Colorectal Cancer FRCR CO2A Flashcards
(255 cards)
1
Q
Types of malignant CRC
A
- ADenocarcinoma
- CArcinoid tumor
- Anal zone carcinoma
Mesenchymal tumors: Leiomyosarcoma
Liposarcoma
Kaposi’s sarcoma
Others: Lymphoma
2
Q
Peak Incidence of CRC
A
60 to 70 yrs
3
Q
Which is more common Colon Vs Rectum cancer?
A
Colon»_space; Rectum by 3:2
4
Q
RFs for CRC
A
- Family Hx
- IBD like UC and crohn’s colitis
- diet low in indigestible starch, high in refined carbs and fat content
- decreased intake of fruits and Vegetables
- Low physical activity
- High BMI (23 to 30 kg/m2)
5
Q
Family Hx and CRC
A
1st degree relative < 40 yrs, increased risk,
Genetic causes 15% of all CRCs
6
Q
what are 2 well recognised inherited CRC syndrome
A
- Lynch Syndrome
- Familial Adenomatous Polyposis (FAP)
7
Q
How is Lynch Syndrome a/w CRC?
A
2% of CRCs, affected gene carriers have 80% of lifetime risk of CRC
8
Q
what type of CRC is a/w Lynch syndrome
A
Autosomal Dominant
RIGHT SIDED, MUCIN PRODUCING, LESS AGGRESSIVE
Other associated factors include: 1. endometrial
2. ovarian
3. gastric
4. pancreatic
5. Renal malignancies
9
Q
How is Lynch Syndrome diagnosed?
A
Modified Amsterdam Criteria
after assessment for MSI, the dx is confirmed by lab testing for MSH1&2 and PMS1&2
10
Q
What is FAP?
A
Autosomal Dominant Condition
Defects in the adenomatous polyposis coli (APC) gene on Chromosome 5
11
Q
what are 3 variants of FAP?
A
- Garder’s syndrome
- Turcot’s syndrome
- Attenuated FAP
12
Q
what is Turcot’s syndrome?
A
Colonic polyps a/w CNS tumors, including ependymomas and medulloblastomas
13
Q
How to prevent CRC?
A
- Diet high in fish and low in red meat
- High Fibre Diet
- Chemoprevention: Aspirin
- Exercise
14
Q
How is screening done for CRC?
A
Faecal Occult Blood (routine in UK between age 60 to 75)
Sigmoidoscopy and colonoscopy: at 55 yrs
15
Q
what prevention strategy can be applied for pts with IBD?
A
Screening with regular colonoscopies and prophylactic pan proctocolectomy in selected cases
16
Q
How the risk of cancer varies with size of polyp?
A
< 1 cm: < 1% risk
1 to 2 cm: 10 % risk
> 2 cm : 50%
17
Q
Regional LNs for Rectum
A
- Pararectal LNs,
- Nodes at bifurcation of the infr mesenteric artery
- the hypogastric nodes
- Presacral Nodes
18
Q
Distant Metastatic site of CRC
A
Liver
Lungs
Bones
19
Q
Right Sided Colon Cancer S/S
A
unexplained Anemia
Ill defined abdominal pain
abdominal mass
weight loss
Rectal Bleeding
20
Q
Left Sided Colon Cancer S/S
A
changes in bowel habit
obstruction
rectal bleeding
tenesmus
mucoid discharge
21
Q
Staging Ix for CRC
A
- FBC
- LFTs
- CEA
- Colonoscopy
- CT Thorax Abdomen and Pelvis
- PET CT only when resection of metastasis is considered
22
Q
CEA in CRC
A
raised in 85% of CRC
higher values : worse prognosis
23
Q
Local Staging for rectal CAncer
A
DRE
EUS and
MRI (established by MERCURY trial)
24
Q
How is MRI helpful in rectal cancer local staging?
A
- identify the MRF and
- Clearance at CRM
25
Treatment of M0 colon cancer
Surgery as an elective procedure
if presents at EMR, defunctioning colostomy/stenting f/b elective definitive Sx
26
what structures are removed in Surgery for Colon Cancer?
