2. POINTS TO BE DISCUSSED
ī Clinical anatomy of colon and rectum
ī Definition of colorectal ca
ī Epidemiology of colorectal ca
ī Risk factor and etiopathogenesis
ī Screening
īPathology and staging
ī Clinical presentation
ī Investigations
īTreatment
īFollow up
3. Clinical anatomy
īColon and rectum approx length 150 cm
īDovelopement occurs from midgut,hindgut and proctodium
īCaecum -7.5 cm diameter and 10 cm in length
īAscending colon apporx 15 cm in length, posterior surface
retroperitonium while anteriolateral surface are
intraperitoneal .white line of told represents fusion of
mesentry with posterior peritoneum.
īTransverse colon approx 45 cm in length
īDescending colon approx 25 cm in length
īSigmoid colon 15 to 50 cm ( average 38 cm )
īHaustration, epiploic appendices,taenia present in colon
while absent in rectum
4. rectum
âĸ 12-15 cm from anal verge.
ī Diameter
ī 4 cm (upper part)
ī Dilated (lower part)
ī Posterior part of the lesser
pelvis and in front of lower
three pieces of sacrum and
the coccyx
ī Begins at the rectosigmoid
junction, at level of third
sacral vertebra
ī Ends at the anorectal
junction, 2-3 cm in front of
and a little below the
coccyx
5. âĸ Divided into 3 parts
īŧ Lower rectum : 3 â 6 cm
from the anal verge
īŧ Mid rectum: 6 cm to 8
-10cm
from anal verge
īŧ Upper rectum: 8 cm to
12 -15cm from anal verge
âĸ 3 distinct intraluminal
curves ( Valves of
Houston)
6. ī Superior 1/3rd of the rectum
ī Covered by peritoneum on the
anterior and lateral surfaces
ī Middle 1/3rd of the rectum
ī Covered by peritoneum on the
anterior surface
ī Inferior 1/3rd of the rectum
ī Devoid of peritoneum
ī Close proximity to adjacent
structure including boney pelvis.
Note: - Distal rectal tumors have no
serosal barrier to invasion of adjacent
structures and are more difficult to
resect given the close confines of the
deep pelvis.
Peritoneal Relations
7.
8.
9.
10.
11. Lymphatic drainage
īUpper and middle rectum
ī Pararectal lymph nodes, located
directly on the muscle layer of the
rectum
ī Inferior mesenteric lymph
nodes, via the nodes along the
superior rectal vessels
īLower rectum
ī Sacral group of lymph nodes or
Internal iliac lymph nodes
īBelow the dentate line
ī Inguinal nodes and external iliac
chain
12. īDefinition
īColorectal Cancer is the cancer affecting caecum,
colon and rectum
īAnal canal and Appendix are not considered in the
definition, and are treated as a separate entities
13. Epidemiology
īColorectal caner is the third most common malignancy
worldwide ( after lung, prostste in males âlung ,breast in females
Worldwide approx. 1 million new cases p.a. are diagnosed, with
529,000 deaths.
īIncidence rate in India is quite low about 2 to 8 per 100,000
īMore than 90% cases diagnosed after 50 yrs of age.
16. Screening for colorectal cancer
īAsymtomatic average risk people-start at the age of
50 yrs and end at 75 yrs with- FOBT yearly (6 samples ) if
positive results then full colonoscopic evaluation
īBaseline colonoscopy and if no pathology then repeat every
10 yearly
īEvery 5 yr flexible sigmoidoscopy or barium enema
īIf precursor lesion are found ,they should be removed and
colonoscopy performed after 1-3 years
īIn high risk people (peraonal or family history of
polyp/familial cancer /african american ethnicity) screening
should be started early
īFAP 10-15yr of age anually
īHNPCC at 20 Yrs every 2 yr and anually after 40 yrs or 10-15
yrs before cancer onset in youngest family member
19. Adenoma to Carcinoma Pathway
APC
loss
Normal
Epithelium
Early
Adenoma
Cancer
Hyper-
proliferation
Intermediate
Adenoma
Late
Adenoma
K-ras
mutation
Chrom 18
loss
p53
loss
AdenomaNormal Cancer
20. Non hereditary colon cancer
ī1-sporadic âno family history ,older age of onset ( 60
to 80 years),isolated colon and rectal lesion
ī2 familial-lifetime risk of colorectal cancer increases
for members in families in which index case is young
<50 yrs and the relative is first degree.
