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60 Cards in this Set
- Front
- Back
CLINICAL MANIFESTATIONS
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Abdominal pain — 44 percent
Change in bowel habit — 43 percent Hematochezia or melena — 40 percent Weakness — 20 percent Anemia without other gastrointestinal symptoms — 11 percent Weight loss — 6 percent |
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Abdominal pain can be caused by a
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partial obstruction, peritoneal dissemination, or intestinal perforation leading to generalized peritonitis
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Approximately _________percent of patients have distant metastatic disease at the time of presentation
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20
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The most common metastatic sites are the:
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regional lymph nodes, liver, lungs, and peritoneum
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Because the venous drainage of the intestinal tract is via the portal system, the first site of hematogenous dissemination is
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usually liver, followed by lungs, bone, and many other sites, including brain.
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tumors arising in the distal rectum may metastasize initially to the
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lungs because the inferior rectal vein drains into the inferior vena cava rather than into the portal venous system
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Unusual presentations
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Local invasion or a contained perforation causing malignant fistula formation into adjacent organs, such as bladder or small bowel
Fever of unknown origin, intraabdominal, retroperitoneal, or abdominal wall abscesses Streptococcus bovis bacteremia and Clostridium septicum sepsis |
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Synchronous cancers
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two or more distinct primary tumors separated by normal bowel and not due to direct extension or metastasis
occur in 3 to 5 percent of patients with colon cancer |
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Metachronous cancers
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nonanastomotic new tumors developing at least six months after the initial diagnosis, develop in 1.5 to 3 percent of patients in the first five years postoperatively, rising to up to 9 percent after several decades
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Preoperative clinical staging
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physical examination (with particular attention to ascites, hepatomegaly and lymphadenopathy), computed tomography (CT) scan of the abdomen and pelvis, and chest radiograph
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The single most common liver test abnormality associated with liver metastases is an elevation in the
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serum alkaline phosphatase level
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MRI
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Contrast-enhanced MRI may identify more hepatic lesions than are visualized by CT and potentially narrow the available therapeutic options for patients with suspected liver metastases
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PET scans
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do not appear to add significant information to CT scans
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EUS for rectal cancer
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sensitivity is higher for advanced than for earlier T stage disease
less successful at correctly predicting nodal (N) status |
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Tumor markers
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CEA
carbohydrate antigen (CA) 19-9 |
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Non-cancer-related causes of an elevated CEA include
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gastritis, peptic ulcer disease, diverticulitis, liver disease, chronic obstructive pulmonary disease, diabetes, and any acute or chronic inflammatory state
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tumor marker screening
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American Society of Clinical Oncology (ASCO) recommended that serum CEA nor CA 19-9 levels not be used as a screening test for colorectal cancer
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PROGNOSIS
Colon cancer |
Stage I (T1-2N0) — 93 percent
Stage IIA (T3N0) — 85 percent Stage IIB (T4N0) — 72 percent Stage IIIA (T1-2 N1)— 83 percent Stage IIIB (T3-4 N1) — 64 percent Stage IIIC (N2) — 44 percent Stage IV — 8 percent |
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accounting for approximately _____ percent of all cancer deaths.
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9
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Incidence
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incidence rates per 100,000 population were 61.2 and 44.8 for men and women
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The lifetime incidence of CRC in patients at average risk is about ______ percent
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5
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familial colon cancer syndromes
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Familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC)
fewer than 5 percent of CRC cases |
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Familial adenomatous polyposis
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Familial adenomatous polyposis (FAP) and its variants (Gardner's syndrome, Turcot's syndrome, and attenuated adenomatous polyposis coli) account for less than 1 percent of colorectal cancers
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Hereditary nonpolyposis colorectal cancer
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autosomal dominant syndrome
1 to 5 percent of all colonic adenocarcinomas Lynch syndrome early age of onset and predominant involvement of the right colon 70 percent of first lesions arise proximal to the splenic flexure 10 percent will have synchronous or metachronous cancers |
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Inflammatory bowel disease
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Pancolitis confers a 5- to 15-fold increase
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Diabetes mellitus and insulin resistance
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elevated risk of colon cancer
hyperinsulinemia, because insulin is an important growth factor for colonic mucosal cells and stimulates colonic tumor cells |
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Cholecystectomy
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relationship between cholecystectomy and right-sided colon cancer has been described in some reports
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Alcohol
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increased risk of colorectal cancer has been observed in several studies
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Obesity
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1.5-fold increased risk of developing colon cancer relative to being normal weight (body mass index 18.5 to 24.9 kg/m2)
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Other risk factors
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coronary heart disease
Cigarette smoking Ureterocolic anastomoses |
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PROTECTIVE FACTORS
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Diet — intake of a diet high in fruits and vegetables
Fiber Resistant starch Folic acid Vitamin B6 (pyridoxine) Calcium Magnesium Garlic Fish consumption Physical activity |
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protective Drugs
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Aspirin and NSAIDs
Postmenopausal hormone therapy Statins DFMO plus sulindac Antioxidants |
