Transcript Colorectal Cancer - Surgical Students Society of Melbourne

Assessment & Management
Orla Dunlea
Surgical Resident
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It is common
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80 Australians die each week from colon cancer
1/12 of us will be diagnosed with it in our lifetime
It is preventable
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90% is treatable if detected early enough
Currently <40% is detected in the early stages
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M=F
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Peak incidence at 65 years
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Family history
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Ulcerative colitis x 8-10 years
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History of polyps
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Fibre intake? (Proposed by Burkitt – Irish)
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Aspirin reduces risk
Morphological term –
protrudes from the bowel
wall into the lumen
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 Pedunculated
 Sessile
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Villous
Most malignant potential
 Frond-like
 Mucus-secreting which may
be presenting complaint or
low K+
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Tubulovillous
Most common type
 Pedunculated
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Tubular
Least malignant potential
 Polyps found in FAP
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Right sided
 Anaemia
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RIF mass
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Don’t tend to cause obstruction
(unless the ileocaecal valve is
involved) as diameter is greater
than left & stool is more liquid
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Left sided
 Change in bowel habit
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PR bleeding
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Tenesmus (lower rectal lesion)
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Pericolic abscess – erodes
through the bowel wall, LIF
pain, tender & swinging pyrexia
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Large bowel obstruction – acute
presentation
Presentation with mets
 Obstructive jaundice – nodes compressing porta hepaticus
 Ureteric or duodenal obstruction – retroperitoneal lymph nodes
 Weight loss, anorexia, hepatomegaly due to liver mets
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Signs of anaemia
Weight loss
Abdo exam
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Normal
Palpable mass
Hepatomegaly due to mets
Ascites
PR exam
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Mass
Local extension into pouch of douglas
Amount of fixation to local structures
FOB
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Bloods
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CEA
HB
LFTs
Barium enema
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Colonoscopy
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Visualise tumour
Biopsy tumour
Look for other
tumours/polyps
+/- stenting if palliative
If histology confirmed
 Imaging
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U/S for liver Mets
CT thorax/abdo/pelvis with contrast for staging
MRI /endoanal U/S for rectal CA (if MRI incompatible)
Apple
core
lesion
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Stage of cancer – is it operable?
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QOL & life expectancy prior to surgery
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Does the patient want surgery?
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Suitable for anaesthetic- anaesthetic review
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Co-morbidities – IHD, DM, COPD etc
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Are risks of complications too high?
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Nutrition and ability to heal
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Routine bloods – FBC,
U&Es, LFTs, Coag
Group & cross match
CEA for baseline
CXR
Consent
+/-bowel prep
NPO
Catheter
IVABs
TEDS
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(Radiotherapy)
(Chemotherapy)
(Stoma education)
(Stoma positioning)
(PFTs)
(Echo/cardiac mibi/
coronary angio)
Caecal & R colon tumours
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Proximal or midtransverse colon
tumours
Splenic flexure and left colon
tumours
Sigmoid tumours
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Low rectal tumours,
FAP
Permanent stoma
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Hartman’s procedure
with formation of a
stoma
If present acutely
If anastomotic healing
doubtful
~50% will be reversed
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HNPCC
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FAP
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Multiple tumours
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Early
 Bleeding
 Infection
 Perforation
 Local structure damage – ureters, bladder, spleen, duodenum
 Anastomotic leak or breakdown
 Wound infection
 Wound dehiscence
 Sepsis & multiorgan failure
 Stoma problems
 TPN
Late
 Diarrhoea due to short bowel syndrome
 Impotence – pelvic parasympathetic nerve damage
 Small bowel obstruction
 Adhesions
 2nd radiotherapy
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Duke’s A
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Bowel wall only
No nodes
No mets
75% 5 year survival
Duke’s B
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Through muscularis propria
No nodes
No mets
55% 5 year survival
Duke’s C
C1
 Node positive but only
around tumour & not
distal
 40% 5 year survival
 C2
 Node positive up to
proximal resection margin
 20% 5 year survival
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Duke’s D
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Distant metastasis
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T = Tumour
 T1 – Invasion into submucosa (connective tissue & glands)
 T2 – Invasion into muscularis propria (muscles layers)
 T3 – Invasion into subserosa
 T4 – Invasion to local organ or structures +/- visceral
peritoneum
N = Nodes
N0 - No lymph node invasion
 N1 – spread to 1-3 regional lymph nodes
 N2 - >4 regional lymph nodes
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M = Metastasis
M0 – No mets
 M1 – Distant mets
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Lymphatic spread to mesenteric & then paraaortic nodes
Absence or presence
of liver mets most
important factor in
determining
prognosis!!!