1. Appropriate bowel segment and its mesentery
2. Vascular pedicle
3. draining LNs
27
Adjuvant Rx for T1/2N0, pMMR/MSS
Observation
28
Adjuvant Rx for T3N0, pMMR/MSS or higher stages
CAPEOX 3 months to 6 months
FOLFOX 3 to 6 months
29
Poor Risk features in N0 colon cancer
1. Serosal involvement
2. Perforated tumors
3. Extramural Vascular invasion
4. < 12 LNs examined
5. involved CRM
30
Adjuvant Rx for dMMR/MSI H (T1-4a N0)
observation
31
Adjuvant Rx for dMMR/MSI H (>T4a or N+)
CAPEOX 3 to 6 months
FOLFOX 3 to 6 months
32
whats the status of bevacizumab and cetuximab as adjuvant therapy?
No significant benefit (AVANT and FFCD. PETACC 8 trial)
33
when to add Aspirin in adjuvant setting for colon cancer?
If PIK3CA
mutation,
add aspirin
100-162 mg
PO daily for
3 years for
stage II-III
disease
34
what are 3 risk categories as per MRI in rectal cancer (MERCURY) study?
1 .Favourable rT1 or rT3a, N0 (min exxtension into rectum)
2. unfavourable >rT3a (significant mesorectal contamination), or N+ve with margin not at risk
3. Advanced T4 or CRM < 1 mm
35
when is pre-op RT indicated in Ca Rectum?
predicted to be likely to recur after surgery
36
surgery in rectal cancer?
Challenging due to narrow pelvis
Very Low tumors: APR
Higher tumors: anterior resection
TME is standard for rectal cancer surgery
37
what surgery is standard in early stage rectal cancer?
local excision an alternative to APR in low rectal cancers
38
what's the mc approach for local excision?
TEM (Trans anal endoscopic microsurgery).
39
Adjuvant Chemo for Rectal cancer
same adjuvant systemic therapy as colon cancer, stage for stage
40
Pre op Vs Post Op RT in Rectal Cancer
Sauer Study
Pre op Vs Post op Long Course CRT
Local Control Rate 13 % Vs 6% in favor of pre op
more toxicity in post op
Pre op CRT standard in UK
41
Pre Op SCRT (25 Gy/ 5#) trials
Dutch TME trial
No survival benefit but increased local control
42
what if N+ but CRM -
Give Post op RT, LCR improved (MRC CR 07 study)
43
In UK, when is post op RT done in rectal cancer
CRM + and no PRE OP RT
in N+, role of post op RT is less certain
44
which trial defines UK standard for REctal CAncer RT Volumes?
UK ARISTOTLE Trial
45
CT simulation for Rectal Cancer
Supine
Radio opaque marker at the anal verge
Gastrografin (oral contrast) 20 ml in 1 L of water 45 to 60 minutes b4 simulation
46
CT simulation Scan Field
Supr: Supr aspecct of L5
Infr: 4 cm below marker or the infr extent of tumor
47
48
slice thickness of simulation CT
3 mm
49
CTV in Rectal Cancer
1. GTV + 1 cm
2. Mesorectum, Presacral Space and Internal iliac nodes
3. Levator muscle invasion, 1 cm lateral and postr margin is applied
50
Should uninvolved Ext Iliac LNs be included in RT field
No
51
RT Field Arrangement for Rectal Cancer
3/4 fields
1 postr, 2 lateral
or 2 postr, 2 lateral
45 degree wedges of lateral fields
52
SCRT approaches for Rectal Cancer
1. 25 Gy/ 5# f/b surgery at 1 week
2. 45 Gy/ 25# f/b surgery at 6 weeks
53
Post op RT dose:
45 to 50 Gy in 25#
Residual disease: Boost of 10 to 15 Gy in 5 to 7 fractions
54
What is ICRU Reference Point?
used for reporting dose, ideally located at the center of the PTV and near the intersection of beam axes
55
Concurrent ChT in Rectal Cancer
Capecitabine @ 900 mg/m2 BD on RT days
5 FU 200mg/m2 per day through out RT treatment
55
C/I for RT in rectal cancer
1. IBD
2. Diverticular disease
3. DM
56
Acute S/E of CRT:
tiredness
diarrhea
cystitis
Severe and painful perineal reaction (low tumors) and Cardiac toxicity
myelosuppression
57
Late S/E of RT (rectal cancer)
1. Menopause (in females)
2. Infertility/sterility
3. impotence
4. bowel dysfunction
5. urge incontinence
58
Mx of RT induced diarrhoea
Imodium and low residue diet and close monitoring
59
Rx of Advanced/inoperable local disease REctal cancer
RT with/without Chemo: useful palliation
s/times converted to operable
DEfunctioning colostomy
60
palliative RT indications?