21. Hereditary colon cancer
īFAP (familial adenosis polyposis )-mutation in
APC gene on chromosome 5 (1% of total colorectal
cases)
īMore then 100 polyps throughout GI tract.
ī100% chances of malignant transformation.
īAge of onset is late 2nd
decade or early 3rd
decade .
īPatient die by fifth decade of life in the absence of
surgical intervention
īGardener syndrome ( adenomatous polyp, osteoma,
desmoid tumer, periampullary ca, medulloblastoma,
CHRPE, thyroid papillary ca, hypertrophicfundic
gastric polyp)
īPEUTZ JEGHAR syndrome
25. cuthbert Dukes staging (originally for ca rectum )
Dukes A: Invasion into but not through the bowel wall.
Dukes B: Invasion through the bowel wall but not involving lymph
nodes.
Dukes C: Involvement of lymph nodes
Dukes D: Widespread metastases ( In modified duke )
Modified astler coller classification-
Stage A : Limited to mucosa.
Stage B1 : Extending into muscularis propria but not penetrating
through it; nodes not involved.
Stage B2 : Penetrating through muscularis propria; nodes not
involved
Stage C1 : Extending into muscularis propria but not penetrating
through it. Nodes involved
Stage C2 : Penetrating through muscularis propria. Nodes involved
Stage D: Distant metastatic spread
26. TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ: intraepithelial or invasion of lamina propria
T1 Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades through the muscularis propria into pericolorectal tissues
T4a Tumor penetrates to the surface of the visceral peritoneum
T4b Tumor directly invades or is adherent to other organs or structures
29. Pathology (microscopic )
WHO Classification (microscopic )
īAdenocarcinoma in situ/Severe dysplasia
īAdenocarcinoma
īMucinous (colloid) adenocarcinoma (>50% mucinous)
īSignet ring cell carcinoma (>50% signet ring cells)
īSquamous cell (epidermoid) carcinoma
īAdenosquamous carcinoma
īSmall-cell (oat cell) carcinoma
īMedullary carcinoma
īUndifferentiated Carcinoma
30. TYPES OF SPREAD
Lymphatic spread âCOLON Ca-epicolic/paracolic/principle LN
IN RECTAL CA- Above the peritoneal reīŦection occurs almost exclusively in an upward direction;
Below that level, the lymphatic spread is still upwards,
but when the neoplasm lies within the īŦeld of the middle rectal artery, primary lateral spread along
the
lymphatics .
Downward spread is exceptional, to the lymph nodes draining the perianal rosette and the epithelium
lining the distal 1â2cm of the anal canal.
A radical operation should ensure that the high-lying lymph nodes are removed by ligating the
inferior mesenteric artery at a high level.
Local spread âcolan ca can occur longitudinal/transverse /radial- involvement of
ureter/duodenum/post abdominal wall /small intestine/pelvic organs occurs
IN RECTAL CA Local spread occurs circumferentially .
A period of 6 months is required for involvement of a quarter of the circumference, and 18 months to 2
years for complete encirclement.
After the muscular coat has been penetrated, the growth spreads into the surrounding mesorectum, but
is initially limited by the meso- rectal fascia.
Anteriorly, in male the prostate, seminal vesicles or bladder
female, the vagina or the uterus is invaded.
Lateral, a ureter may become involved.
Posterior penetration may reach the sacrum and the sacral plexus.
