Bowel cancer History Mr Allan, 63 year old engineer, came to GP asking about his risk developing colorectal ca.

. His 75 y/o uncle, Dx w ca of rectum in 2008. No current Sx attributable to colorectal ca. Take family Hx and lifestyle Hx 1) Risk factor Family Hx Low fibre diet Physical exercise Smoking Alcohol Obesity Processed meat 2) PE could pertain to colorectal cancer Conjunctival pallor anemia result from blood loss Rectal examination rectal ca, or evidence of bleeding. Abdominal examination abdo masses or ascites are signs of advanced colorectal ca Liver span liver involvement w metastases lead to increase liver span 3) DRE Is done to : Check growths in or enlargement of the prostate gland. Felt as hard lump. Check if hv Sx, change in urination. Check for problem in womans repro organs, such as uterus and ovaries. Check if Sx, pelvic pain or vaginal bleeding Help find cause of Sx eg rectal bleeding or change in bowel habits Collect stool sample to test blood in stool Check for hemorrhoids or growths. Sigmoidoscopy needed to diagnose internal hemorrhoids. Risks small amount of bleeding, lightheaded and faint (rare!)- vasovagal syncope Results Normal no problems such as organ enlargements or growths are felt Abnormal - BPH or prostatitis (inflammation of the prostate gland) in men. Tumors of cervix, uterus or ovaries in women. Others : hemorrhoids, polyps, tumors,abscesses in lower rectum. Anal fissures as well. Others If DRE is done to detect for prostate ca, must do blood-test for prostatespecific antigen (PSA). Further test, Pelvic US and prostate biopsy.

4) Bowel cancer screening Pt identified by family Hx greater than average risk shud be monitored by FOBT. Flexible sigmoidoscopy or colonoscopy every 5 yrs FOBT cost effective, simple, main problem is high false positive and false negative rate and low predictive value for bowel cancer. Limited reach of sigmoidoscopy major weakness. Does not reach splenic flexure and may not advance beyond sigmoid colon Colonoscopy most accurate, low compliance and high cost disadvantage. Main complications : perforation

Stool test for bowel cancer FOBT Fecal immunochemical test (FIT) Stool DNA test (sDNA) looks for abnormal DNA from cancer or polyp cells Blood in stool is common Sx of colorectal cancer. But not usually the case. Can also be : Hemorrhoids, Anal fissures, Colon polyps, Peptic ulcers, UC + CD, GORD, NSAIDs use or aspirin, diverticulosis *Most common metastases is hepatic. Pulmonary metastases more frequent from lower rectal carcinomas than upper rectal or colon carcinomas. This is bacause low rectal tumors drain into the systemic venous system (via internal illiac veins) rather than into portal venous vein.

Colonoscopy Enables visual inspection of the entire large bowel from distal rectum to cecum Purpose : screening and follow-up of colorectal cancer Average-risk adults 50y/o. annual FOBT and periodic flexible sigmoidoscopy w follow-up colonoscopy also recommended. Polyps >1cm must examine whole colon, risk of additional polyps and it is also belief that most cancer arise in preexisting adenomatous polyps Polypoid lesions greater that 0.5cm in diameter should be excised. Afer removal, if there is concern about adenoma, repeat colonoscopy in 3-4 months. Pt w multiple bening polyps observed n removed f/u colonoscopy in 1 yr Pt w 1 polyp every 3 yrs. If free from polyps, 5-yr interval Pt who had large bowel ca removed colonoscopy 6mnths to 1 yr after surgery followed by yearly colonoscopy on 2 occasions. Individual w famiy Hx of FAP (Familial adenomatous polyposis) every 12 months W first-degree relative diagnosed w colon cancer or adenoas <60yrs, every 3-5 yrs HNPCC (Hereditary nonpolyposis colorectal cancer) autosomal dominant, consider Dx in pt who have several relatives w colorectal cancer Management of IBD Colonoscopy f/u and management for pt w UC + CD Colonoscopy w multiple biopsies to diff UC from CD Post- procedure Complications after colonoscopy : colonic perforation, bleeding, infection, abdominal distention, postpolypectomy coagulation syndrome, splenic rupture, small bowel obstruction, meds effect. 5) How do bowel cancer arise? -benign precursor lesions or adenomas tru clonal proliferation continue Hx : had colonoscopy abd 1cm polyp seen in ascending colon.removed polyp.ulcerating tumor seen in hepatic flexure.rest of colon looks normal 6) How does colorectal cancer spread? a- by lymphatics b- by the blood stream c-direct invasion tru bowel wall e-by surgical implantation

