3/3/19
ABOUT MY PATIENT
• Female
• Age: 58 years old
RECTAL CANCER • Histology: rectal adenocarcinoma
CAS E P R ES ENTATION • Stage: T3N1M0
B Y: KR IS TEN JOHNS ON • Treated at The James on Vault 3
• Last four MRN digits: 8939
HER TIMELINE
SOCIAL HISTORY FAMILY HISTORY
• January 2018: S y mpto ms. P t no te d blo o d sto o l.
• S ingle , live s alo ne , 3 • Mo the r – Ane ury sm
• 2/ 14/ 2018: Co lo no sco py sho we d re ctal mass and co lo n po ly p.
gro wn daughte rs and 1
• Fathe r – passe d away
• 4/ 6/ 2018: MR I re ctum sho ws a 5.5 cm mid to uppe r re ctal mass suspicio us fo r T3 dise ase , gro wn so n
fro m bo ne cance r
e ntire e x te nt is difficult to visualize . Two 4-5 mm pe rire ctal LN invo lve d. • Une mplo y e d
• 4/ 12/ 2018: S e e n in the GI S urgical Onco lo gy clinic se e king se co nd o pinio n fo r surgical • Histo ry o f alco ho lism but
e valuatio n and manage me nt o f this – the y re co mme nde d ne o adjuvant che o mo radiatio n quit in 2011
fo llo we d by surge ry • To bacco abuse , 40 pack
• 5/ 4/ 2018: unde rwe nt a CT o f Che st/ abdo me n/ pe lvis which re ve ale d no e vide nce o f me ts y e ar smo king histo ry
• 5/ 24/ 2018: S tarte d chemo the rapy (Xelo da) and began R T tre atme nts CEA: 38.99 • S till co ntinue s to smo ke
• 6/ 28/ 2018: Co mple te d R T and che mo the rapy CEA: 10.3 • S he has ne ve r use d
smo ke le ss to bacco
• 8/ 29/ 2018: S urge ry à Minimally invasive (R o bo tic/ Laparo sco pic) Lo w ante rio r re se ctio n
• No re cre atio nal drug use
NORMAL PRESENTING
PAST MEDICAL HISTORY PATIENT’S SYMPTOMS SYMPTOMS
• Anxiety • Blood in stool • Rectal bleeding
• Depression • Increasing pain with bowel • Change in bowel habits
• Hemorrhoid - Swollen and inflamed veins movements • Pencil thin stools
in the rectum and anus that cause
• Fatigue • Constipation or diarrhea
discomfort and bleeding
• Muscular hip pain • Tenesmus – spasms in the rectum
• Hiatal hernia - A condition in which part of the stomach pushes up through the
diaphragm muscle.
• Ulcer, stomach peptic - A sore that develops on the lining of the stomach
1
3/3/19
ETIOLOGY OUR PATIENT:
EPIDEMIOLOGY FOR RECTAL CANCER
• High fat, low fiber diets • Never mentioned her diet
• Colorectal cancer is the 3rd most common cancer and 3rd leading cause of
• Genetic • No one in her family has a history of cancer death in US
• Mutatio n in the ge ne o n chro mo so me 5 rectal cancer (only her dad was
• Median age is 60 years
• Yo u can ge t te ste d fo r this mentioned to have bone cancer)
• Distribution of Cancers:
• Polyps – mucosal tumors • Colonoscopy did show that she had
• 24% of colorectal cancers in ascending colon
• Inflammatory bowel disease a polyp in her rectum
• 16% in transverse colon
• Chro nic ulce rative co litis • No inflammatory bowel diseases • 7% in descending colon
• Cro hn’s dise ase
• 38% in sigmoid colon
• 15% in rectum
RECTUM HISTOLOGY
• Begins at the 3rd sacral vertebrae • >90% are adenocarinoma
• 3 valves • Other types include: carcinoid, leiomyosarcoma, lymphoma, and squamous cell
• S upe rio r • Distal re ctal – po ssible fo r squamo us ce ll carcino ma
• Middle • OUR PATIENT: rectal adenocarcinoma
• Infe rio r
• Terminal inch is the anus
• Does anyone remember what these 3 valves do?