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STAGE II DISEASE chemotherapy
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adjuvant chemotherapy cannot be considered as a standard of care
high-risk resected stage II disease: Fewer than 13 nodes in the surgical specimen T4 lesion (table 1) or perforation/obstruction at presentation Poorly differentiated (including signet ring and mucinous) histology Lymphovascular or neural invasion 5-FU |
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For patients who have undergone potentially curative resection of locoregional colon cancer, the goal of postoperative (adjuvant) therapy is to
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eradicate micrometastases
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Stage III disease adjuvant therapie
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six month course of FOLFOX
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unresectable metastatic CRC
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palliative chemotherapy can relieve symptoms, improve quality of life (QOL), and prolong survival
instituting chemotherapy at diagnosis, and when possible, before patients become symptomatic FOLFOX, XELOX, or FOLFIRI |
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Liver metastases resection In surgical case series, five-year survival rates after resection range from
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24 to 58 percent, averaging 40 percent
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In patient with liver metastasies surgical exploration should only be ruled out in the following situations
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Extensive unresectable extrahepatic disease as detected by CT and/or PET scans
Radiographic evidence of involvement of the hepatic artery, major bile ducts, or main portal vein Extensive liver involvement (>70 percent, more than six segments (figure 1), or involvement of all three hepatic veins) Inadequate postresection functional hepatic reserve |
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TF We suggest immediate surgical resection for medically fit patients with four or fewer isolated hepatic metastases
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T
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For patients with a good performance status who have more than four metastases (unless all are localized to a single lobe), radiographic suspicion for portal node involvement, or bilobar disease (ie, tumor involving any segments of the left and right hemi-liver), we suggest initial systemic chemotherapy followed by surgical reevaluation
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T
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benefit of combined hepatic intraarterial (HIA) and systemic chemotherapy compared to systemic leucovorin-modulated 5-FU alone was shown
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T
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Chemotherapy following metastasectomie
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six month course of systemic chemotherapy containing oxaliplatin
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Thus, updated ASCO guidelines recommend an H&P every
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three to six months for the first three years, every six months during years four and five, then annually thereafter
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elevated preoperative levels of CEA should return to baseline after complete resection;
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T
residual disease should be suspected if they do not |
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estimated sensitivity of CEA to detect disease relapse in patients with completely resected CRC ranges
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from 58 to 89 percent
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Arguments against serial CEA testing
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30 to 40 percent of all CRC recurrences do not produce CEA [12]
The benefit of CEA monitoring is limited to a small number of patients with recurrent CRC and is not cost-effective There are no data showing that CEA testing improves quality of life |
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CT control for reccurence
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annual CT of the chest, abdomen and pelvis for three years in patients at high risk of recurrence (those with lymphatic or venous invasion, poorly differentiated tumors)
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ASCO guidelines suggest that postoperative serum CEA testing be performed every
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three months for at least three years after initial therapy in patients with stage II or III disease
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For those presenting with an obstructing cancer, full colonoscopy is recommended within
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six months of surgery.
Subsequent colonoscopies are suggested after three years, and then, if normal, every five years |
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Thus, ASCO guidelines recommend flexible proctosigmoidoscopy every
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six months for five years only for patients who have not received pelvic radiotherapy
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postoperative recommendation
History and physical examination |
Every three to six months for the first three years; every six months during years four and five, then annually thereafter.
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postoperative recommendation
Carcinoembryonic antigen |
Serum CEA testing should be performed every three months for at least three years in patients with stage II or III colon or rectal cancer if they would otherwise be candidates for surgery or systemic therapy. Since aduvant 5-FU-based therapy can falsely elevate the serum CEA, waiting until adjuvant therapy is finished to initiate surveillance is advised.
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postoperative recommendation
Liver function tests |
Not recommended
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postoperative recommendation
Complete blood cell count |
Not recommended
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postoperative recommendation
Fecal occult blood test |
The data are sufficient to recommend against periodic FOBTs in surveillance for colorectal cancer recurrence*.
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postoperative recommendation
Chest x-ray |
Not recommended
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postoperative recommendation
Computed tomography of the chest and abdomen |
Patients with colon or rectal cancer at higher risk of recurrence (stage III or stage II with multiple poor risk features) should undergo annual CT of the chest and abdomen for three years if they would otherwise be eligible for curative intent surgery.
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postoperative recommendation
Pelvic imaging |
Annual pelvic CT for three years should be considered for rectal cancer surveillance, particularly if the patient has not been treated with pelvic radiation therapy.
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postoperative recommendation
Colonoscopy |
All patients with colon or rectal cancer should have a full colonoscopy in the preoperative or perioperative setting to document a cancer-free and polyp-free colon. Patients who present with an obstructing cancer should undergo full colonoscopy within six months of surgery. Repeat colonoscopy is recommended at three years, and if normal, every five years thereafter. For patients with high-risk genetic syndromes, the panel recommended that the screening guidelines of the American Gastroenterology Association (AGA) be followed
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postoperative recommendation
Flexible proctosigmoidoscopy, rectal cancer |
For patients who have not received pelvic radiation therapy, direct imaging of the rectum with flexible proctosigmoidoscopy is recommended every six months for five years.
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