COLORECTAL CANCER

Jackson Baumgartner
Patient History
 74 year old Caucasian male
 Treated on v1 at the James
 Diagnosis: T3N0M0 (Stage IIA) Rectal Cancer
(adenocarcinoma)
 Moderately differentiated adenocarcinoma, 6.5 cm,
arising in the rectum
 Adeno CA extends through the muscularis propria into the
surrounding fat
 26 nodes tested (all negative for involvement)
Anatomy of Colon
Layers of Colon
Anatomy of Rectum
Epidemiology

 Third most common cancer (both men and women) in the united states
excluding skin cancer (if you include skin cancer it is listed as the 4th
most common cancer in the US)
 95,520 new cases of colon cancer/year
 39,910 new cases of rectal cancer/year
 Overall lifetime risk of developing colorectal cancer – 1/21 (men) and
1/23 (women)
 Median age is 60 years
 Third leading cause of cancer related death in women (in the US).
Second leading cause of cancer related death in men (in the US)
 Expected to cause ~50,260 deaths during 2017
Etiology – Risk Factors

 Obesity
 Physical inactivity – but he did start going for 1 mile walks
 Certain diets
 Diets high in red/processed meats, high fat, low fiber
 Fried, broiled, or grilled foods (may create chemicals that can cause cancer)
 Smoking
 Heavy Alcohol Use
 History of polyps
 Personal/Family history of inflammatory bowel disease
 Hereditary diseases or mutations
 Most common is Familal adenomatous polyposis (FAP)
 African American and Jews of Eastern European descent (not understood why this is)
 Type II diabetes
 Inflammatory bowel disease
Common Presentation
 Usually starts as a polyp on the inner lining of the colon or rectum – 2 main
types:
 Adenomatous polyps (adenomas) – sometimes change into cancer, thus they are
also called a pre-cancerous condition
 Hyperplastic polyps and inflammatory polyps – the most common type of polyp,
generally NOT pre-cancerous
 A change in bowel habits
 A feeling that you need to have a bowel movement that is not relieved by
having one
 Rectal bleeding – most common
 Blood in the stool
 Cramping or abdominal (belly) pain
 Weakness and fatigue
 Unintended weight loss
Screening
 Person with average risk – digital rectal exam
and occult blood test annually at age 50 with
possible colonoscopy every 10 years;
sigmoidoscopy
 High risk – start screening at age 40 and more
frequently
Routes of Spread/Sites
 Route of spread: Lymph vessels or via blood
 May invade adjacent structures of the pelvis
 Can travel along portal drainage to the liver
 Can travel systemically to the lungs
Rectum Lymphatics
 Superior Half of Rectum
 Peri-Rectal

 Sacral

 Sigmoidal

 Inferior Mesenteric nodes

Staging
 Duke’s staging most commonly used
 Stage 0 – has not invaded past the mucosa
 Stage I – grown into submucosa, no nodes, no mets
 Stage II – grown into serosa or adjoining tissues, no nodes,
no mets
 Stage IIIA-B – grown into submucosa, muscularis propria,
serosa, or adjoining tissues with 3 or less nodes involved,
no mets
 Stage IIIC – tumor of any size with 4 or more nodes
involved, no mets
 Stage IV – any tumor size, any node stage, mets to other
organs
Treatment options by stage
 Stage I – local excision; adjuvant chemo/radiation
for T2 lesions
 Stage II & III (resectable) – Preop Chemo/Radiation
therapy then transabdominal resection with postop
chemo
 Stage III (unresectable) – Chemo/Radiation therapy
 Stage IV – Chemo and/or radiation, followed by
surgery for mets sites; may do postop chemo
regime
Treatment Borders
 AP/PA
 Superior - L5 – S1
 Inferior – 3 cm below inferior aspect of tumor, lower
portion of rectum should include anus
 Lateral – 1.5 - 2 cm beyond the pelvic brim

 Laterals – same superior and inferior borders

 Anterior – posterior to pubic symphysis if ≤ T3, anterior
to pubic symphysis if T4
 Posterior – behind the sacrum
History Continued
 History of arthritis, club foot, hypertension, Rheumatic
fever, and obesity
 Past surgeries: Removal of cataract, ankle surgery in
20’s
 No family history of colorectal cancer
 Social history: Never smoker, 3.0 ounces of liquor/week,
5 cans of beer/week
 States he drank heavily for 20+ years then toned it down in
his 40’s
 Uses illicit drugs once/week
 Physically inactive
Presenting signs and symptoms
 Presented to the hospital complaining of
constipation and other problems with bowel
movements
 Resultwas a flexible sigmoidoscopy which showed a
partially obstructing mass – removed the following day
 Until now he had never had a colonoscopy exam
Treatment Plan

 Rectum + Boost total = 5040 cGy

 Rectum Treatment
 4500 cGy in 25 fractions (180 cGy/fraction)
 15 MV
 5 fields (PA, R LAT, RF R LAT, L LAT, RF L LAT – Dynamic wedges on lateral fields, not
including the reduced fields)
 Boost
 540 cGy in 3 fractions (180 cGy/fraction)
 Chemotherapy
 Xeloda in 4 week cycles for 2 months, then 5+ weeks of Xeloda +
Radiation, then another 2 months of Xeloda (sandwich treatment)
 11/2/16: Xeloda 2000mg BID X7 days, every other week
 Positioning
Possible Side Effects

 Fatigue
 Skin irritation including dryness, redness, and itchiness
 Possible irritation of bowels causing cramping and/or loose stools
 Possible decrease in blood counts
 Possible inflammation of rectum and anus causing pain, spasm, discharge, or
bleeding
 Possible irritation of bladder causing burning, frequency, spasm, pain, and
hematuria
 Damage to bowel causing blockage or fistula (hole)
 Shrinking of the bladder resulting in frequent urination
 Dysuria
 Weight loss
Prognosis and Survival
 Stage I – 87%
 Stage IIA – 80%

 Stage IIB – 49%

 Stage IIIA – 84%

 Stage IIIB – 71%

 Stage IIIC – 58%

 Stage IV – 12%
Sources
 "What Is Colorectal Cancer?" American Cancer Society.
N.p., n.d. Web. 10 Mar. 2017.
 "Colorectal Cancer Risk Factors." American Cancer
Society. N.p., n.d. Web. 10 Mar. 2017.
 "Colorectal Cancer Signs and Symptoms." American
Cancer Society. N.p., n.d. Web. 10 Mar. 2017.
 Washington, Charles M., and Dennis T. Leaver. "Chapter
33: Digestive System Tumors." Principles and Practice of
Radiation Therapy. St. Louis, MO: Elsevier, Mosby, 2016.
705-18. Print.