Downward spread is >4 cm is rare
31. TYPES OF SPREAD
īHematogenous spread â
Principal sites are liver (34%), lungs (22%) ,ovary ,brain ,kidney , adrenals .
âĸ Peritoneal dissemination â
spread by way of cells dislodging from serosa of the bowel or via
subperitoneal lymphatics
32. Clinical presentation of colorectal cancer
īSymptoms âin right sided ca symptoms are often
absent untill tumor has grown to a significant size,
only vague symptoms like unexplained weight
loss,anaemia and weakness from chronic blood
loss,melana,episodes of colicky abdominal pain,
because of liquid/semisolid nature of stool in right
colon tumer grow very large size before causing
obstruction.
īLeft side tumor ( colon/rectum) presentation â
changes in bowel habbit,rectal bleeding,mucous
discharge,tenesmus,decreasing diameter of stool
,pelvic pain due to nerve or sphinctor
invasion,features of large bowel obstruction,passing
of faeces/flatus other than anal opening/wt loss
34. īSigns
īPallor,cachexia,dehydration
īAbdominal mass
īPR mass
īJaundice
īLymph node enlargement ( like left supraclavicular-
troisier sign)
īNodular enlarged liver
īFeatures of obstruction/peritonitis
īAscites
īRectal metastasis travel along portal drainage to liver via
superior rectal vein as well as systemic drainage to lung via
middle & inferior rectal veins.
35. Diagnostic Workup
īHistoryâ including family history of colorectal cancer or polyps
īPhysical examinations
īAbdominal examination -Abdominal examination is normal in early cases.
ī Occasionally, annular tumour at the rectosigmoid junction, signs of obstruction of the large intestine .
ī Metastases in the liver may be palpable.
ī When the peritoneum has become studded with sec- ondary deposits, ascites results.
ī Digital rectal examination (DRE) and complete pelvic examination in women: size, location, ulceration,
mobile vs. Fixed to surrounding structures(prostate/vagina/sphinctor), distance from anal verge
īProctoscopyâ including assessment of mobility, minimum diameter of the lumen, and distance from
the anal verge
ī flexible sigmoidoscopy-60 cm ,possible to assess bowel up to splenic flexure
Colonoscopy â To exclude a synchronous tumour ( 3-5%%), be it an adenoma or a
carcinoma.If a prox- imal adenoma snared and removed via the colonoscope for biopsy
If a synchronous carcinoma is present, the operative strategy will need changing.
If a full colonoscopy is not possible due to obstruction, a CT colonography( virtual colonoscopy) or
barium enema can be
performed.
In stenosing carcinoma it may not be possible to visualise the proximal colon.
However, in view of the high incidence of synchronous tumours, it is imperative that a colonoscopy is always
performed either before or within a 6 months of surgical resection.
36.
37. Figure: Carcinoma of the rectum. Double-
contrast barium enema shows a long
segment of concentric luminal narrowing
(arrows) along the rectum with minimal
irregularity of the mucosal surface.
Barium enema
38.
39.
40. Routine pre-op work up
īComplete blood count
īRenal function test/liver function test
īECG
īCXR
īStool for occult blood(minimum 6 samples needed to
say negative and at least 10 ml blood /day should be
there in stool for positive results)
īSerum CEA level ( for prognostic purpose )
41. EVALUATION OF LOCAL TUMER EXTENT AND
METASTATIC DISSEMINATION
īCECT abdomen and pelvic (to see status of lymph
node /fat planes/metastasis /ascitis)
īCXR if positive findings then CECT Chest
īMRI (for local lymph node in ca rectum/ for stenotic
lesion where even DRE is also not possible )
īTRUS( for t stage in ca rectum accuracy 80-95% /LN
detection if size more than 5 mm,not useful when
tumer > 14 cm from anal verge or stenoting tumer)
īPET scan( indicated in recurrence/high serum CEA
which is not explained by CECT/MRI )
42. AIMS OF TREATMENT
īLocal control
īLong-term survival
īRestoration of bowel continuity and Preservation of anal
sphincter.
