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Surgery M4 part 2 > Colonic Polyps & Carcinoma > Flashcards

Colonic Polyps & Carcinoma Flashcards

1
Q

What are the histological types of colonic polyps?

A

LOW MALIGNANT POTENTIAL

  • inflammatory polyps (UC)
  • mucosal/submucosal polyps
  • hyperplastic polyps -> most common (rectosigmoid)
  • hemartomatous polyps (throughout GIT)

MODERATE MALIGNANT POTENTIAL

  • serrated polyps -> sessile (>5mm in proximal colon)
    - > traditional adenoma (rectosigmoid)

HIGH MALIGNANT POTENTIAL

  • adenomatous polyps -> tubular (<5% malignant)
    - > tubulo-villous (20% malignant)
    - > villous: in rectum (50% malignant)
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2
Q

What are the clinical features of colonic polyps?

A
  • asymptomatic usually
  • hematochezia
  • change in bowel habits
  • mucus in stool
  • pallor
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3
Q

What are the variants of adenomatous polyposis syndromes?

A

FAMILIAL ADENOMATOUS POLYPOSIS (more than 100 polyps)

  • Gardener Syndrome
  • Turcot syndrome
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4
Q

What are the variants of hamartomatous polyposis syndromes?

A
  • Peutz-Jeghers Syndrome

- Juvenile Polyposis Syndrome

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5
Q

What is familial adenomatous polyposis?

A
  • autosomal dominant mutation of APC gene
  • in 20-30s
  • has a lifetime risk of progression to cancer -> 100% by 45 years
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6
Q

how is familial adenomatous polyposis diagnosed & treated?

A

DIAGNOSIS
- flexible sigmoidoscopy/colonoscopy -> > 100 polyps

TREATMENT

  • PROPHYLACTIC PROCTOCOLECTOMY + ilioanal anastomoses
  • celecoxib & aspirin can induce regression
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7
Q

What is Gardner’s syndrome?

A

FAP + osteomas of mandible or skull + dental abnormalities

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8
Q

What is Turcot Syndrome?

A

FAP + brain tumors

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9
Q

What is Peutz-Jeghers syndrome?

A

hemartomatous polyps + melanotic macules

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10
Q

What is Juvenile polyposis syndrome?

A

hamartomatous polyposis syndromes in < 5 year old children

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11
Q

How are polyps treated?

A

Remove polyps to prevent cancer

  • snare polypectomy <5mm
  • endoscopic resection
  • surgical resection -> lesions larger than 2cm
    - > suspected malignancy
    - > hereditary polyposis syndrome -> proctocolectomy
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12
Q

When is the peak incidence of colonic cancer?

A

7th decade

  • 2nd cause of cancer death after lung
  • all begin as benign polyps or adenoma (5%)
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13
Q

What does the transformation of a polyp into cancer depend on?

A

TYPE of polyp
- Adenomatous polyps -> VILLOUS

SIZE of polyp
- >5mm

NUMBER of polyps
- if multiple -> higher risk

AGE of patient
- older age -> higher risk

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14
Q

What is the most common type of colonic cancer?

A

ADENOCARCINOMA (95%)

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15
Q

What are the causes of colonic cancer?

A
  • chronic inflammation
  • bile salts
  • increased fat
  • decreased fibers
  • decreased calcium
  • body size & habitus
  • decrease physical activity
  • alcohol
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16
Q

What are the risk factors of colonic cancer?

A
  • genetic/family history
  • polyps
  • inflammatory bowel disease
  • diet, nutrition, smoking
17
Q

What is the pathology of colonic cancer?

A

MACROSCOPIC
- polypoidal or sessile growth

MICROSCOPIC

  • well differentiated
  • moderately differentiated
  • poorly differentiated

LN INVOLVEMENT

18
Q

What are the clinical features of of colorectal cancer?

