Colorectal MCQs TNM Staging of colorectal cancer - PowerPoint Presentation

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Colorectal MCQs

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TNM Staging of colorectal cancer

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ypT3N1M0

ypT4N2M0 R0

pT3N3M1

ypT2N1M0 R0 V0

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Chemotherapy for colonic

cancer

Oxaliplatin

and

5FU

would be the standard regime

(

FOLFOX

regime: FOL = Folinic acid OX = oxaliplatin)

Adjuvant versus neoadjuvant

Metastatic patients -

Irinotecan

may be used in combination with 5FU and folinic acid, the

FOLFIRI

regime.

The monoclonal antibody

cetuximab

may be useful for patients with wild type K RAS. It is either given alone or together with

irinotecan

.

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Adverse

effects

Neuropathy

is the main side effect of

oxaliplatin

. It is also ototoxic though less than the other platinum chemotherapy drugs.

Side effects of 5FU include;

myelosuppression

,

mucositis

, dermatitis and

diarrhoea

.

Side effects of

irinotecan

are severe

diarrhoea

and extreme suppression of the immune system.

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Most

fissures are idiopathic

P

ainful

mucocutaneous

defect in the posterior midline (90% cases)

.

Fissures

are more likely to be anteriorly located in females, particularly if they are multiparous.

Multiple

fissures and those which are located at other sites are more likely to be due to an underlying

cause: .

Crohn’s

disease

Tuberculosis

Internal rectal prolapse

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Treatment

Stool softeners are important as the hard stools may tear the epithelium and result in recurrent symptoms. The most effective first line agents are topically applied GTN (0.2%) or

Diltiazem

(2%) paste. Side effects of

diltiazem

are better

tolerated.

Resistant cases may benefit from injection of

botulinum

toxin or lateral internal

sphincterotomy

(beware in females). Advancement flaps may be used to treat resistant cases

.Surgery is used following failure of botulinum toxin and may be undertaken without ano rectal manometry studies in males who have not had previous anal surgery. All others should have manometry performed. Surgery for high pressure fissures should include tailored sphinterotomy. For low pressure fissures an advancement flap should be considered.

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VY advancement Flap for chronic anal fissure

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STAGING RECTAL CANCER

Rectal

cancer is staged with MRI

Endoanal

USS is considered

ONLY for

cases where a TEM is

planned (T1 tumours)

CT

scanning for distant disease

MRI for T and N staging within the

mesorectum

The presence of tumour within 1mm of the CRM following resection is a strong predictor of poor survival and local recurrenceGenerally a distance of >1mm on MRI is taken as being predictive of a clear CRMHigh quality MRI scanning of the pelvis is the current standard for staging rectal cancer.

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RECTAL CANCER: TREATMENT

S

hort

course radiotherapy is shown to increase sexual dysfunction in males following

surgery

The

Swedish cancer trial was the largest trial to be undertaken

D

emonstrated

a reduction in local recurrence with the addition of short course

radiotherapy

Other

, large, multicentre trials have demonstrated similar benefits from short course radiotherapy The main group to benefit from pre operative radiotherapy are those patients with a threatened or involved CRM (usually by T4 tumours). Radiotherapy in this setting is given as long course and the addition of chemotherapy to the regime produces improved downstaging (at the cost of increased toxicityIndeed, in some patients complete regression of the tumour is

seen.

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Rectal cancer = tumours with distal margin 15cm or less from the anal verge as measured with rigid

sigmoidoscopy

.

All patients with rectal cancer should have rectal MRI scanning to assess nodal disease, T and N stages.

The

addition of chemoradiotherapy is of proven benefit in

downstaging

and reducing local recurrence rates in patients with a threatened CRM or suspicion of bulky nodal disease in the

mesorectum

.

The evidence for short course radiotherapy stems primarily from the

Swedish Rectal cancer trial

where local recurrence rates decreased from 27% to 11% . Such benefits were also seen in the Dutch TME trial 8.2% to 2.4%.

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Familial

adenomatous polyposis coli (FAP)

Hundreds of colonic

polyps - as

a result of mutation of APC gene on chromosome

5q

Autosomal dominant inheritance

Risk

of malignancy nearly 100%

Duodenal adenomatous polyps

20%

occur as a new mutation and not be part of an FAP

family80% of cases with FAP will be familial

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Endoscopic appearance

Macroscopic appearance

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Duodenal Polyps: FAP

Gastric

Fundic

gastric polyps are seen in up to 50% of patients, these have a

low

malignant potential.

Duodenal adenomas occur in nearly all patients. They are severe in 10% and malignant transformation occurs in 5%

.

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Activity related

polyarthropathy

is seen in up to 20% of patients with ulcerative colitis

Questions

regarding the 'extra-intestinal' features of inflammatory bowel disease are common.