medically unfit for Surgery
symptoms of local pain, discharge or bleeding
61
Dose of Palliative RT
8 Gy SF
25 Gy/ 5#
20 Gy/ 4 #
Fitter Pts: 45 Gy/ 25# with capecitabine ChT
62
pall RT in caecal tumors purpose
bleeding and recurrent anaemia
63
Palliative SUrgery
better than just bypass, increased survival and better QOL
64
Recurrent Disease
CRT f/b assessment for Sx, if RT not given previously
65
Does resection of oligo liver mets increase survival?
yes, 31 Vs 11 months
66
when is liver mets not recommended for Sx?
1. extends outside the liver
2. Hepatic veins are involved, all
3. not enough viable liver tissue left
67
what about NACT for metastatic disease
evidence supports the use of preoperative ChT prior to resection in Pts with potentially operable liver mets
68
metastatic Rectal Cancer
1st L
* FOLFOX ± bevacizumab
* KRAS/NRAS/BRAF WTi
:
FOLFOX + (cetuximab or panitumumab)j
CAPEOX + (cetuximab or panitumumab)j
FOLFIRI
+ (cetuximab or panitumumab)j
* BRAF V600E mutation positive
:
Encorafenib + (cetuximab or panitumumab) + FOLFOX
69
Targeted therapy for rectal cancer (metastatic)
BRAF V600E mutation positive:
Encorafenib + (cetuximab or panitumumab)
(Encorafenib + [cetuximab or panitumumab]FOLFOXe)
* HER2-amplified and RAS and BRAF WTj
(Trastuzumab + [pertuzumab or lapatinib or tucatinib])k
* HER2-amplified (IHC 3+)
Fam-trastuzumab deruxtecan-nxkit
* KRAS G12C mutation positive
(Sotorasib or adagrasib)u + (cetuximab or panitumumab)
* NTRK gene fusion-positive
Entrectinib
Larotrectinib
RET gene fusion-positive
Selpercatinib
70
mCRC dMMR/MSI-H
1st L
nivolumab ± ipilimumab,
pembrolizumab, dostarlimab-gxly,
cemiplimab-rwlc,
retifanlimab-dlwr,
toripalimab-tpzi, or
tislelizumab-jsgr.
70
Predictors of prognosis when starting chemo
1. poor P.S
2. Low serum albumin
3. High ALP
4. Liver Involvement
## Footnote
@ PAAL
71
Role of Bevacizumab as single agent as a maintenance therapy
No benefit
72
Bevacizumab S/Es
1. HTN
2. Proteinuria
3. Bowel Perforation
73
when is cetuximab or panitumumab used?
monotherapy in wt RAS as the last line or
in combination with irinotecan or oxaliplatin in 1st/2nd Line
74
S/Es of cetuximab
skin rash
paronychia
splitting in the pulps of fingers and toes
75
follow up duration in CRC
3 monthly in 1st year
every 6 months thereafter and then annual
76
Status of Regorafenib in CRC
last Line, not approved by NICE
77
What percentage of all malignant GI cancers do small intestinal malignancies constitute?
2–3%
78
Which part of the small intestine is the most frequent site of tumours?
Ileum
79
Are small intestinal tumours more common in males or females?
Males
80
What is one of the common causes of death in patients with familial adenomatous polyposis (FAP) after colectomy?
Small intestinal adenocarcinoma
81
Which disease is associated with adenocarcinoma of the small intestine?
Crohn's disease
82
What type of lymphoma is associated with coeliac disease?
Enteropathy associated T cell variant
83
Which condition is linked to lymphoma in the small intestine?
Tropical sprue
84
What type of tumour is associated with MEN type-1 in the duodenum and jejunum?
Gastrin producing tumour
85
What are the three origins of tumours in the small intestine?
Epithelial, mesenchymal, lymphoid
86
What type of cancer occurs most frequently in the small intestine?
Adenocarcinomas
87
What percentage of small intestine tumours are adenocarcinomas?
45%
88
Where do adenocarcinomas commonly occur in the small intestine?
Ampulla of Vater in the duodenum and jejunum
89
What percentage of small intestinal malignancies are carcinoids or neuroendocrine tumors?
30%
90
Where are sarcomas most commonly found in the small intestine?
Ileum
91
What type of tumor constitutes the majority of sarcomas?
