoropyrimindine) is equivalent to 5 FU IV and
may have superior efficacy

Question 7

Stage IV- New agents can complement 5 FU, including

Answer 7

Bevacizumab
¨ Panitumumab: binds and inhibits EGFR which is overexpressed in 60 to 80% of CRC and is
associated with worse survival
¨ Cetuximab and panitumumab are effective only on tumours which do not have a mutation of
KRAS à genetic testing recommended to confirm the absence of KRAS mutation before
recommending their use

Question 8

Follow up

Answer 8

intensive follow-up improves overall survival in low-risk patients
o Combination of periodic CT chest/abdomen/pelvis, CEA, and colonoscopy is recommended
§ CEA to monitor for initial response to treatment, and to assess for recurrence every 3 months (not a
screening test). A rising CEA requires further tests for metastatic disease (CT, MRI, PET).
§ 85% of recurrences are detected within 2 years from resection. This is the reason why a colonoscopy
should be performed one year after the operation and repeated annually until an examination reveals
the absence of polyps