Extra

-intestinal features include

sclerosing

cholangitis,

iritis

and

ankylosing

spondylitis.Related to disease activity Arthritis: pauciarticular, asymmetricErythema nodosumEpiscleritisOsteoporosis Arthritis is the most common extra-intestinal feature in both CD and UCEpiscleritis is more common in

Crohns

disease

Unrelated to disease

activity

Arthritis

:

polyarticular

, symmetric

Uveitis

Pyoderma

gangrenosum

Clubbing

Primary

sclerosing

cholangitis Primary

sclerosing

cholangitis is much more common in UC

Uveitis is more common in UC

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Erythema

Nodosum

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Pyoderma

gangreonosum

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Primary

sclerosing

cholangitis – ‘string of beads’ sign

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Primary

sclerosing

cholangitis – ‘string of beads’ sign

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Uveitis

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Terminal

ileal resection impairs the

enterohepatic

circulation.

This

may result in impaired bile salt absorption, this is a risk factor for both

diarrhoea

and gallstone formation.

The

normal inflammatory makers make

Crohn’s

recurrence unlikely. The normal red cell folate and B12 make bacterial overgrowth unlikely.

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COLONIC INJURIES

Colonic injuries usually arise as a result of penetrating trauma, typically 75% occur as a result of gunshot injuries.

Historically, the typical treatment for most types of colonic injury was resection and formation of stoma/

exteriorisation

.

Non destructive colonic injuries in a stable patient can be managed by primary repair

.

More

significant injuries can be managed by resection and primary anastomosis. In the damage control setting, attempts to

anastomose are

associated with leak rates of 20% or

more.

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Ileostomy output is roughly in the range of 5-10ml/Kg/ 24 hours.

Output

in

excess requires

supplementary intravenous fluids.

Early

high output is not uncommon

AKI risk with high output

Excessive

fluid losses are generally managed by administration of oral

loperamide

(up to 4mg QDS) to try and slow the output

.Codeine Phosphate / PPI

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End ileostomy

Ileostomies are generally fashioned in the right iliac fossa in a triangle between the anterior superior iliac spine,

symphysis

pubis and umbilicus.

They should lie one-third of the distance between the umbilicus and anterior superior iliac

spine

Ileostomies

that are too short may cause problems with appliance fixation and those which are too long may cause problems with tension and subsequent ulceration or prolapse.

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Plain

xray

of Pseudo-obstruction

Caecum most vulnerable site for rupture

Why ?

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Neostigmine affects the degradation of acetylcholine and will therefore stimulate both nicotinic and muscarinic receptors.

It

may produce symptomatic

bradycardia

and should therefore only be administered in a monitored environment.

In

colonic pseudo-obstruction it produces

generalised

colonic contractions and its onset is usually rapid.

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Anal sphincter

Internal anal sphincter composed of smooth muscle continuous with the circular muscle of the rectum. It surrounds the upper two- thirds of the anal canal and is supplied by sympathetic nerves.

External anal sphincter is composed of striated muscle which surrounds the internal sphincter but extends more distally.

The nerve supply of the external anal sphincter is from the inferior rectal branch of the

pudendal

nerve (S2 and S3) and the

perineal

branch of the S4 nerve roots.

The

external anal sphincter is innervated by the inferior rectal branch of the

pudendal

nerve, this has root values of S2, 3 and the

perineal branch of S4

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The

external sphincter

muscle is a striated muscle under voluntary

control.

The

internal sphincter

muscle is a smooth muscle under autonomic control and is an extension of the circular muscle of the rectum

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Contents

Males

Spermatic

cord and

ilioinguinal

nerve As it passes through the canal the spermatic cord has 3 coverings:

External spermatic fascia from external oblique

aponeurosis

Cremasteric

fascia

Internal spermatic fasciaFemales Round ligament of uterus and ilioinguinal nerve

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Contents

The

genitofemoral

nerve divides into two branches as it approaches the inguinal ligament.

The

genital branch passes anterior to the external iliac artery through the deep inguinal ring into the inguinal canal.

It

communicates with the

ilioinguinal

nerve in the inguinal

canal.

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Genitofemoral

nerve

Supplies

Small area of the upper medial thigh

Path

Arises from the first and second lumbar nerves

Passes obliquely through Psoas major, and emerges from its medial border opposite the fibrocartilage between the third and fourth lumbar vertebrae.

It then descends on the surface of Psoas major, under cover of the peritoneum

Divides into genital and femoral branches.

The genital branch passes through the inguinal canal, within the spermatic cord, to supply the skin overlying the skin and fascia of the scrotum. The femoral branch enters the thigh posterior to the inguinal ligament, lateral to the femoral artery. It supplies an area of skin and fascia over the femoral triangle.

It may be injured during abdominal or pelvic surgery, or during inguinal hernia repairs.

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Accessory

spleen (

splenunclus

) is

a common anomaly and compromise the outcome of

splenectomy.

They

occur in up to 20% of patients.

80

% of accessory spleens are located at the hilum.