GIST
92
What percentage of small intestinal malignancies are lymphomas?
15%
93
Which type of lymphoma is the most common in small intestinal malignancies?
B cell NHL
94
Which cancers are more common, metastatic cancers or primary cancers?
Metastatic cancers
95
List some usual primary cancers that lead to metastatic disease in the small intestine.
* GI tract
* Breast
* Uterus
* Ovary
* Melanoma
96
What are some nonspecific symptoms of small intestinal malignancies?
* Abdominal pain
* Anaemia
* Nausea
* Bleeding
* Weight loss
97
What surgical emergencies can patients with small intestinal malignancies present with?
* Perforation
* Intussusception
98
What symptoms can duodenal tumors present with?
* Obstruction
* Jaundice
99
What syndrome can metastatic liver carcinoid present with?
Carcinoid syndrome
100
What symptoms may lymphoma present with?
* Pain
* Weight loss
* Features of malabsorption
101
How do GISTs commonly present?
* Anaemia
* Sometimes with an abdominal mass
102
What imaging technique is useful in suspected obstruction?
Plain X-rays
103
What is abdominal ultrasound useful for detecting?
* Liver metastasis
* Ascites
* Biliary dilatation
104
What can a CT scan of the chest, abdomen, and pelvis delineate?
Primary tumour and disease extent
105
How does lymphoma appear on imaging of the small intestine?
Diffuse segmental thickening
106
How does GIST appear on imaging?
Well circumscribed mass
107
What is the purpose of a 111In-octreotide scan?
To rule out metastatic disease in carcinoid
108
What is essential prior to definitive treatment of small intestinal malignancies?
Tissue biopsy confirmation
109
What methods can be used to obtain tissue diagnosis?
* Endoscopic
* CT guided
* Laparoscopic
* Laparotomy
110
How is adenocarcinoma staged?
Similar to colonic cancer
## Footnote
Refer to page 163 for detailed staging criteria
111
What staging system is used for lymphomas?
Ann Arbor staging
## Footnote
Refer to page 299 for details on the Ann Arbor staging system
112
What is the management approach for localized small intestinal adenocarcinoma?
Resection of visible disease and regional lymph nodes
## Footnote
This is the primary management strategy for localized cases
113
What role does surgery play in advanced small intestinal adenocarcinoma?
May help with palliation of symptoms
## Footnote
Surgery is not curative in advanced stages but can alleviate symptoms
114
What chemotherapy regimen is used for small intestinal adenocarcinoma?
Same as that of colonic cancer
## Footnote
Refer to page 165 for specific chemotherapy details
115
What was the reported response rate and median survival for a combination of oxaliplatin with capecitabine?
| metastatic setting
Response rate of 50% and median survival of 20 months
## Footnote
This was based on a small study
116
How are Stage I and II B-cell non-Hodgkin lymphomas treated?
Surgically with or without chemotherapy
## Footnote
Treatment varies based on disease stage
117
What is the treatment for Stage III–IV B-cell non-Hodgkin lymphomas?
Primary chemotherapy with or without surgical debulking
## Footnote
Emphasis on chemotherapy for advanced stages
118
How are gastrointestinal stromal tumors (GISTs) managed?
Similar to GIST occurring elsewhere
## Footnote
Refer to page 261 for management details
119
What factors influence the prognosis of small bowel adenocarcinoma?
Type of cancer and stage
## Footnote
Advanced disease typically has a worse prognosis
120
What is the 5-year survival rate for small intestinal adenocarcinoma?
30%
## Footnote
This statistic reflects the poor prognosis associated with the disease
121
What is the 5-year survival rate for duodenal tumors?
50%
## Footnote
Duodenal tumors generally have a better prognosis than other small intestinal adenocarcinomas
122
What is the 10-year survival rate for lymphomas?
60%
## Footnote
This statistic highlights the comparatively better prognosis for lymphomas
123
What factors affect the prognosis of small bowel GIST?
Size and mitotic rate
124
What is the rank of colorectal cancer (CRC) among cancers in the UK?
Third commonest cancer
## Footnote
Following breast and lung cancers
125
How many new cases of colorectal cancer are diagnosed annually in the UK?
Over 36,000
## Footnote
In the USA, around 105,500 new cases are diagnosed per year
126
At what age is colorectal cancer most commonly diagnosed?
Over 60 years
## Footnote
Rare below the age of 40, except in hereditary forms
127
What is the male:female incidence ratio for colorectal cancer?