īBladder and sexual function and maintenance or
improvement in quality of life.
43.
44. pre-op preparation before surgery
ī 1-The bowel is prepared by mechanical cleansing using a combina- tion of diet,
purgatives and enemas -NICHOLS preparation ( Contravesial acc.to ERAS protocol )
ī 2- Prophylactic systemic antibiotics peroperatively. (cefazolin 1000 mg plus
metronidazole 500 mg given on induction of anaesthesia or within 1 hour of surgery
,dose repeated after 4 hore or if bleeding is more)
ī 3-If a patient comes to surgery with a loaded colon, on-table intraoperative irrigation
can be performed.
ī 4-Counselling for :-stoma care nurse preoperatively and be sited for a temporary or
ī permanent ileostomy or colostomy.
ī complications of the pro- cedure, and particularly about the risks of
ī pelvic autonomic nerve damage causing bladder and sexual
ī disturbance, especially impo- tence.
ī 5-Blood and electrolyte deīŦciencies are corrected.
ī 6-An indwelling catheter is inserted into the bladder /RT should be inserted
ī 7-Deep vein thrombosis prophylaxis ( 5000 iu heparin sc )
ī 8-Cross-matching of blood.
ī 9 According to ERAS protocol patient can take clear fluid till 2 hour before surgery.
47. Emergency surgery
ī1 -Tumor obstruction-if proximal obstruction RA like
RH ,ERH hould be performed.
īIf tumor on left side,stool load proximal to obstruction is
of concern for healing of distal anastomosis and
synchronous lesion can be missed.
īSo staged procedure ( like hartman ) or colonoscopic
placement of self expanding stents to convert it to a
elective procedure is done
ī2-perforation-results in tumer spillage and treated as
staged 4
ī3-massive colonic bleeding-surgry if repeated
transfusion
48. Management of advance disease
īLocally advanced disease-en block resection should
be done
īOperable metastasis-chemotherapy and surgical
metastasectomy, in case of resectable metastasis
resection of colonic primary tumer should be done in
oncological fashion ( at present only C/I in case of
metastasis is unable to remove all disease âEKEBERG
criteria )
īInoperable disease-palliative Rx
49. Principles of surgery for ca rectum
ī1-Radical excision of the rectum, together with the mesorectum and associated
lymph nodes, should be the aim. Even in the presence of widespread
metastases, a rectal excision is best means of palliation. (Even in the presence
of liver metastases).
2- Locally advanced tumour(i.e. invading a neighbouring structure or
threatening to breach the circumferential resection margin), preoperative
chemoradiotherapy may reduce its size and make curative surgery possible.
3-Patients unīŦt for radical surgery or who have widespread metastases, a local
procedure such as transanal excision, laser destruction or interstitial radiation
should be considered.
4-The aim should be to restore gastrointestinal continuity and continence by
preserving the anal sphincter. A sphincter-saving operation (anterior
resection) is usually possible for tumours whose lower margin is two or more
centimetres above the anal canal.
51. TYPES OF SURGERY
īLocal excision- reserved for superficially invasive (T1) tumors with low
likelihood of LN metastases
īTumors less than 4 cm in diameter
īTumors within 6 cm of anal verge(below peritoneal reflection)
īEncompass less than 40% of circumference of bowel wall,
īT1 or T2 tumor
īwell or moderately well differentiated histology,
īNo pathological evidence of venous or lymphatic vessel invasion on biopsy
īShould be considered a total biopsy, with further treatment based on
pathology
īWith unfavorable pathology patient should undergo total mesorectal excision
with or without sphincter-preservation:
ī positive margin (or <2 mm), lymphovascular invasion,
ī poorly differentiated tumors, T2 lesion
Drawback- do not allow full histopathological staging or
deal with the mesorectal or lymphatic spread of the tumour
52. LOCAL EXCISION TECHNIQUES
īTransanal Excision.