A

early -> asymptomatic

Constitutional

  • weight loss
  • night sweats
  • fever
  • fatigue
  • abdominal discomfort

Right sided Colon Cancer

  • occult bleeding or melena
  • iron deficiency anemia (due to chronic bleeding)

Left sided colon carcinoma

  • changes in bowel habits
  • colicky abdominal pain (due to obstruction)
19
Q

What investigations should be done to diagnose colon cancer?

A
  • complete history & physical examination
  • flexible sigmoidoscopy
  • colonoscopy (gold standard)
  • CEA

STAGING

  • endorectal ultrasound -> rectal cancer
  • chest x-ray -> metastasis
  • liver ultrasound -> metastasis
  • abdominal CT scan -> metastasis
20
Q

When should screening for colonic cancer start?

A

COLONOSCOPY from 45-50 years

21
Q

What are the indications of double-contrast barium enema?

A
  • alternative to CT colongraphy in patients who cant undergo complete colonoscopy at presentation

findings

  • endoluminal filling defect -> irregular margins
  • apple core sign (napkin ring sign)
22
Q

What is the 5 year survival rate of colonic cancer?

A

Stage I -> 90%
Stage II -> 80%
Stage III -> 27-69%
Stage IV -> 8%

23
Q

What preop prep should be done on patient undergoing colonic cancer surgery?

A
  • NPO
  • IVF
  • mechanical bowel prep
  • chemical bowel prep
  • cross match blood
  • DVT prophylaxis
  • Foley’s catheter
  • stoma marking
24
Q

when is right hemicolectomy indicated?

A

Tumor in the cecum & ascending colon

Resect -> part of distal ileum

  • > ileocecal valve
  • > cecum
  • > ascending colon
  • > hepatic flexure
  • > proximal part of transverse colon
25
Q

When is an extended right hemicolectomy indicated?

A

tumor near hepatic flexure/ proximal or middle transverse colon

Resection -> right hemicolectomy + transverse colon

26
Q

When is left hemicolectomy indicated?

A

tumor in descending colon

Resect -> distal third of transverse colon

        - > splenic flexure 
        - > descending colon 
        - > sigmoid colon
27
Q

When is sigmoid colectomy indicated?

A

tumor in sigmoid colon

28
Q

When is total or subtotal colectomy indicated?

A
  • multifocal carcinomas

- underlying colonic disease -> FAP or UC

29
Q

Which patients should get chemotherapy after their surgery?

A
  • All stage 3 patients (positive nodes)
  • High risk stage 2 patients (T3 or T4)
  • > obstruction or perforation
  • > poorly differentiated
  • > mucinous
  • > LV invasion
30
Q

What is the systemic therapy used post op?

A
  • Chemo -> FOLFOX (folinic acid + 5-FU + oxaliplatin)
  • Biologics -> anti-VEGF antibodies (bevacizumab)
    - > EGFR antibodies (cetuximab)
31
Q

Should radiotherapy be used after surgery?

A

NO

has adverse effects on the small intestine -> enteritis & strictures

32
Q

How should a colonic cancer patient be followed up with?

A

Office visit

  • every 3 months for 2 years
  • every 6 months for 3 years

Regular blood work
- CEA

Colonoscopy

  • at year 1 -> if normal
  • after 3 years -> if normal
  • every 5 years

CT scan
- every year for 5 years

33
Q

What is GIST?

A

submucosal lesion originating from the cells of Cajal

- c-KIT mutation

34
Q

How should GIST be treated?

A
  • wide surgical resection
  • Imatinib (tyrosine kinase inhibitor) IF -> necrosis
    - > >5cm
    - > mitosis > 5
  • high risk areas (duodenum or low rectal) need neoadjuvant therapy before surgery
35
Q

What are carcinoid tumors?

A

APUD (neuroendocrine tumors) in submucosa

  • produce 5-HT serotonin
  • if they metastasis to liver -> skin flushing, GI diarrhea, heart, respiratory effects
  • 24hr urinary 5-HIAA & blood chromogranin A
  • surgery is the main treatment even if its to debulk

Surgery M4 part 2 (36 decks)

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