1.2:1.0
## Footnote
Indicates a slightly higher incidence in males
128
What is the lifetime risk of developing colorectal cancer in the UK?
1 in 18
## Footnote
This statistic indicates the prevalence of the disease in the population
129
What is the male-to-female ratio for colorectal cancer incidence?
1 in 15 for men and 1 in 20 for women
130
Where are the majority of primary colorectal cancers located?
Two-thirds in the colon and one-third in the rectum
131
Which side of the colon is more commonly affected by cancers?
Left-sided cancers are more common than right
132
What percentage of colorectal cancer cases are sporadic?
The majority are sporadic
133
What characterizes hereditary bowel cancer?
Early age at diagnosis, right-sided cancers, synchronous/metachronous colorectal tumours
134
What percentage of patients with colorectal cancer have a positive family history?
Up to 25%
135
What does familial adenomatous polyposis (FAP) account for in colorectal cancer cases?
1% of all cases
136
What does hereditary non-polyposis colorectal cancer (HNPCC) account for in colorectal cancer cases?
About 5% of all cases
137
What is the relative risk of developing colorectal cancer for those with an affected first-degree relative?
Relative risk 2.25
138
How does inflammatory bowel disease affect the risk of colorectal cancer?
Increases the risk
139
What is the cumulative risk of developing colorectal cancer in ulcerative colitis at 20 years?
8%
140
What is the cumulative risk of developing colorectal cancer in ulcerative colitis at 30 years?
18%
141
What dietary factors increase the risk of colorectal cancer?
High intake of red meat, calorie and high body mass index
142
What dietary factors are protective against colorectal cancer?
High vegetable intake and high-fibre diet
143
What is the risk of developing CRC for females on hormone replacement therapy?
Low risk
## Footnote
Hormone replacement therapy and regular aspirin use are associated with a low risk of colorectal cancer (CRC).
144
What lifestyle factor increases the risk of adenomas and CRC mortality?
Long-term smoking
## Footnote
Long-term smokers have a high risk of developing adenomas and mortality from colorectal cancer.
145
What effect does regular physical activity have on CRC risk?
Reduces risk, particularly in men
## Footnote
Engaging in regular physical activity is associated with a lower risk of colorectal cancer.
146
What type of cancer predominantly arises in adenomatous polyps?
Adenocarcinomas
## Footnote
Almost all colorectal cancers are adenocarcinomas that develop through a multi-step process.
147
What is the typical differentiation and morphology of most colorectal adenocarcinomas?
Moderate to well differentiated with typical morphology
## Footnote
The majority of colorectal adenocarcinomas exhibit moderate to well differentiation.
148
What are the CK7 and CK20 expression patterns in primary colorectal adenocarcinomas?
CK7− CK20+
## Footnote
About 80% of primary colorectal adenocarcinomas and 70% of metastases show CK7− CK20+ expression.
149
Name two rare histologic types of colorectal cancer.
* Squamous cell carcinoma
* Small cell carcinoma
## Footnote
Other rare types include adenosquamous carcinoma and medullary carcinoma.
150
What percentage of patients with bowel cancer present with symptoms at diagnosis?
About 85%
## Footnote
A significant majority of bowel cancer patients show symptoms at the time of diagnosis.
151
What are common symptoms at diagnosis for patients with bowel cancer?
* Altered bowel habit or obstructive symptoms
* Iron deficiency anaemia
## Footnote
Approximately one-third of patients present with altered bowel habits or obstructive symptoms, and another third with iron deficiency anaemia.
152
What symptoms are associated with left-sided tumors in bowel cancer?
Obstructive symptoms
## Footnote
Left-sided tumors often cause obstructive symptoms due to the narrower distal bowel.
153
What symptoms are associated with right-sided tumors in bowel cancer?
Iron deficiency anaemia
## Footnote
Right-sided tumors commonly present with iron deficiency anaemia.
154
What additional symptoms may be present in rectal cancers?
* Faecal incontinence
* Passage of mucus
* Tenesmus
## Footnote
Rectal cancers can lead to specific symptoms like faecal incontinence and mucus passage.
155
What percentage of bowel cancer patients may present with acute colonic obstruction?
Up to 30%
## Footnote
A notable percentage of patients with bowel cancer may experience acute colonic obstruction.
156
What symptoms may advanced tumors cause?