ī TEM
īEndoscopic snare polypectomy
ī Fulguration
ī Endoscopic laser
ī Staging of such lesions should be performed using EUS to minimize
likelihood of doing a local excision for T3 tumors.
53. ī- for tumors in upper/mid rectum; allows preservation of anal
sphincter
īIf there is concern about integrity of anastomosis,temporary
proximal colostomy can be done,which can be closed after 10
weeks
īTo improve bowel function(frequency) a J-pouch or coloplasty
can be done
īIf it is done below peritoneal reflection it is called LOW Anterior
Resection ( minimum 5 cm proximal and distal margin required
but with chemoradiation distal margin of 2 cm enough (ULTRA
low anterior resection ) circumferential margin of 2 mm
required.
īPrinciple of TME should be applied to mid and low rectal cancer
Anterior Resection
54.
55.
56.
57.
58.
59.
60.
61. Total mesorectal excision
ī local failures are most often due to inadequate surgical clearance of radial margins.
ī conventional resection violates the mesorectal circumference during blunt dissection,
leaving residual mesorectum.
ī TME involves precise dissection and removal of the entire rectal mesentery as an intact
unit.
ī local recurrence with conventional surgery averages approx. 25-30% vs. TME 4-7% by
several groups (although several series have higher recurrence)
Dissection in appropriate anatomic planes is essential because dissection medial to
the endopelvic fascia investing the mesorec-tum may doom the patient to local
recurrence of the disease, and dissection laterally to the avascular anatomic
risks injury to the mixed autonomic nerves, causing impotence in men and bladder
dysfunction in men and women.
67. Abdominoperineal resectionī for tumors of distal rectum with distal edge up to 6 cm from anal verge
ī associated with permanent colostomy and high incidence of sexual and genitourinary
dysfunction
ī Chances of recurrence APR>AR
ī Previously was done in Trendelenberg lithotomy position.
ī Recently ,Abdominal procedure is done in Lloyd davies position & then
ī the patient prone
ī Types:-a)MILES-abdomen first,perineum later.
ī b)GABRIEL-perineim first,abdomen later
ī c)Lloyd âDavies-synchronised(togehther),(combined)
68.
69.
70.
71. En block removal with rectum
īPosterior vaginectomy
īProstatectomy
īPelvic exenteration
īIn post op period patient will not be allowed to sit for
5 days
72. Post op Complication of surgery
Early (within 1 month ) Late (after 1 month)
īCommon to all major GI
surgeries (pain/bleeding
/infection/wound
sepsis/atelectasis/pneumonia
/DVT/MI
īAnastomosis leak
īSpecific complications(low
ant,resection syndrome or
clustering)
īBladder dysfunction
īPerineal wound infection
īEarly complication of stoma
īImpotence
īFaecal fistua
īRecurrence
īDelayed complication of
stoma
73. LOCAL RECURRENCE
ī Local recurrence is a major problem.
ī Eighty per cent of all local recurrences develop within 2 years following surgery,
ī The most common cause is inadequate removal of all the tumour (due to the
presence of microscopic tumour deposits in the tissues surrounding the rectum.)
ī Other causes include implantation of viable cells on the suture line and the
development of a new primary tumour.
ī SIGNS & SYMPTOMS â
ī Persistent pelvic pain, which radiates down the legs (if the sacral roots are
involved.) Bladder problems may occur.
ī If recurrence develops after abdominoperineal excision, a swelling or induration
may be present in the perineum,or an abscess or discharging sinus may develop.
Occasionally, bilateral leg oedema caused by pressure or invasion of lymphatics or
veins.
ī After sphincter-saving resection, may produce a change in bowel habit or the
passage of blood per rectum.
74. īSigmoidoscopic examination may reveal friable tissue at the
anastomosis which, when biopsied, conīŦrms the diagnosis.
īHowever, the recurrence is usually situated extrarectally, and is
detected either as induration on digital examination or by
endoluminal ultrasonography, CT or MRI.
