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60 Cards in this Set

  • Front
  • Back
CLINICAL MANIFESTATIONS
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
Abdominal pain can be caused by a
partial obstruction, peritoneal dissemination, or intestinal perforation leading to generalized peritonitis
Approximately _________percent of patients have distant metastatic disease at the time of presentation
20
The most common metastatic sites are the:
regional lymph nodes, liver, lungs, and peritoneum
Because the venous drainage of the intestinal tract is via the portal system, the first site of hematogenous dissemination is
usually liver, followed by lungs, bone, and many other sites, including brain.
tumors arising in the distal rectum may metastasize initially to the
lungs because the inferior rectal vein drains into the inferior vena cava rather than into the portal venous system
Unusual presentations
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
Synchronous cancers
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
Metachronous cancers
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
Preoperative clinical staging
physical examination (with particular attention to ascites, hepatomegaly and lymphadenopathy), computed tomography (CT) scan of the abdomen and pelvis, and chest radiograph
The single most common liver test abnormality associated with liver metastases is an elevation in the
serum alkaline phosphatase level
MRI
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
PET scans
do not appear to add significant information to CT scans
EUS for rectal cancer
sensitivity is higher for advanced than for earlier T stage disease
less successful at correctly predicting nodal (N) status
Tumor markers
CEA
carbohydrate antigen (CA) 19-9
Non-cancer-related causes of an elevated CEA include
gastritis, peptic ulcer disease, diverticulitis, liver disease, chronic obstructive pulmonary disease, diabetes, and any acute or chronic inflammatory state
tumor marker screening
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
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
accounting for approximately _____ percent of all cancer deaths.
9
Incidence
incidence rates per 100,000 population were 61.2 and 44.8 for men and women
The lifetime incidence of CRC in patients at average risk is about ______ percent
5
familial colon cancer syndromes
Familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC)
fewer than 5 percent of CRC cases
Familial adenomatous polyposis
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
Hereditary nonpolyposis colorectal cancer
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
Inflammatory bowel disease
Pancolitis confers a 5- to 15-fold increase
Diabetes mellitus and insulin resistance
elevated risk of colon cancer
hyperinsulinemia, because insulin is an important growth factor for colonic mucosal cells and stimulates colonic tumor cells
Cholecystectomy
relationship between cholecystectomy and right-sided colon cancer has been described in some reports
Alcohol
increased risk of colorectal cancer has been observed in several studies
Obesity
1.5-fold increased risk of developing colon cancer relative to being normal weight (body mass index 18.5 to 24.9 kg/m2)
Other risk factors
coronary heart disease
Cigarette smoking
Ureterocolic anastomoses
PROTECTIVE FACTORS
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
protective Drugs
Aspirin and NSAIDs
Postmenopausal hormone therapy
Statins
DFMO plus sulindac
Antioxidants
STAGE II DISEASE chemotherapy
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
For patients who have undergone potentially curative resection of locoregional colon cancer, the goal of postoperative (adjuvant) therapy is to
eradicate micrometastases
Stage III disease adjuvant therapie
six month course of FOLFOX
unresectable metastatic CRC
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
Liver metastases resection In surgical case series, five-year survival rates after resection range from
24 to 58 percent, averaging 40 percent
In patient with liver metastasies surgical exploration should only be ruled out in the following situations
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
TF We suggest immediate surgical resection for medically fit patients with four or fewer isolated hepatic metastases
T
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
T
benefit of combined hepatic intraarterial (HIA) and systemic chemotherapy compared to systemic leucovorin-modulated 5-FU alone was shown
T
Chemotherapy following metastasectomie
six month course of systemic chemotherapy containing oxaliplatin
Thus, updated ASCO guidelines recommend an H&P every
three to six months for the first three years, every six months during years four and five, then annually thereafter
elevated preoperative levels of CEA should return to baseline after complete resection;
T
residual disease should be suspected if they do not
estimated sensitivity of CEA to detect disease relapse in patients with completely resected CRC ranges
from 58 to 89 percent
Arguments against serial CEA testing
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
CT control for reccurence
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)
ASCO guidelines suggest that postoperative serum CEA testing be performed every
three months for at least three years after initial therapy in patients with stage II or III disease
For those presenting with an obstructing cancer, full colonoscopy is recommended within
six months of surgery.
Subsequent colonoscopies are suggested after three years, and then, if normal, every five years
Thus, ASCO guidelines recommend flexible proctosigmoidoscopy every
six months for five years only for patients who have not received pelvic radiotherapy
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.
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.
postoperative recommendation
Liver function tests
Not recommended
postoperative recommendation
Complete blood cell count
Not recommended
postoperative recommendation
Fecal occult blood test
The data are sufficient to recommend against periodic FOBTs in surveillance for colorectal cancer recurrence*.
postoperative recommendation
Chest x-ray
Not recommended
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.
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.
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
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.