Rectal cancer

Question 1

What is the position of examination of the rectum?

Answer 1

Lithotomy position

Question 2

What are the usual patient complaints in rectal cancer?

Answer 2

• pain -> fissure
• bleeding -> cancer & hemorrhoids
• swelling -> hemorrhoids & rectal prolapse
• incontinence
• itching
• discharge -> fistula

Question 3

What are the red flags of rectal cancer?

Answer 3

• family history of malignancy
• new history of anemia
• abdominal pain
• change in bowel habits -> constipation
• PR bleeding mixed with stool
• mucous discharge
• unexplained weight loss -> 10% in 6 months

Question 4

How do you describe the location of a mass in the anal canal?

Answer 4

12 o’clock -> perineum
3 o’clock -> left lateral
6 o’clock -> anal cleft
9 o’clock -> right lateral

Question 5

When should screening for rectal cancer begin?

Answer 5

at 45 years until 75
if patient has good general health -> 76 - 85 should be individualized

• colonoscopy every 10 years for average risk patients
• fecal occult blood -> every year
• stool DNA testing -> every 1 to 3 years
• CT colonongraphy -> every 5 years

Question 6

What are the unmodifiable risk factors of rectal cancer?

Answer 6

• age > 50
• african american
• male
• family history of polyps or cancer
• personal history of polyps or cancer
• inflammatory bowel disease
• chronic ulcerative colitis
• Crohns disease

genetic conditions

• FAP
• HNPCC
• hamartomatous polyposis

Question 7

What are the modifiable risk factors for rectal cancer?

Answer 7

• tobacco
• alcohol
• physical inactivity
• diet high in red meat & animal fats
• low fiber diet

Question 8

How does a patient present with rectal cancer?

Answer 8

• suspicious signs/symptoms
• asymptomatic discovered by routines screening
• bowel obstruction

Question 9

What is the difference between rectal & anal cancer?

Answer 9

Adenocarcinoma -> rectal

squamous cell carcinoma -> anal

Question 10

How is rectal carcinoma diagnosed?

Answer 10

• colonoscopy
• CT colonongraphy -> high risk patients
• CEA -> follow up
• CA 19-9 -> follow up

Question 11

what is the endoscopic criteria suggesting polyp malignancy?

Answer 11

• firm consistency
• adherence
• ulceration
• friability

Question 12

How should assessment of the patient occur?

Answer 12

• CAP CT -> chest, abdomen , pelvis
• MRI
• EUS

Question 13

What is the surgical approach to rectal cancer?

Answer 13

wide resection with histologically negative margins & total mesorectal excision with resection of local lymph nodes

Question 14

What surgery should be done for superficially invasive small rectal cancer?

Answer 14

local excision -> transanal excision

                    - > transanal endoscopic microsurgery (TEM) 
                    - > transanal minimally invasive surgery (TAMIS) alone

Question 15

How are tumors in the upper & middle rectum managed?

Answer 15

sphincter-sparing procedure (LAR)

Question 16

How are tumors in the lower rectum managed?

Answer 16

APR -> curative resection can’t be achieved with sphincter sparing procedures

• patients with small lower rectal cancer -> local excision to spare the sphincter function
• larger of more invasive tumors -> neoadjuvant therapy -> sphincter sparing procedure

Question 17

Which patients should get adjuvant therapy after surgery?

Answer 17

• all stage 3 -> positive nodes

- high risk stage 2 -> obstruction or perforation

Question 18

When should the follow up occur after rectal cancer resection?

Answer 18

• office visit -> every 3-4 months for 3 years -> every 6 months in 4th & 5th years
• serum CEA at each follow up for at least 3 years after resection
• colonoscopy -> 1 year after surgery -> 3 years -> 5 years