Oncology - Colorectal Cancer Briefly

Colorectal Cancer Typical HPI Over 40 y. o. Male Western

Rectal Bleeding Change in bowel habit Incomplete emptying “pencil” stools Weight Loss

Examination LOOK FOR: Jaundice Cachexia Pallor Previous surgery

NHMRC doc cp64; eMedicine; Harrissons’; NIH website, “Cancer Medicine” 5th ed

Fever Abdominal Pain Constipation Distension + colic Bone pain

PALPATE FOR Mass Abdo distension Abdo tenderness

Past History

…Which risk category?… Smoking, Alcohol, Dietary excess of animal protein and fat Family history of early onset bowel cancer, polyps, other cancers Sedentary lifestyle / lack of exercise / fluctuating weight + Obesity

Liver + Spleen Lymph nodes Hernia orifices Bony tenderness

NEURO EXAM Focal signs Increased ICP MMSE

AUSCULTATE Heart sounds Lung fields Bowel sounds

PELVIC EXAM- 10% are palpable Examine anus, rectum, perineum Look for ballooning + anal tone Blood on the glove? Haemorrhoids?

Screening recommended for over 50s Digital Rectal exam + FOB annually

Laboratory Investigations Faecal Occult Blood Test (FOBT)

Double-contrast barium enema every 5 – 10 years Flexible sigmoidoscopy every 5 years

Must be performed 3 times

Carcinoembrionic Antigen (CEA) To have a baseline before surgery BUT: 1) CEA is also elevated in hepatic and pancreatic cancer 2) Low post-op CEA does not exclude recurrence

Full Blood Count, Electrolytes, Biochemistry Pre-operative assessment, Anaemia, hypercalcaemia, thrombocytopenia

Pattern of spread Lungs, Liver, Brain and Bone

Imaging Investigations Abdomen X-ray Looking for distended small bowel loops with gas, or bony disease

Chest X-ray Looking for lung opacities, …for baseline

Barium Enema

Liver Function Tests

Looking for site of obstruction, “Apple Core” appearance

Mainly checking for metastasis

CT Scan of chest, abdomen & pelvis Lymph node involvement extension into adjacent organs metastasis to liver, kidneys, lungs, etc

? PT + APTT reasons for blood in the stool may be haemostasis disorder

Proctoscopy, Sigmoidoscopy, Colonoscopy Histopathology of biopsy sample

Gold standard: visualise lesion, take sample, snip polyps

Histological subtype and degree of differentiation are necessary for decision-making in management.

Trans-rectal Ultrasound

Staging Dukes: A- Limited to mucosa + submucosa B- extends into the muscularis (B1),

Risk categories 1No Hx, or one 1st or 2nd degree

relative hand cancer after 55 y.o st

into or through the serosa (B2)

CD-

Involves nodes

Identified mutation eg. FAP, HNPCC

3 Multiple cancer Hx throughout family

Is metastatic

Management Strategies Surgery Dukes A

1 degree rel. before 55 y.o 2 One or two 2nd degree rels of any age

Mainstay of treatment Temporary colostomy unless FAP +ve ( FAP = remove whole bowel)

Chemotherapy

Radiotherapy

Limited use

Limited use

Dukes B

Remove primary cancer+ whatever tissue it adheres to. + temp colostomy Pathology
check margins clearance

Should be offered – 5FU + leukovorin

Better rates of local control with 45/25 (fewer recurrences over 5yr interval) esp. locally advanced disease

Dukes C

Remove bowel + any involved nodes Colostomy or ileostomy

Should be encouraged; improves survival

Better rates of local control (fewer recurrences over 5yr interval) esp. locally advanced disease

Dukes D

De-bulking surgery if appropriate Usually inoperable

Palliate symptoms of metastatic spread; occasionally remission

Palliative Bio Psycho Social Follow-Up

Control of bony met pain Alleviate effects of brain mets

Oral pain control with MS contin, oral morphine; battery of analgesics (but don’t superimpose opiates) Bony met pain + neuropathy = controlled with tricyclics, Ketamine, anticonvulsants eg. valproate Key words: Dignity, comfort, daily activity assistance and counselling of end-of-life decisions Stoma specialist Counselling (esp. regarding sexuality, fertility) Psychiatrist

Occupational therapist Genetic counselling Bowel Cancer Support network

METASTATIC or HIGH-GRADE DISEASE DUKES A to C CT scans every 2 months while on chemo, Regular and frequent occult blood or Regular follow-up until next recurrence colonoscopy of remaining colon for 5 years is identified Yearly FOB thereafter

Dietitian Legal advice re. enduring guardianship, will etc

PALLIATIVE Regular monitoring of pain status and QOL, with relevant alterations to management strategy