Weight loss
## Footnote
Advanced colorectal tumors can lead to significant weight loss among patients.
157
What symptoms are associated with nausea and anorexia in gastrointestinal conditions?
Abdominal pain and distension from ascites or hepatomegaly.
158
What are the initial investigations for suspected colorectal cancer?
Double contrast barium enema (DCBE), sigmoidoscopy, colonoscopy.
159
What percentage of patients may have synchronous cancers or adenomas?
Approximately 5% have synchronous cancers and up to 40% have synchronous adenomas.
160
What is an alternative to double contrast barium enema?
CT colonography.
161
What should be performed for patients suspected of intestinal obstruction?
Cross-sectional imaging preoperatively unless signs of peritonitis are present.
162
What blood tests are included in further investigations for colorectal cancer?
Full blood count, liver function tests, U&E, serum carcinoembryonic antigen (CEA).
163
What is the significance of examining 12 or more nodes after radical resections?
It correlates with prognosis for Dukes’ B cancers.
164
What does the pathology report need to inform about in colorectal cancer?
Presence/absence of tumour perforation, extramural vascular invasion, radial margins, lymph nodes examined and involved, completeness of resection.
165
What is the management for Stage I (Dukes’ A) colon cancer?
Surgery.
166
In Stage II (Dukes’ B) colon cancer, when should adjuvant chemotherapy be considered?
In patients with PS0-2 if there are high risk factors or if the patient is under 70 years.
167
What is the management for Stage III (Dukes’ C) colon cancer?
Surgery and consider adjuvant chemotherapy in all patients with PS 0–2.
168
What role does PET scan play in colorectal cancer management?
It may help in potentially resectable metastatic disease to rule out extensive metastasis.
169
What imaging is done for patients with resectable liver metastasis?
MRI of the liver.
170
What are the palliative treatments available for colorectal cancer?
Palliative chemotherapy, palliative radiotherapy, other palliative treatments, active symptom control.
171
What are the benefits of laparoscopic surgery compared to open surgery in colectomies?
Equal survival, better cosmesis, shorter hospital stays.
172
What is the absolute survival benefit of 5-fluorouracil/folinic acid (5FU/FA) chemotherapy in stage III (Dukes’ C) disease?
Between 8–13%.
173
What is the recommended duration of chemotherapy in stage III colon cancer?
6 months is as effective as 1 year.
174
What is the effect of adding oxaliplatin to 5FU/FA in patients with stage II and III CRC?
Improved 3-year DFS by 5% over infusional 5FU/FA alone.
175
Fill in the blank: Adjuvant chemotherapy is not beneficial in _______ disease.
Dukes’ A
176
What are the tumor invasion classifications in colorectal cancer staging?
* Tis: confined to mucosa or lamina propria
* T1: invades submucosa
* T2: invades muscularis propria
* T3: invades subserosa/pericolic/mesorectal tissue
* T4: invades other organs or tumor on serosal surface
177
What is the TNM stage for Dukes stage C?
T1-4 N1-2 M0
178
What percentage of patients are typically classified in Dukes stage IV?
29%
179
What is the recommendation for radical surgery in Stage IV colorectal cancer?
Consider radical surgery with perioperative chemotherapy if resectable liver +/- lung metastases.
180
What percentage of patients with metastatic disease are feasible for resection?
Only 10%.
181
What is the maximum recommended duration for preoperative chemotherapy before surgery?
12 weeks.
182
What are rectal cancers defined as?
Tumours arising <15 cm from the anal verge or below the peritoneal reflection
## Footnote
In the USA, rectal cancers are defined as those arising <12 cm from the anal verge.
183
What is the treatment for Stage I rectal cancer?
* Surgery TME AR or APR
* Local excision for T1 tumours of mid or lower rectum
* Short course pre-op RT for T2 low rectal cancers requiring APR
184
What is the treatment for Stage II rectal cancer?
* Surgery TME AR or APR
* Short course preoperative RT for T3 low rectal cancers requiring APR
185
Which chemotherapeutic agents are associated with liver parenchyma damage?
* Oxaliplatin
* Irinotecan
186
What was the increase in 3-year PFS for patients undergoing surgery with perioperative oxaliplatin/modified de Gramont chemotherapy?
9% increase (42% vs. 33%)
187
What is the reported 5-year survival for patients undergoing combined liver and lung metastasectomy?
Around 30%
188
What is the reported 5-year survival for lung metastasectomy alone?