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In the blood to the liver
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Unusually to bone, lung or brain
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5-Fluorouracil +/- Leucovorin
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Following resection of stage 3, +/- stage 2
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Metastatic disease
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Radiation may be used in rectal cancer to
reduce the size of the lesion & allow
preservation of sphincter
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CEA levels
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Colonoscopy
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CT thorax/abdo/pelvis
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Hereditary non-polyposis colorectal cancer
(HNPCC)
 Lynch syndrome 1 – hereditary colon cancer
 Lynch syndrome 2 – hereditary colon cancer +
increased risk of other GIT or reproductive tumours
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Familial adenomatous polyposis (FAP)
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Unknown mutations
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DNA mismatch repair gene mutation (several different
chromosome locations)
Autosomal dominant – 50% chance of offspring having mutation
Polyps become malignant over 2-3 years (compared to 8-10 years
for non hereditary colon cancer)
70-80% lifetime chance of getting colon cancer
Lynch syndrome 2 increased risk of endometrial, ovarian, upper
urinary tract & stomach
Treatment
Colectomy with ileo-rectal anastomosis
 Colectomy & permanent ileostomy
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Used to identify people at risk of HNPCC
>3 more relatives with HNPCC-related cancer
 2 successive generations
 At least 1 of the cancers diagnosed <50 years
 FAP has been excluded
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Rare
100% penetrance
Autosomal dominant
Deletion on chromosome 5 (adenomatous polyposis
coli gene)
Extra-intestinal features – BORED
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Brain tumours
Osteomas
Retinal pigment hypertrophy
Epidermal cysts
Dentition abnormality
Treatment
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Panproctocolectomy & ileostomy
Good for
screening as
present in
~95% people
with gene
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National screening
programme if >50
years
Home FOB test – send
off – GP contacted if
positive
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Polyps with the most potential to become
malignant are tubulovillous polyps – T or F
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Mr Murphy is a 69 year old man who has
noticed passage of blood with stools over the
last week – please take a history. What
investigations would you like to perform?
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Post-operative patient with a stoma
 Ostomy = Surgically created opening connecting an
internal organ to the surface of the body
 Stoma = The opening of the ostomy
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Stoma important for exams
 Ileostomy
 Colostomy
 Ileal-conduit
EXTREMELY
COMMON FOR LONG
CASES!!!!!!
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Ileostomy
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To protect a distal at risk
anastomosis
Distal bowel rest for
Crohn’s
Permanent after
panproctocolectomy
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Colostomy
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To protect a distal at risk
anastomosis
Perforation, infection or
ischaemia means an
anastomosis would not
heal & may be performed
at later date
Permanent after
abdomino-perineal
resection
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3.
Stoma itself
Stoma surroundings
Stoma bag
1. Stoma itself
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2. Stoma surroundings
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Skin
Scars
Patient general health
Where is it?
How many lumens?
Type of spout
Does it look healthy?
3. Stoma bag
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What kind of bag?
What’s in the bag?
1. Stoma itself
RIF = ileostomy, left = colostomy – but beware
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Where is it?
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How many lumens?
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Type of spout
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Does it look healthy?
2 = may be loop ileostomy (temporary)
Flush with skin = colostomy, spouted= ileostomy
(or prolapsing colostomy!)
Ischaemic? Prolapsing? Retracted?
Stenosed?
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2. Stoma surroundings
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Skin
Rash, necrosis, parastomal hernia
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Scars
Previous surgeries, previous stoma sites
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Patient general health
Young =UC or Crohn’s, dehydrated
looking = high stoma output,
cachexic = palliative stoma
3. Stoma bag
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What kind of bag?
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What’s in the bag?
Tap & transparent = post-op for output
measurements. Non-transparent no tap
= long-term
Greenish fluid = ileostomy
Brownish = colostomy
Yellow = ileal-conduit
Any mucus or blood?
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Choosing a site
Stoma nurse
 Important for success of the stoma post-op
 Assess site when sitting, standing
 Avoid
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 Previous scars/wound site
 Belt line
 Bony prominence
 Umbilicus
 Skin crease
 Obesity poses problems
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Stoma itself
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Area surrounding stoma
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Living with a stoma
1. Stoma itself
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Ischaemia
Retraction
Prolapse
Obstruction
Stenosis
2. Area surrounding stoma
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Leakage
Hernia
Skin irritation (ileostomy)
Fistula (Crohn’s)
Living with a stoma
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Increased output/short gut syndrome (electrolytes,
dehydration)
Psychological/psychosexual – especially if odour (charcoal
filter helps)
Kidney & gall stones (if terminal ileum diseased/sacrificed)
“From little things, big things grow”
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N Engl J Med. 2010 Jan 7;362(1):85; author
reply 85.Screening for colorectal cancer.
Mohammed F.
Lancet. 2009 Mar 7;373(9666):790-2.Rectal
cancer: optimum treatment leads to optimum
results. Madoff RD.