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home - Colon - Colorectal and Anal Cancer - Rectal Cancer Written by Dr Sebastian Zeki

Knows the pathology of benign and malignant tumours of the colon
and rectum
Has awareness of the molecular genetics of colorectal
carcinogenesis and the adenoma-carcinoma sequence
Knows the range of predisposing conditions including inherited
syndromes and acquired colonic diseases
Knows the range of clinical presentation and the means of
diagnosis, investigation, management and follow-up
Knows the strategy for prevention including procedures for

Uses clinical assessment and selects investigations to reach a rapid
conclusion as to whether a patient might have colorectal cancer and
arranges timely investigation.
Refers the patient to the multi-disciplinary team CbD, mini-CEX,

Shows ability to react to possible diagnosis of malignancy in a timely

Communicates with patient and family in a sympathetic and
understanding manner, explains next steps, involves other health
professionals (including the GP) as appropriate

Rectal Cancer

T1-2 Surgery in all other cases and if positive margins or T2 at endoscopy If positive nodes or pT3, then for combination chemo T3N0 or Tany,N1-2or T4 and/or locally unresectable ChemoRad Combination chemo Surgery if possible Combination chemoChemoRadSurgery Surgery to resect primary and mets ChemoRad Combined chemo Or chemorad (latter if higher stage) Combined chemo Combination chemo=FOLFOX ± bevacizumab orFOLFIR± bevacizumab orCapeO± bevacizumab ChemoRad=Continuous IV 5-FU/pelvic RT or bolus 5-FU+ leucovorin/pelvic RT or Capecitabine/RT TAny,NAny, M1Resectable synchronous metastases Inoperable Recurrence Anastomotic/ Isolated pelvic recurrence All other mets ChemoRad Operation Unresectable- Resectable (including those converted from unresectable Neoadjuvant chemo and Resection + hepatic artery infusion therapy Chemo -combined with FOLFOX if patient can tolerate intensive therapy, otherwise capecitabine +/- bevacicumab Transanal excision: Diagnostics:Colonoscopy.CT Chest/ abdo/pelvis.MRI pelvis.CEA. Follow-up investigations: CEA every 6months for 5 years for >T2 lesions. PET scan is not routine. CT C/A/P every year for 3 years in high risk patients. Colonoscopy at 1 year . Colonoscopy 6 m post-op if not done pre-op. 2-5cm margin 45Gy Transabdominal Resection:Abdominoperineal resection or low anterior resection or coloanal anastomosis using total mesorectal excision.Aim: 5-10 weeks following full dose 5 1/2 wk neoadjuvant chemoradiationRemoval of primary tumor with adequate marginsRemove draining lymphatics by total mesorectal excisionRestoration of organ integrity, if possibleTotal mesorectal excisionReduces positive radial margin rate.Extend 4-5 cm below distal edge of tumors for an adequate mesorectal excision.In distal rectal cancers (ie, < 5cm from anal verge),negative distal bowel wall margin of 1-2 cm may be acceptable, this must be confirmed to be tumor free by frozen section.Full rectal mobilization allows for a negative distal margin and adequate mesorectal excision.Lymph node dissectionBiopsy or remove clinically suspicious nodes beyond the field of resection if possible.Extended resection not indicated in the absence of clinically suspected nodes. 5-FU/RT orCapecitabine/RT(category 2B)Resection of involved rectal segmentLaser recanalizationDiverting colostomyStentingChemotherapy alone Well to moderately differentiatedNo lymphadenopathy on pretreatment imaging< 30% circumference of bowel or < 3 cm in sizeMargin clear (> 3 mm)Mobile, nonfixed/ Within 8 cm of anal vergeT1 or T2 (use caution in T2, due to high recurrence rate)Endoscopically removed polyp with cancer or indeter-minate pathologyNo lymphovascular (LVI) or perineural invasion Principles of RadiotherapyThe tumour/tumor bed should be included, with a 2-5 cm margin presacral + internal iliac nodes.Multiple radiation therapy fields should be used.Positioning and other techniques to minimize the volume of small bowel in the fields should be encouraged.For postoperative patients treated by abdominoperineal resection, the perineal wound should be included within the fields.Use 45 Gy if resectable, 54 Gy if not resectable. Rectal Cancer Then follow colonoscopy screening guidelines Written by Dr Sebastian Zeki

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