īThe mainstay of therapy for local recurrence is radiotherapy, which is
invariably palliative. Surgery is occasionally indicated and will usually
involve hysterectomy, bladder resection and even partial sacrectomy.
75. LAPAROSCOPIC SURGERY
īADVANTAGES:-
1-More precise anatomical TME dissection
As is under direct vision with better illumination & magnified vision.
2-Reduced trauma to the oncologic specimen with less inadverent
compromise of specimen quality
3- Early recovery ofbowel function,reduced blood loss,less post-
operativepain & decreased hospital stay
with adequate tumour& lymph node clearance
PATIENT SELECTION:-
Would be challenging in patients with significant comorbidities,high
BMI,locally advanced cancers orwho have undergone preoperative long
course downstaging chemoradiotherapy.
76.
77. īCONVERSION TO OPEN SURGERY:-
Due to :-a)Technical difficulties secondary to tumour fixity.
b)Dense adhesion.
c)Inadequate visualisation due to obesity
d)uncertainities regarding oncological completeness
e)hemorrhage.
78. ROBOTIC SURGERY
īADVANTAGE:-a)Tri-dimensional imaging & instruments with seven degree of
freedom without hand tremors.
b)Decreased conversion rates in TME in narrow pelvis.
c)Better identification of hypogastric plexus,dissection of
inferior mesentric vessels & mobilisation of splenic flexure.
DISADVANTAGES:-cost,conversion,standardisation of technique & training.
79.
80. Purpose of Radio(chemo)therapy in Rectal Cancer
âĸ To lower local failure rates and improve survival in
resectable cancers
âĸ to allow surgery in primarly inoperable cancers
âĸ to facilitate a sphincter-preserving procedure
âĸ to cure patients without surgery: very small cancer or
very high surgical risk
81. ADVANTAGES OF PRE OP CT+RT
âĸ Down staging, hence increased resectability
âĸ Decreased risk of dissemination during surgery.
âĸ Radiation more effective with tumour cells highly
vascular.
âĸ Less serious bowel toxicity due to easy exclusion.
âĸ Possibility of increasing sphincter preservation in
borderline cases.
âĸ Small bowel not exposed to radiation (in ca rectum)
82. ī§ 5Fu
ī§ Leucovorin
ī§ Oxaliplatin
ī§ Irinotecan
ī§ Bevacizumab
ī§ cetuximab
Combinations
FOLFOX : leucovorin, 5-FU, and
oxaliplatin
FOLFIRI leucovorin, 5-FU, and irinotecan
Leucovorin/5FU
âĸ CapeOX: capecitabine and oxaliplatin
âĸ Any of the above combinations, plus
either bevacizumab or cetuximab (but
not both)
âĸ 5-FU and leucovorin, with or without
bevacizumab
âĸ Capecitabine, with or without
bevacizumab
âĸ FOLFOXIRI: leucovorin, 5-FU,
oxaliplatin, and irinotecan
âĸ Irinotecan, with or without cetuximab
âĸ Cetuximab alone
âĸ Panitumumab alone
âĸ Regorafenib alone
Chemotherapy agents
83. NEOADJUVANT
CHEMOTHERAPY
īREGIMENS :
īą 5- FU : 225 mg/ m2 â daily continous infusion
īą Capecitabine : 825 mg/ m2 BD on days of radiation
īą 5- FU : 400 mg / m2 IV bolus + leucovorin 20 mg /m2 IV
bolus for 4 days : wk 1 & wk 5.
5-FU has been infused into the portal vein during and immediately after the primary operation
have shown a small beneīŦt. Such intraportal adjuvant therapy is thought to kill malignant cells,
which are released into the circulation during operative manipulation of tumour, and thus prevent
the formation of metastases.
