COLORECTAL CANCER
Jackson Baumgartner
Patient History
74 year old Caucasian male
Treated on v1 at the James
Diagnosis: T3N0M0 (Stage IIA) Rectal Cancer
(adenocarcinoma)
Moderately differentiated adenocarcinoma, 6.5 cm,
arising in the rectum
Adeno CA extends through the muscularis propria into the
surrounding fat
26 nodes tested (all negative for involvement)
Anatomy of Colon
Layers of Colon
Anatomy of Rectum
Epidemiology
Third most common cancer (both men and women) in the united states
excluding skin cancer (if you include skin cancer it is listed as the 4th
most common cancer in the US)
95,520 new cases of colon cancer/year
39,910 new cases of rectal cancer/year
Overall lifetime risk of developing colorectal cancer – 1/21 (men) and
1/23 (women)
Median age is 60 years
Third leading cause of cancer related death in women (in the US).
Second leading cause of cancer related death in men (in the US)
Expected to cause ~50,260 deaths during 2017
Etiology – Risk Factors
Obesity
Physical inactivity – but he did start going for 1 mile walks
Certain diets
Diets high in red/processed meats, high fat, low fiber
Fried, broiled, or grilled foods (may create chemicals that can cause cancer)
Smoking
Heavy Alcohol Use
History of polyps
Personal/Family history of inflammatory bowel disease
Hereditary diseases or mutations
Most common is Familal adenomatous polyposis (FAP)
African American and Jews of Eastern European descent (not understood why this is)
Type II diabetes
Inflammatory bowel disease
Common Presentation
Usually starts as a polyp on the inner lining of the colon or rectum – 2 main
types:
Adenomatous polyps (adenomas) – sometimes change into cancer, thus they are
also called a pre-cancerous condition
Hyperplastic polyps and inflammatory polyps – the most common type of polyp,
generally NOT pre-cancerous
A change in bowel habits
A feeling that you need to have a bowel movement that is not relieved by
having one
Rectal bleeding – most common
Blood in the stool
Cramping or abdominal (belly) pain
Weakness and fatigue
Unintended weight loss
Screening
Person with average risk – digital rectal exam
and occult blood test annually at age 50 with
possible colonoscopy every 10 years;
sigmoidoscopy
High risk – start screening at age 40 and more
frequently
Routes of Spread/Sites
Route of spread: Lymph vessels or via blood
May invade adjacent structures of the pelvis
Can travel along portal drainage to the liver
Can travel systemically to the lungs
Rectum Lymphatics
Superior Half of Rectum
Peri-Rectal
Sacral
Sigmoidal
Inferior Mesenteric nodes
Staging
Duke’s staging most commonly used
Stage 0 – has not invaded past the mucosa
Stage I – grown into submucosa, no nodes, no mets
Stage II – grown into serosa or adjoining tissues, no nodes,
no mets
Stage IIIA-B – grown into submucosa, muscularis propria,
serosa, or adjoining tissues with 3 or less nodes involved,
no mets
Stage IIIC – tumor of any size with 4 or more nodes
involved, no mets
Stage IV – any tumor size, any node stage, mets to other
organs
Treatment options by stage
Stage I – local excision; adjuvant chemo/radiation
for T2 lesions
Stage II & III (resectable) – Preop Chemo/Radiation
therapy then transabdominal resection with postop
chemo
Stage III (unresectable) – Chemo/Radiation therapy
Stage IV – Chemo and/or radiation, followed by
surgery for mets sites; may do postop chemo
regime
Treatment Borders
AP/PA
Superior - L5 – S1
Inferior – 3 cm below inferior aspect of tumor, lower
portion of rectum should include anus
Lateral – 1.5 - 2 cm beyond the pelvic brim
Laterals – same superior and inferior borders
Anterior – posterior to pubic symphysis if ≤ T3, anterior
to pubic symphysis if T4
Posterior – behind the sacrum
History Continued
History of arthritis, club foot, hypertension, Rheumatic
fever, and obesity
Past surgeries: Removal of cataract, ankle surgery in
20’s
No family history of colorectal cancer
Social history: Never smoker, 3.0 ounces of liquor/week,
5 cans of beer/week
States he drank heavily for 20+ years then toned it down in
his 40’s
Uses illicit drugs once/week
Physically inactive
Presenting signs and symptoms
Presented to the hospital complaining of
constipation and other problems with bowel
movements
Resultwas a flexible sigmoidoscopy which showed a
partially obstructing mass – removed the following day
Until now he had never had a colonoscopy exam
Treatment Plan
Rectum + Boost total = 5040 cGy
Rectum Treatment
4500 cGy in 25 fractions (180 cGy/fraction)
15 MV
5 fields (PA, R LAT, RF R LAT, L LAT, RF L LAT – Dynamic wedges on lateral fields, not
including the reduced fields)
Boost
540 cGy in 3 fractions (180 cGy/fraction)
Chemotherapy
Xeloda in 4 week cycles for 2 months, then 5+ weeks of Xeloda +
Radiation, then another 2 months of Xeloda (sandwich treatment)
11/2/16: Xeloda 2000mg BID X7 days, every other week
Positioning
Possible Side Effects
Fatigue
Skin irritation including dryness, redness, and itchiness
Possible irritation of bowels causing cramping and/or loose stools
Possible decrease in blood counts
Possible inflammation of rectum and anus causing pain, spasm, discharge, or
bleeding
Possible irritation of bladder causing burning, frequency, spasm, pain, and
hematuria
Damage to bowel causing blockage or fistula (hole)
Shrinking of the bladder resulting in frequent urination
Dysuria
Weight loss
Prognosis and Survival
Stage I – 87%
Stage IIA – 80%
Stage IIB – 49%
Stage IIIA – 84%
Stage IIIB – 71%
Stage IIIC – 58%
Stage IV – 12%
Sources
"What Is Colorectal Cancer?" American Cancer Society.
N.p., n.d. Web. 10 Mar. 2017.
"Colorectal Cancer Risk Factors." American Cancer
Society. N.p., n.d. Web. 10 Mar. 2017.
"Colorectal Cancer Signs and Symptoms." American
Cancer Society. N.p., n.d. Web. 10 Mar. 2017.
Washington, Charles M., and Dennis T. Leaver. "Chapter
33: Digestive System Tumors." Principles and Practice of
Radiation Therapy. St. Louis, MO: Elsevier, Mosby, 2016.
705-18. Print.
