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Flashcards in Colorectal + Prostate Deck (27):

Prostate Gland function

Secretes proteolytic enzymes into the semen, which act to break down clotting factors in the ejaculate


Three zones of the prostate

Central-Surround ejaculatory ducts. 25% of normal prostate volume

Transitional-surround urethra 10-15% normal prostate volume. Most prone to BPH

Peripheral-makes up main body of prostate (65%). Commonly felt on DRE. High association with prostate carcinoma


Blood supply: prostate

Prostate artery (internal iliac arteries)


Prostate carcinoma signs and symptoms

Urinary frequency All in late stages or in BPH

Abnormal DRE- Asymmetrical nodular prostate


Risk factors for prostate cancer

North american/northwest european
High fatty intake


Management of prostate cancer

Low risk: Expectant management
Med risk: External beam radiography
Antiandrogen (Bicalutamide, flutamide)
AND LHRH agonist (leuprorelin, goserelin)
High risk: Radical prostatectomy and pelvic lymph node dissection


Complication of radical prostatectomy

Peripheral zone is next to neurovascular bundles hence in surgery inevitably one of the bundles gets damaged resulting in erectile dysfunction.


Management of BPH

Alpha blocker (Terazosin, Doxazosin, Tamsulosin, Silodosin)
PDE-5 (Sildenafil, Tadalafil, vardenafil)


Four parts of the colon, intra or retro, artery supply and mid/hindgut

Ascending colon (retro)-ileocolic + R.colic (SMA)-midgut
Transverse colon (Intra)- R.,M.Colic (SMA), L.Colic (IMA)-mid/hind gut (2/3 mid)
Descending colon (retro)- L.Colic (IMA)-hindgut
Sigmoid colon- sigmoid art. (IMA)-hindguut


Colorectal cancer presentation

Rectal bleeding
change in bowel habit (more common in left sided colon
Rectal mass


Risk factors for colorectal cancer

Increasing age (common incidence 40-60)
Adenomatous polyposis coli (APC) gene mutation
Lynch syndrome


Common ways patients present to hospital

Outpatients with suspicious symptoms and signs

Asymptomatic individuals discovered by routine screening of average and high-risk subjects

Emergency admission with intestinal obstruction, peritonitis or, rarely, bleeding.


Key diagnostic investigations

flexible sigmoidoscopy in low risk patients
Colonoscopy indicated in all patients except of obstruction contraindicated bowel preperation

Biopsy of lesions


When does it become rectal cancer

any cancer whose distal margin is seen at 15 cm or less from the anal verge using a rigid sigmoidoscope


Management for rectal cancer stage 1 (T1 + T2, NO)

Low risk is local excision done via:
Transanal resection of tumour (TART)
Transanal endoscopic microsurgery (TEM)

High risk
anterior resection with sphincter preservation and colorectal anastomosis

for tumours in the distal 2/3 of the rectum excision is by low anterior resection (LAR) and colo-anal anastomosis


Low risk stage 1 rectal cancer

<3 cm diameter
Involves <30% of the circumference of the bowel
Moderately or well-differentiated histology
Localised (T1, N0, M0).


High risk stage 1 rectal cancer
(contraindicated for local excision)

>3 cm diameter
Poor differentiation
Lymphovascular or perineural invasion
Invasion of the anal sphincter complex.


Management of rectal cancers II and III

Pre-op radiotherapy with concomitant fluoropyrimidine-based chemo-radiotherapy
LAR and sphincter preservation or APR depending on site
Post op Chemotherapy


Cancer staging

Primary tumour (T)
Regional lymph nodes (N)
Distant metastasis (M)


Cancer staging Primary tumour (T)

Tx: Primary tumour cannot be assessed

T0: No evidence of primary tumour

Tis: Tumour involves only the mucosa. Also known as intramucosal carcinoma (carcinoma in situ)

T1: Tumour extends through the mucosa and into submucosa

T2: Tumour extends through the submucosa and into muscularis propria

T3: Tumour extends through the muscularis propria and into the subserosa but not to any neighbouring organs or tissues

T4a: Tumour extends through to the surface of the visceral peritoneum

T4b: Tumour directly invades other organs or tissues.


Cancer staging: Regional lymph nodes (N)

NX: Regional lymph nodes not assessed

N0: No lymph node involvement is found

N1: Metastasis in 1 to 3 regional lymph nodes

N1a: Metastasis in 1 regional lymph node

N1b: Metastasis in 2 to 3 regional lymph nodes

N1c: Tumour deposits in subserosa, mesentery, or non-peritonealised pericolic or perirectal tissues, without regional lymph node metastasis

N2: Metastasis in 4 or more regional lymph nodes

N2a: Metastasis in 4 to 6 regional lymph nodes

N2b: Metastasis in 7 or more regional lymph node


Cancer staging: Distant metastasis (M)

MX: Distant metastasis cannot be assessed (not evaluated by any modality)
M0: No distant metastasis
M1: Distant metastasis
M1a: Metastasis in 1 organ or site
M1b: Metastasis in more than 1 organ or site, or the peritoneum.


Cancer staging: Group staging

Stage 0 : Tis, N0, M0
Stage I: T1-T2, N0, M0
Stage II-III: T2-T4, N0, M0 to any T, N1-N2, M0
Stage IV: Any T, any N, M1

Stage IIA: T3, N0, M0

Stage IIB: T4a, N0, M0

Stage IIC: T4b, N0, M0

Stage IIIA: T1-T2, N1/N1c, M0; T1, N2a, M0

Stage IIIB: T3-T4a, N1/N1c, M0; T2-T3, N2a, M0; T1-T2, N2b, M0

Stage IIIC: T4a, N2a, M0; T3-T4a, N2b, M0; T4b, N1-N2, M0

Stage IVA: Any T, any N, M1a

Stage IVB: Any T, any N, M1b


Management for rectal cancer stage IV

Systemic combination chemotherapy

Chemoradiotherapy targerted at primary tumour and met lesions followed by resection

Mets resected, followed by chemoradiotherapy for primary tumour and then resection of the primary tumour


Management for rectal and colon cancers where surgery not suitable

Monoclonal antibodies (bevacizumab, cetuximab)
Stenting (for those with obstructive tumours)


Management of colon cancer stage 1-3

Colectomy with en bloc removal of regional lymph nodes and immediate anastomosis
Post op chemo

extent of the colectomy depends on resection of the portion of the colon and arterial arcade that contains the regional lymph nodes

Minimum of 12 nodes is needed for accurate staging


Management of colon cancer stage IV

Preoperative Chemo

Synchronous or segmental resection (colectomy)