Description
Colorectal cancer is the third most common type of cancer worldwide and a leading cause of cancer death. Surgery represents the mainstay of treatment in early cases but often patients are primarily diagnosed in an advanced stage of disease and sometimes also distant metastases are present.
Join and participate in this upcoming session by Dr Gunjan Desai, Gastrointestinal Surgeon, Director Edusurg Clinics who will be explaining the current diagnosis and management of CRC pointing out the extreme need for a multidisciplinary approach to achieve the best results in patient outcomes.
Summary Listen
- A 59-year-old male presented with painless rectal bleeding, weight loss, and low hemoglobin. Imaging and endoscopy are crucial steps, prioritizing ruling out malignancy before addressing hemorrhoids. CT scans with both oral and IV contrast are vital for assessing the colon and potential lymph node involvement. The location of the lesion on the scan influences the subsequent type of endoscopy and contrast needed.
- Preoperative assessment involves diagnosis, patient performance status, and disease extent. Diagnosis includes physical rectal exams, proctoscopy, and CT scans. Patient fitness is evaluated through cardiac workups and blood tests. Assessing the disease extent typically involves a CT scan of the chest, abdomen, and pelvis, along with CEA tumor marker analysis. A PET CT is only considered if the CEA is high or if metastatic disease is suspected.
- Right hemicolectomy is considered when a lesion is found in the ascending colon. The surgery respects vascular claims for optimal nodal clearance. The key vessels involved are the ileocolic, right colic, and right branch of the middle colic arteries. Extended right hemicolectomy includes the left branch of the middle colic artery, often necessitating removal of the splenic flexure and anastomosis to the descending colon.
- After a right hemicolectomy, adjuvant chemotherapy is determined by the cancer stage. Stage I and II (T1-T2 N0 and T3-T4 N0) cases may only require follow-up, whereas stage II T3, T4 cases with high-risk features (obstructive, perforated, young patients, microsatellite instability) or stage III (node-positive) necessitate adjuvant chemotherapy. Patient fitness for chemotherapy is often indicative of their fitness for surgery.
- For stage IV colorectal cancer with liver metastasis, management differs significantly. Common sites include the liver, lungs, and peritoneum. Treatment options include chemotherapy, surgery, radiotherapy, and liver-specific interventions like TACE, TARE, and ablation. Targeted therapy and immunotherapy also play a role. The resectability of the metastasis dictates the treatment approach.
- Resectable synchronous metastasis may warrant upfront surgery if R0 resection is achievable. If not, neoadjuvant therapy is the standard. For synchronous disease, a liver-first approach is often preferred. Targeted therapy is most beneficial when R0 resection is unlikely. Biomarker testing (RAS, MSI) is crucial for determining the suitability of targeted therapies and predicting prognosis.
- Sequencing treatment for stage IV colorectal cancer involves assessing resectability. If R0 resection is possible upfront, surgery is an option. Otherwise, neoadjuvant chemotherapy with or without targeted therapy is given and reassessed. PET scans, tumor markers, and patient performance status are used to reassess. Stable disease may lead to site-specific interventions, while progression requires switching therapies.
- The rectum is divided into upper and lower portions, with the peritoneal reflection determining intra- and extraperitoneal areas. This distinction is crucial as only the extraperitoneal rectum is amenable to radiation therapy. For lower rectal tumors (6-8 cm from the anal verge) at stage II (T3-T4) or III (node-positive), neoadjuvant chemoradiation is indicated.
- Surgery for rectal cancer depends on tumor location (upper, middle, or lower third) and adherence to Modified Rudders Classification. Upper third tumors often allow for anterior resection. Lower third tumors may require low anterior resection or ultra-low anterior resection based on proximity to the anorectal ring. Tumors involving the anal canal necessitate abdominoperineal excision.
Sample Certificate
About the Speakers
Dr Gunjan Desai
Gastrointestinal Surgeon Director Edusurg Clinics | Mumbai and Navi Mumbai
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