Colorectal Cancer

Typical HPI
Over 40 y. o. Male
Western Rectal Bleeding Change in bowel habit Incomplete emptying pencil stools Weight Loss

NHMRC doc cp64; eMedicine; Harrissons; NIH website, Cancer Medicine 5th ed

Fever Abdominal Pain Constipation Distension + colic Bone pain

Past History

Which risk category? Smoking, Alcohol, Dietary excess of animal protein and fat Family history of early onset bowel cancer, polyps, other cancers Sedentary lifestyle / lack of exercise / fluctuating weight + Obesity NEURO EXAM Focal signs Increased ICP MMSE AUSCULTATE Heart sounds Lung fields Bowel sounds PELVIC EXAM- 10% are palpable Examine anus, rectum, perineum Look for ballooning + anal tone Blood on the glove? Haemorrhoids?

Examination
LOOK FOR: Jaundice Cachexia Pallor Previous surgery

PALPATE FOR Mass Abdo distension Abdo tenderness

Liver + Spleen Lymph nodes Hernia orifices Bony tenderness

Laboratory Investigations
Faecal Occult Blood Test (FOBT)
Must be performed 3 times

Screening recommended for over 50s Digital Rectal exam + FOB annually
Double-contrast barium enema every 5 10 years Flexible sigmoidoscopy every 5 years

Pattern of spread Lungs, Liver, Brain and Bone

Carcinoembrionic Antigen (CEA)

To have a baseline before surgery BUT: 1) CEA is also elevated in hepatic and pancreatic cancer 2) Low post-op CEA does not exclude recurrence

Imaging Investigations
Abdomen X-ray
Looking for distended small bowel loops with gas, or bony disease

Full Blood Count, Electrolytes, Biochemistry

Pre-operative assessment, Anaemia, hypercalcaemia, thrombocytopenia

Chest X-ray
Looking for lung opacities, for baseline

Liver Function Tests

Mainly checking for metastasis

Barium Enema
Looking for site of obstruction, Apple Core appearance

CT Scan of chest, abdomen & pelvis

Lymph node involvement extension into adjacent organs metastasis to liver, kidneys, lungs, etc

? PT + APTT
reasons for blood in the stool may be haemostasis disorder

Proctoscopy, Sigmoidoscopy, Colonoscopy Histopathology of biopsy sample

Histological subtype and degree of differentiation are necessary for decision-making in management. Gold standard: visualise lesion, take sample, snip polyps

Trans-rectal Ultrasound

Staging Dukes: A- Limited to mucosa + submucosa B- extends into the muscularis (B1),
into or through the serosa (B2)

Risk categories 1No Hx, or one 1st or 2nd degree

st

relative hand cancer after 55 y.o

CD-

Involves nodes Is metastatic

before 55 2 One 1 2degree rel.rels of any y.o or two nd degree age

3 Multiple cancer Hx throughout family

Identified mutation eg. FAP, HNPCC

Management Strategies Surgery Dukes A Dukes B Dukes C Dukes D Palliative Bio Psycho Social Follow-Up
Mainstay of treatment Temporary colostomy unless FAP +ve ( FAP = remove whole bowel) Remove primary cancer+ whatever tissue it adheres to. + temp colostomy Pathology check margins clearance Remove bowel + any involved nodes Colostomy or ileostomy De-bulking surgery if appropriate Usually inoperable

Chemotherapy
Limited use Should be offered 5FU + leukovorin

Radiotherapy
Limited use Better rates of local control with 45/25 (fewer recurrences over 5yr interval) esp. locally advanced disease Better rates of local control (fewer recurrences over 5yr interval) esp. locally advanced disease Control of bony met pain Alleviate effects of brain mets

Should be encouraged; improves survival Palliate symptoms of metastatic spread; occasionally remission

Oral pain control with MS contin, oral morphine; battery of analgesics (but dont superimpose opiates)
Bony met pain + neuropathy = controlled with tricyclics, Ketamine, anticonvulsants eg. valproate Key words: Dignity, comfort, daily activity assistance and counselling of end-of-life decisions Stoma specialist Counselling (esp. regarding sexuality, fertility) Psychiatrist Occupational therapist Genetic counselling Bowel Cancer Support network Dietitian Legal advice re. enduring guardianship, will etc

METASTATIC or HIGH-GRADE DISEASE DUKES A to C CT scans every 2 months while on chemo, Regular and frequent occult blood or Regular follow-up until next recurrence colonoscopy of remaining colon for 5 years is identified Yearly FOB thereafter

PALLIATIVE Regular monitoring of pain status and QOL, with relevant alterations to management strategy