Question: Which of the following other investigations would you perform preoperatively ? Explain why you might do each of them Answers: A CT chest, abdomen and pelvis is used for staging. Chest x-ray, ECG, Full Blood Count and renal and liver functions are important for fitness for surgery. MRI pelvis is used in the pretreatment staging of rectal cancer but not in colon cancer CT brain is performed only if cerebral symptoms are present. PET scan is occasionally used to exclude distant metastases if they are suspected on clinical grounds or if surgical resection of metastatic disease is being considered upfront Coagulation studies are part of a routine preoperative assessment. Renal function is part of preoperative assessment, not an indicator of spread. LFTs are not a good indicator of spread. CEA is a tumour marker. A preoperative CEA can be helpful to monitor response to treatments

7) Which operation would you advise a- Polypectomy only b-Right Hemicolectomy c-Total Colectomy d-Anterior resection e-Abdomino Peritoneal Resection right hemicolectomy, aim is to achieve adequate margins of excision and removal of regional LN to assist staging. This entails division of blood vessels, ileocolic and middle colic vessels, branches of the superior mesenteric vessels. no prognostic advantage in removing additional colonic tissue as in a total colectomy. Anterior resection is reserved for tumours in the sigmoid colon or proximal rectum. Abdomino perineal resection is undertaken for carcinomas in the distal 3rd of the rectum 8) Consequences of opt and colostomy? -will damage ureter, testicular vessels, pancreas and duodenum The ascending colon is an immediate anterior relation to the second part of the duodenum and head of the pancreas and can be injured during mobilization of the colon. The testicular vessels and ureter lie posterior to the proximal ascending colon and can be injured during mobilization of this area. 9) In opt, discuss how to reduce risk of : 1) infection 2) bleeding 3)thromboembolism 4) respiratory complications to be reduced?

Infection less hospital stay can prevent infection spread postoperatively. Besides, it can be control by maintaning sterile environment troughout the surgery by proper handwashing technique and continously using alcohol senitizer if get in contact with patient surrounding. Antibiotic administered postoperation will help in control of infection. Bleeding patient INR should be determine preoperatively. If patient on any anti-coagulation or anti-thrombotic drug it should be withhold as per discussion with the cardiologist. Thromboembolism patient should be monitored in term of early mobilization and should be given careful attention to fluid and electrolyte needs. On the evening after the surgery patient should be encourage to sit up,cough and breath deeply and walk around if possible as walking will allow better circulation to lower extremities and lessen the danger of venous thromboembolism. Respiratory complication should be prevented starts from preoperatively. For instance, smoking habit must be ceased for 6 weeks before the surgery. Intraabdominal pressure will be decrease by correction of gross obesity and risk of wound and respiratory complications and improves ventilation postoperatively continue Hx : Path report shows a 60mm moderately differentiated adenocarcinoma of hepatic flexure, invasion into muscularis propria, resection margins are clear, 1/19 LN contain malignancy Prognosis : pt w more that 5LN and low grade had 5yr survival rate of 11-39% after surgery, increasing 27%-57% w 5-fluourouracil based chemotherapy.adjuvat chemo for stage iii colon cancer - routinely uses oxaliplatin in combination w iv or ora fluorouracil 10) If pt see you in 3 mnths.what test would you do? and why? -currative resection, possible recurrence 80-90% in 2-3yrs, fewer than 5% occur after 5yrs. Essentially for the first 2 years, CEA and review every 3 months. CT chest/abdo/pelvis every 6 months for first 3 years . Colonoscopy 1 year postoperatively, another 3 years later and then every 5 years.