Fever in the Neutropenic Patient (PowerPoint)

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					Colon Cancer
    Joehar Hamdan
             Colon Cancer
        Clinical Manifestations
• The majority of patients with CRC have hematochezia or melena,
  abdominal pain, and/or a change in bowel habits. Two reports
  evaluated the frequency of initial symptoms in patients presenting
  with potentially resectable colon cancer Some patients have more than
  one abnormality:

•   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

• Patients who are symptomatic at diagnosis have a somewhat worse
  prognosis In one report, the five-year survival rate for symptomatic
  and asymptomatic patients was 49 versus 71 percent.
• Colonoscopy — The majority of colon and rectal
  cancers are endoluminal adenocarcinomas that arise
  from the mucosa. Colonoscopy is the single best
  diagnostic test in symptomatic individuals, since it
  can localize lesions throughout the large bowel,
  biopsy mass lesions, detect synchronous neoplasms,
  and remove polyps.
                        Staging   •   The most common current staging system is
                                      the TNM (for tumors/nodes/metastases)
                                      system, T - The degree of invasion of the
There are two staging systems         intestinal wall
                                        • T0 - no evidence of tumor
  used.                                 • Tis- cancer in situ (tumor present, but
                                            no invasion)
                                        • T1 - invasion through submucosa into
Duke’s Classification:                      lamina propria (basement membrane
• Proposed by Dr Cuthbert E.            • T2 - invasion into the muscularis
  Dukes in 1932, identifies the             propria (i.e. proper muscle of the bowel
  stages as                             • T3 - invasion through the subserosa
• A - Tumor confined to the             • T4 - invasion of surrounding structures
  intestinal wall                           (e.g. bladder) or with tumour cells on
                                            the free external surface of the bowel
• B - Tumor invading through      •   N - the degree of lymphatic node
  the intestinal wall                   • N0 - no lymph nodes involved
• C - With lymph node(s)                • N1 - one to three nodes involved
  involvement                           • N2 - four or more nodes involved
                                  •   M - the degree of metastasis
• D - With distant metastasis           • M0 - no metastasis
                                        • M1 - metastasis present

Stage I     T1      N0       M0      Duke’s A

            T2      N0       M0

Stage II    T3      N0       M0      Duke’s B

            T4      N0       M0

Stage III   any T   N1       M0      Duke’s C

            any T   N2, N3   M0

Stage IV    any T   any N    M1      Duke’s D
   Clinical staging evaluation
• Preoperative clinical staging is best accomplished by physical
  examination (with particular attention to ascites, hepatomegaly
  and lymphadenopathy), computed tomography (CT) scan of the
  abdomen and pelvis, and chest radiograph.

• liver enzymes may be normal in the setting of small hepatic
  metastases, and are not a reliable marker for liver involvement.
  The single most common liver test abnormality associated with
  liver metastases is an elevation in the serum alkaline
  phosphatase level.
                    CT Scan
• The sensitivity of CT for detecting distant metastasis
  is higher (75 to 87 percent) than for detecting nodal
  involvement (45 to 73 percent) or the depth of
  transmural invasion (approximately 50 percent)

• Compared to colon cancers, the sensitivity of CT for
  detection of malignant lymph nodes is higher for
  rectal cancers; any perirectal adenopathy is presumed
  to be malignant since benign adenopathy is not seen
  in this area.
High-resolution magnetic resonance imaging
(MRI) is the single best test for predicting the
status of the circumferential resection
margins (ie, tumor infiltration of the
mesorectal fascia) at the time of surgery. Such
patients have a high rate of failure after
surgery, and are appropriate candidates for
neoadjuvant approaches.
When to use PET Scans ?
PET scanning in colorectal cancer is as an adjunct to other
  imaging modalities in the following settings:

• Localizing site(s) of disease recurrence in patients who
  have a rising serum CEA level and nondiagnostic
  conventional imaging evaluation following primary

• For patients with symptoms or a rising serum CEA level
  who are suspected of having metastatic disease but whose
  diagnostic workup is negative, PET scanning can
  potentially localize occult disease, permitting the selection
  of patients who may benefit from exploratory laparotomy.

NOTE: Chemotherapy may alter the sensitivity of PET for
  the detection of colorectal metastases, thought related to
      decreased cellular metabolic activity of the tumor
     Endorectal Ultrasound
EUS exceeds the capability of CT scan to
 locally stage the depth of transmural
 invasion and the presence of perirectal
 nodal involvement for rectal cancers.

However, EUS has been less successful at
 correctly predicting nodal (N) status.
             Tumor Markers
• Carcinoembryonic antigen (CEA), and carbohydrate
  antigen (CA) 19 9 markers have a low diagnostic
  ability to detect primary CRC due to significant
  overlap with benign disease, and low sensitivity for
  early stage disease.

• Noncancer-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
   So when do you use these
Serum levels of CEA do have prognostic utility
  in patients with newly diagnosed CRC.
  Patients with preoperative serum CEA > 5
  ng/mL have a worse prognosis, stage for
  stage, than those with lower levels.
ASCO guidelines recommend that serum CEA
  levels be obtained preoperatively in patients
  with demonstrated colorectal cancer to aid in
  staging, surgical treatment planning, and in
  the assessment of prognosis.
• 153,760 new cases of large bowel cancer are
  diagnosed each year in the United States, of which
  112,340 are colon and the remainder rectal cancers.

• Approximately 52,180 Americans die of large bowel
  cancer each year.

• Patients who are symptomatic at diagnosis have a
  somewhat worse prognosis. In one report, the five-
  year survival rate for symptomatic and
  asymptomatic patients was 49 versus 71 percent.
Never go to a doctor whose office plants
 have died. ~Erma Bombeck

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