LOWER GASTROINTESTINAL CANCER - COLORECTAL

{ INVESTIGATIONS
SITI NUR SYAKINAH BINTI MD SABUDIN

AIMS :
SCREENING DIAGNOSTIC STAGING MONITORING

SCREENING
Faecal Occult Blood Tests Sigmoidoscopy*

Faecal Occult Blood Tests (FOBT)

The rationale of using faecal occult blood testing as a screening test is based on the concept that colonic neoplasms such as early-stage cancer and large adenomatous polyps will bleed and therefore become detectable by an occult blood test. Dietary restrictions are necessary at least 24 hours before and during the collection of the stool samples and some commonly used drugs should be avoided. Certain foods such as red meat and fresh fruit have peroxidase or pseudoperoxidase activity and can cause false positive reactions Aspirin and nonsteroidal anti-inflammatory drugs can cause occult gastrointestinal bleeding. Vitamin C, an antioxidant, can interfere with the reaction and cause a false negative result.

SCREENING

FOBT

The faecal occult blood test most commonly used and the one to which most of the available evidence relates is the Hemoccult II test. Hemoccult II is a guaiac-based test that detects pseudoperoxidase activity of haem or haemoglobin. Such activity converts colourless guaiac to a blue colour in the presence of hydrogen peroxide in the developing reagent. Two faecal samples from each of three consecutive stools are smeared on the two windows of the test cards.

Sigmoidoscopy

There have been no randomised controlled trials on the effectiveness of screening sigmoidoscopy. As a modality of screening, the advantages of sigmoidoscopy over FOBT include direct visualisation of the bowel and lesions encountered can be biopsied during the procedure. It also has a high sensitivity and specificity for the detection of polyps in the region examined. The disadvantage is that about 50% of cancers and adenomatous polyps will be beyond the reach of the sigmoidoscope and the procedure involves some discomfort, risk and inconvenience to the patients.

SCREENING & DIAGNOSTIC

SIGMODOSCOPY

DIAGNOSTIC
Subjects found to be positive on screening are subsequently been referred for examination of the entire colon. Currently available investigations include :

Total Colonoscopy Double contrast barium enema (DCBE) in combination with sigmodoscopy Virtual colonoscopy employing highresolution helical/spiral CT scanning.

COLONOSCOPY VS DCBE

In terms of cost, the charges for colonoscopy and DCBE are broadly similar. An advantage of DCBE over colonoscopy is that the latter carries a higher risk of complications such as perforation and bleeding. The major advantage of colonoscopy over DCBE is that it permits a tissue diagnosis and therapeutic procedures such as polypectomies. Other advantage of colonoscopy over DCBE as the first investigation is that it obviates the need for repeat bowel preparation and a second examination if an abnormality is detected.

DCBE

DCBE

DCBE

STAGING
Ultrasonography CT MRI FDG PET-CT

FDG PET CT

[18F]Fluorodeoxyglucose (FDG) positron emission tomography (PET) Localizes tumors by identifying cells in the body that have increased glucose uptake and metabolism. FDG-PET in colorectal cancer addressed the differentiation between scar tissue and local recurrence in rectal cancer. FDG-PET plays a pivotal role in the detection of :

recurrent disease the assessment of residual masses after treatment the localization of recurrence in patients with an unexplained rise of serum CEA in staging patients before surgical resection of local recurrence and metastatic disease.

FDG-PET has been noted to have a sensitivity of 84100% and a specificity of 80100% in the detection of local recurrence and the accuracy ranges from 74% to 96%. FDG-PET in the initial preoperative staging of newly diagnosed colorectal cancer is not discussed due to its poor sensitivity regarding detection of early tumor spread to regional lymph nodes

MONITORING

Plasma carcinoembryonic antigen (CEA)

The role of tumour markers such as plasma CEA levels in the management of patients with colorectal cancer remains a controversial issue . It is clear from the very low sensitivity (around 20-40%) of this test in normal populations that there is no role for CEA assessment as a screening tool for colon cancer. The area of most interest for CEA monitoring has been the potential for its use after curative resection. Some studies have suggested that finding an elevated CEA level after an initial postoperative decline from an elevated preoperative level may predate the findings of other signs and symptoms of metastatic disease by 1 to 3 month. In patients receiving chemotherapy for metastatic colon cancer, elevations of CEA generally indicate disease progression, while decreases are indicative of improvement.