Around 50%
189
What is the Modified Roswell Park chemotherapy regimen for rectal cancer?
* 5FU: 500 mg/m2
* Folinic acid: 20 mg/m2
* IV B weekly 6/8
* Indications: Adjuvant patients <70 years, Dukes’ B
190
What are the indications for the Capecitabine regimen?
* Adjuvant Dukes’ B (high risk)
* Adjuvant Dukes’ C
* First line palliative
191
What does TME stand for in rectal cancer treatment?
Total Mesorectal Excision
192
What is the goal of preoperative short course radiotherapy in rectal cancer?
Reduce the risk of local recurrence by >50%
193
What is the significance of R0 resection in rectal cancer?
Reduces the rate of local recurrence by 90% and mortality rate by 66%
194
What are the side effects of radiotherapy for rectal cancer?
* Early morbidity (wound complications)
* Late morbidity (bowel, anorectal and sexual function)
195
Fill in the blank: Preoperative _______ is used to downstage tumours enabling R0 resection in rectal cancer.
chemo-radiotherapy
196
What is the benefit of concurrent chemotherapy in rectal cancer treatment?
Improves pathological complete response rates and reduces local recurrence
197
What is the main focus of strategies in recent years for rectal cancer treatment?
Reducing local recurrence rates
198
What is the typical follow-up strategy for patients after treatment for colorectal cancer?
* Colonoscopy within 6 months if not fully imaged at diagnosis
* Initial colonoscopy 1–3 years after treatment if fully imaged
* 5-yearly colonoscopy thereafter in polyp free patients
199
True or False: There is proven benefit for postoperative adjuvant 5FU chemotherapy after preoperative bolus 5FU CRT schedule.
False
200
What is the recommended dose for short course preoperative radiotherapy for low rectal cancer requiring APR?
25 Gy over 5 fractions
201
What does APR stand for in rectal cancer treatment?
Abdominoperineal resection
202
What is the purpose of endoluminal procedures in colorectal cancer treatment?
Relieve obstructive symptoms
203
What is the median survival benefit of fluropyrimidines over best supportive care alone?
Approximately 4 months (10 vs. 6 months)
204
What is the role of palliative chemotherapy in rectal cancer?
Given early for better outcomes without adverse effects on quality of life
205
What is the typical response rate for the infusional regimen Modified de Gramont and oral capecitabine?
Approximately 30%
206
What is the standard surgical approach for T1 tumours in rectal cancer?
Local excision if no risk factors for relapse
207
What is the recommended follow-up for patients who do not have their entire colon imaged at diagnosis?
Colonoscopy within 6 months of treatment to exclude synchronous polyps or cancers.
208
What is the follow-up recommendation for patients who have had complete bowel imaging at staging?
Initial colonoscopy 1–3 years following treatment, followed by 5-yearly colonoscopy.
209
In which patients should colonoscopy be done more frequently than every 5 years?
In patients with ≥5 polyps.
210
What is the association between intensive follow-up and 5-year overall survival in Dukes’ B and C patients?
Intensive follow-up is associated with significantly improved 5-year overall survival (HR 0.81).
211
What follow-up is recommended after radical treatment for Dukes’ B or C cancer?
* 6-monthly CEA for 2 years followed by yearly until 5 years
* CT liver (and pelvis in rectal cancer) at 12 and 18–24 months
* CT if rising CEA with PET if CT fails to identify relapse.
212
What is the impact of screening by faecal occult blood (FOB) on CRC mortality?
Reduces the risk of death from CRC by 16% overall, and by 23% in those who are actually screened.
213
What does the NHS Bowel Cancer Screening Programme (BCSP) offer for individuals aged 60–69?
2-yearly FOB tests and colonoscopy to those with abnormal results.
214
What is the most important prognostic factor for CRC?
Stage.
215
What are the 5-year survival rates for stage I CRC?
>90% for stage I (Dukes’ A).
216
What are the common side effects of bevacizumab?
* Hypertension
* Proteinuria
* Gastrointestinal perforation
* Intra-abdominal infections
* Impaired wound healing
* Increased arterial thromboembolic events.
217
What is the effect of cetuximab in combination with irinotecan/5FU according to the CRYSTAL study?
Increased response rate (RR) (39% vs. 47%) and improved progression-free survival (PFS) (8 m vs. 8.9 m).
218
True or False: Mutated K-ras is associated with improved response to anti-EGFR antibodies.