Neo adjuvant chemoradiotherapy has no difference in overall survival
84. CHEMOTHERAPY
REGIMENS :
ī 5-FU : bolus weekly regimen ( leucovorin 20 mg/m2 over 2
hrs : 5- FU 500 mg/ m2 bolus weekly for 6 weeks :
īąWeekly Roswell Park regimen : 5-FU + leucovorin
( leucovorin 500 mg /m2 given over 2 hrs followed by 5-FU
bolus after 1 hour ) :repeated after 4 weeks for 6 cycles .
īąFOLFOX -5-FU 2800mg/m2 ,leucovorin
1200mg/m2,oxaliplatin 80-100mg/m2 ( every other week
with infusional 5-FU )
īą oral Capecitabine 1000 â 1250 mg/ m2 from day 1-14 ( 21 day
cycle) plus parentral oxaliplatin (capeox)
īąFolfiri-irinotecam 100-200mg/m2
īąFolfox plus bevacizumab
85. īPost op chemotherapy for the patient with stage 2
colon ca is contraversial.
īIt is suggested that 5- FU based chemotherapy can be
given if at least one poor prognostic factor
( insufficient<12 LN sampling,T 4lesions ,poorly
differentiated histology or bowel perforation.
īPatients with stage 3 clearly benefit from adjuvent
chemotherapy (FOLFOX )
īStage 4 chemo with bevacizumab,
cetuximab,panitumumab as monotherapy or with
FOLFOX/FOLFIRI
86. ī Side effects of chemo therapy
ī 1âĸ Hair loss
ī 2âĸ Mouth sores
ī 3âĸ Loss of appetite
ī 4âĸ Nausea and vomiting
ī 5âĸ Low blood counts -This can lead to:
ī 6âĸ Increased chance of infections ,Easy bruising or bleeding ,Fatigue
ī some side effects are specific to certain medicines, for example:
ī Hand-foot syndrome can occur during treatment with capecitabine or 5-FU (when given as an
infusion). This starts out as redness in the hands and feet, which can then progress to pain and
sensitivity in the palms and soles. If it worsens, blistering or skin peeling can occur, sometimes
leading to open, painful sores. treated lowering the dose of the drug or stopping it for a time.
ī Neuropathy is a common side effect of oxaliplatin. Symptoms include numbness, tingling, and
even pain in the hands and feet. It can also cause patients to have intense sensitivity to hot and
cold in the throat and esophagus .
ī Diarrhea is a common side effect with many of these drugs, but can be particularly bad with
irinotecan. It needs to be treated right away â at the first loose stool â to prevent severe
dehydration. Treated by taking drugs like loperamide
87. ROLE OF RADIOTHERAPY
īBiologic property of rectum and its distance from small bowel
provides an opportunity for radiation therapy alone that is not
feasible for colon cancer,as large bowel can tolerate radiation
dose up to 6000cGY but that radiation will include small bowel
in field that canât tolerate this radiation.
ī
Neo-adjuvant/Adjuvant RT in resectable Ca Rectum
pre-op
post-op
īRT in locally advanced rectal cancer
pre-op for down staging
IORT
īDefinitive RT
unfit for surgery
īPalliative RT â in inoperable tumours or local recurrence
88. ī Types of radiation therapy
ī External-beam radiation therapy: most often used .
ī The radiation is focused on the cancer from a machine outside the body.
ī Endocavitary radiation therapy: used for some rectal cancers.
ī A small device is placed through the anus and into the rectum to deliver high-intensity
radiation over a few minutes. This is repeated about 3 more times at about 2-week
intervals for the full dose. it is less likely to cause side effects.as the radiation reaches
the rectum without passing through the skin and other tissues of the abdomen . Itis
used only for small tumors
ī Brachytherapy (internal radiation therapy): uses small pellets of radioactive
material, put into a catheter that was placed next to or directly into the cancer. The
radiation travels only a short distance, limiting the effects on surrounding healthy
tissues.
ī Radioembolization: Radiation can also be given during an embolization procedure.
89. Radiotherapy for ca rectum
īProne position: radiopaque markers include anal, vaginal, rectal,
perineal skin; wperineal scar if present; small bowel contrast, ensure
bladder full.