DIAGNOSIS/ DIAGNOSTIC STUDIES: TYPICAL LYMPH NODE DRAINAGE
• FIRST LINE OF DRAINAGE IS PERI-RECTAL
• Rectal digital exam – palpation • Superior half of rectum – peri-rectal, sacral,
sigmoidal, inferior mesenteric
• Colonoscopy vs Virtual CT Colonoscopy
• Inferior half of rectum – peri-rectal, internal
• Co lo no sco py - can be use d as a pre ventative surgery because it go e s thro ugh the re ctum
illiac, hypogastric, external illiac
and co lo n and can re mo ve po ly ps
• Virtual CT co lo no sco py – can no t take sample s o r re mo ve po lyps, just lo o king around • Low rectal or anal tumors may drain to inguinal
as well
• CT scan
• PET scan • Our patient: involvement in peri-rectal nodes
2
3/3/19
STAGE/ GRADE
TREATMENT METHODS:
• Our patient: Stage T3N1M0
• Stage I – local excision, T2 lesions will get adjuvant chemo/RT
• Duke Staging is used for colorectal cancers
• A- tumo r invade s submuco sa o r muscularis pro pria (T1 and T2) • Stage II/III (resectable) – preop chemo/RT then transabdominal resection with
adjuvant chemo
• B - tumo r invade s thro ugh muscularis pro pria into subse rosa or pe rforate s the visce ral
pe rito ne um o r invade s o the r o rgans (T3 and T4) • Stage III (unresectable) – chemo/RT
• C- me tastasis to pe rico lic o r pe rirectal ly mph no de s
• D – wide spre ad me tastasis
• Our patient: preop chemo/RT then surgery
• Robotic low anterior resection - surgically treat tumors in the upper part of the rectum,
where it joins the colon. In this procedure, part or all of the rectum is removed and the
colon is then surgically reattached to the remaining rectum or anus
COMMON RT TREATMENT METHODS TREATMENT PRESCRIPTION
• Treat whole pelvis area to about 4500 cGy • Curative
• Tre ating all the ly mph no de s to o • VMAT
• Boost more to a more confined volume to 5040-5400cGy • 200 cGy a day
• Make sure y o u are minimizing do se to small bo we l • 25 Fractions
• TD 5/ 5 is 4500 cGy • Total dose of 5,000 cGy
• Whe n co mbine d with che mo y o u wo uld bo o st up to o nly abo ut 5000 cGy
• 10 MV
• SIB
• S imultane o us inte grate d bo o st
• CBCT daily
TREATMENT PLAN FOR RECTAL CA SURGERY
• VMAT • 8/29 à Robotic low anterior resection - surgically treat tumors in the upper
• 3 arcs part of the rectum, where it joins the colon. In this procedure, part or all of the
• G 240-170 rectum is removed and the colon is then surgically reattached to the remaining
• G 118- 242 rectum or anus
• G 240- 120
• Negative margins!
• 17 lymph nodes negative for metastasis
• Seemed to be doing very well after surgery
3
3/3/19
EXPECTED SIDE EFFECTS FROM RADIATION PATIENT’S SIDE EFFECTS
Acute: Chro nic:
DURING TREATMENT AFTER TREATMENT ENDED
• Diarrhea – recommend a low • P e rsiste nt diarrhe a
fiber diet
• Bloody diarrhea 3-4x a day • Diarrhea (no blood)
• P ro ctitis – inflammatio n o f the re ctum
• Rec tal pain – started with tylenol, then perc oc et, then
• Abdominal cramping and • Urinary inco ntine nce oxyc odone • Fatigue
• Anxiety/ Depression – taking antidepressant: fluoxetine
bloating • B ladde r atro phy • Poor appetite
• Bloody or mucosal discharge • Damage to small bo we l le ading to • Fatigue
• Dysuria e nte ritis • Weight loss – drank Ensures
• • Oc c asional nausea
• P ainful urinating Adhe sio ns
• By the end of tx she was urinating about every 30 min
• Obstructio n o f the bo we l throughout the day
• Burning when urinating – took phenazopyridine
REFERENCES
• Cleveland Clinic Cancer. “Xeloda.” Chemocare, Chemocare.com , 2018,
chemocare.com/chemotherapy/drug-info/Xeloda.aspx.
• “Colorectal Cancer.” American Cancer Society, 2018,
www.cancer.org/cancer/colon-rectal-cancer.html.
• “Rectal Cancer.” Mayo Clinic, Mayo Foundation for Medical Education and
Research, 4 Jan. 2018.
• Ruth Hackworth, “Colorectal CA”, 2018