False.
219
What is the median survival achieved by percutaneous radio-frequency ablation (RFA) for liver metastases?
Up to 36 months.
220
What percentage of recurrences from CRC occur within the first 2 years?
80%.
221
What initial assessments are included in the management of localized tumors?
* Digital rectal examination
* Examination under anaesthesia (EUA)
* Biopsy.
222
What is the recommended treatment for localized tumors in stage I patients?
Local excision.
223
What is the median survival of inoperable metastatic CRC with best supportive care alone?
6 months.
224
What are the initial investigations for colorectal cancer?
Double contrast barium enema (DCBE), sigmoidoscopy, colonoscopy
## Footnote
Sigmoidoscopy allows visualization up to splenic flexure at 60 cm. Colonoscopy images the whole colon.
225
What percentage of patients have synchronous cancers?
Approximately 5%
## Footnote
Synchronous adenomas can be present in up to 40% of patients.
226
What is an alternative to double contrast barium enema?
CT colonography
## Footnote
CT colonography is also a method for imaging the colon.
227
What does endoscopy allow in the investigation process?
Biopsy confirmation
## Footnote
Endoscopy is crucial for obtaining tissue samples for diagnosis.
228
What should patients presenting with suspected intestinal obstruction undergo preoperatively?
Cross-sectional imaging
## Footnote
This is unless there are signs of peritonitis, in which case emergency surgery takes precedence.
229
What blood tests are included in further investigations?
Full blood count, liver function tests, U&E, serum carcinoembryonic antigen (CEA)
## Footnote
These tests help assess the patient's overall health and detect any abnormalities.
230
What does elevated CEA preoperatively indicate?
It can be used to detect early recurrence in patients who may be appropriate for further curative surgery.
231
What is the purpose of a CT scan in colorectal cancer (CRC) patients?
To stage the cancer.
232
What imaging is required for locoregional staging in rectal cancer?
Pelvic MRI.
233
What does T2W image MRI help to define in rectal cancer?
The extent of the tumour and to identify mesorectal margin invasion by tumour.
234
What is the accuracy of endorectal ultrasound in assessing small T1 lesions?
87%.
235
When is a PET scan useful in CRC?
In the context of rising nausea, anorexia, abdominal pain, and distension from ascites or hepatomegaly.
236
What are the initial investigations for CRC?
Double contrast barium enema (DCBE), sigmoidoscopy, and colonoscopy.
237
What percentage of CRC patients may have synchronous cancers?
Approximately 5%.
238
What should be done for patients suspected of intestinal obstruction?
They should have cross-sectional imaging preoperatively.
239
What blood tests are included in further investigations for CRC?
Full blood count, liver function tests, U&E, and serum carcinoembryonic antigen (CEA).
240
What is the significance of examining 12 or more nodes after radical resections?
It correlates with prognosis for Dukes’ B cancers.
241
What is the management for Stage I (Dukes’ A) colon cancer?
Surgery.
242
What factors may lead to consideration of adjuvant chemotherapy in Stage II (Dukes’ B) patients?
High risk factors and young age (<70 years).
243
What is the standard adjuvant chemotherapy for Stage III (Dukes’ C) disease?
5-fluorouracil/folinic acid (5FU/FA).
244
What is the absolute survival benefit of 5FU/FA chemotherapy in Stage III disease?
Between 8–13%.
245
What is the role of oxaliplatin in the treatment of Stage III colon cancer?
It improves 3-year disease-free survival (DFS) by 5% over infusional 5FU/FA.
246
What is the recommended timing for initiating adjuvant chemotherapy after surgery?
Within six weeks of surgery.
247
What does Tis indicate in the TNM staging for colorectal cancer?
Confined to mucosa or lamina propria (no significant metastatic potential).
248
Fill in the blank: N1 indicates _______.
1–3 lymph nodes contain metastatic carcinoma.
249
What does the Dukes stage C1 or C2 signify?
Presence of metastatic carcinoma in lymph nodes.
250
What is the percentage of patients at Stage IIIB?
29%.
251
What is the management strategy for Stage IV colorectal cancer?
Consider radical surgery with perioperative chemotherapy if resectable liver or lung metastases.
252
What is the maximum recommended duration of preoperative chemotherapy for metastatic disease?
12 weeks.
253
What is the significance of resectability in patients with metastatic disease?
Only 10% of patients with metastatic disease can undergo resection.