īPurpose is to displace bowel superior and anteriorly & bladder
anteriorly
īBlocks are used to spare the posterior muscle and soft tissues behind
the sacrum and small bowel.
īTarget Volume: Primary Tumor or Tumor bed, with margin
presacral, and internal iliac nodes (if T4, external iliac nodes also).
īEnergy
ī6 MV Co60
90. Dose
īPreoperative radiotherapy (stage 2 or higher within 10 cm
from anal verge )
īShort course: 25 Gy in 5 daily fractions of 5 Gy given in 1
week.
īLong course
180 cGy each day for 5 days in a week for 6 weeks (total
30 doses ) surgery done after 6-10 weeks
īPostoperative radiotherapy
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks.
Phase 2 (optional)
5.4â9 Gy in 3â5 daily fractions of 1.8 Gy.
91. īPalliative radiotherapy
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks.
Phase 2 (optional)
5.4â14.4 Gy in 3â8 daily fractions of 1.8 Gy
or a hypofractionated regimen can be used
30â36 Gy in 5â6 fractions of 6 Gy once weekly given in 5â6
weeks.
īDose limitations (at standard fractionation )
īSmall bowel 45â50 Gy
īFemoral head and neck 42 Gy
īBladder 65 Gy
īRectum 60 Gy
92. ī Side effects of radiation therapy
ī 1âĸ Skin irritation -range from redness to blistering and peeling
ī 2âĸ Nausea
ī 3âĸ Rectal irritation, which can cause diarrhea, painful bowel movements, or blood in the
ī stool
ī 4âĸ Bowel incontinence
ī 5âĸ Bladder irritation, which can cause problems like frequency, burning pain while
ī urinating, or hematuria
ī 6âĸ Fatigue/tiredness
ī 7âĸ Sexual problems (impotence in men and vaginal irritation in women)
ī Most side effects should lessen after treatments are completed, but problems such as
rectal and bladder irritation may not go away completely.
93. Medical history and physical exam
A physical exam every 3 to 6 months for the first 2 years after treatment, then every 6
months for 5 yrs so for the next few years.
Colonoscopy
A colonoscopy within a year after surgery. If the results are normal, most patients
need another about every 5 years unless no family history.and annually if polyp
detected or removed
Imaging tests
Imaging tests will depend on the stage of disease and other factors. CT scans may be
done regularly, such as once a year, for those at higher risk of recurrence, especially in
the first 3 years after treatment. People who had tumors in the liver or lungs removed
might be tested even more frequently.
Blood tests for tumor markers
Carcinoembryonic antigen (CEA) and CA 19-9 . If the tumor marker level goes up again,
it can be a sign that the cancer has come back, and colonoscopy or imaging tests may
be done to try to locate the site of recurrence. Tumor markers tend to be most useful in
the first 2 years after treatment, when recurrences are most likely to occur.
If the cancer does recur at some point, further treatment will depend on where the
cancer is located. can be seen elevated inulcerative colitis, non-cancerous tumors of the
intestines, or some types of liver disease or chronic lung disease. Smoking can also
raise CEA levels
94. Prognostic factors
ī§ Good prognostic
factors
ī§ Old age
ī§ Gender(F>M)
ī§ Asymptomatic pts
ī§ Polypoidal lesions
ī§ Diploid
ī§ Poor prognostic factors
ī§ Obstruction
ī§ Perforation
ī§ Ulcerative lesion
ī§ Adjacent structures involvement
ī§ Positive margins
ī§ Signet cell carcinoma
ī§ High CEA
ī§ Tethered and fixed cancer
ī§ Vascular & perineural invasion
ī§ Primary mucoid carcinoma
ī§ Tumour in lower 1/3 rectum
ī§ Poor histological grade tumours
ī§ Node positive tumours
Editor's Notes
Polyp removal leads to CRC prevention
Polyp is surrogate marker