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Surgical Oncology

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Author Topic: Group E

Stephen Boyce

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You have identified some of the difficulties in managing such a patient.

 

Deborah you gave a very comprehensive answer of the possible treatment options for this lady with Stage III ovarian disease.

 

Surgery will not be curative in this woman. The aim of surgery will be to palliate symptoms. The patients symptoms may be improved medically without recourse to surgery.

 

Investigations such as CT should aim to determine the level of mechanical obstruction. If there are multiple levels of obstruction, usually due to gross peritoneal disease, surgery may be futile.

 

Clearly the views of the patient are of utmost importance. Where the outlook is bleak with or without surgery decision making becomes more difficult.

 

Guidelines for the management of bowel obstruction in ovarian cancer are given at

 

http://www.sign.ac.uk/guidelines/fulltext/75/section8.html

 

Interestingly small bowel obstruction is a relative contraindication.

 

I have enjoyed chairing this discussion board,

 

Stephen

Daniel ROBINSON

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Agree. But of immediate concern would be to relieve the patient's symptoms. Is it appropriate to continue managing her conservatively in regards to her symptom of bowel obstruction in light of the CT scan result? Are there absolutely no roles for surgery here?

Deborah SANDHU

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The FIGO staging for ovarian carcinoma is as such

 

Stage I - limited to the ovaries

IA - involving one ovary; capsule intact

IB – involving both ovaries

IC – tumour limited to the ovaries with any of the following of ruptured capsule, tumour on ovarian surface or positive washings

 

Stage II - pelvic extension or implants

IIA - extension onto uterus or fallopian tube; negative washings

IIB - extension onto other pelvic structures; negative washings

IIC - pelvic extension with positive peritoneal washings

 

Stage III - microscopic peritoneal implants outside of the pelvis; or limited to the pelvis with extension to the small bowel or omentum

IIIA - microscopic peritoneal metastases beyond pelvis

IIIB - macroscopic peritoneal metastases beyond pelvis <2 cm in size

IIIC - peritoneal metastases beyond pelvis > 2 cm or lymph node metastases

 

Stage IV - distant metastases to the liver or outside the peritoneal cavity

 

For this patient, with peritoneal nodules, ascites and malignant cells in the ascitic fluid (and no mets in the liver/bone), her stage would be IIIB or IIIC depending on the size of the peritoneal nodules.

 

Her treatment options will depend on the type of ovarian CA she has, her co-morbidities and her wishes.

Stage III ovarian CA is unlikely to be curable. Surgery ( TAH- BSO or unilateral oophorectomy) could be an option, for diagnostic purposes and perhaps increase length of survival. However given her age of 82, palliative chemo +/- radiotherapy might be the best option.

 

I would involve an oncologist and discuss her case at a joint MDT.

Stephen Boyce

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Hi,

 

Good answers people.

 

The issue of tumour markers is an interesting one Lestyn. The potential use of an individual tumour marker is disease specific. So, as Daniel says CEA should not be used for detecting or screening for colon cancer but is useful in follow up; CA125 can however be reasonably used as part of the investigations for suspected ovarian epithelial cancer; PSA can be used in conjunction with symptoms in detecting prostate cancer but is not approved as a screening tool.

 

 

SBO in a virgin abdomen suggests malignancy. (Never miss a femoral hernia!) Priorities are to replace fluid losses and decompress with a NG tube.

 

 

OK the CT shows multiple fluid small bowel loops. There is no definite transition point. The omentum is thickened. There are peritoneal nodules. There is moderate ascites. There is a 15cm mass in the pelvis. The conclusion is one of probable ovarian carcinoma. CA125 is >3000. Ascitic tap shows malignant cells fitting with ovarian cancer.

 

What stage of disease is this?

 

What are the options for this lady?

 

What would you do and why?

Daniel ROBINSON

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The search for the perfect tumour marker goes on... :) I have to agree with James here..most of the literatures, specifically if we focus on the role of CEA and colorectal cancer does not seem to point to the role of CEA as a diagnostic tool but rather for prognostication and treatment response/ monitoring instead. But the key word here is  "early stage" and therefore the test is unsuitable for screening the population. However, if  "combined" with other information, i.e the presenting history, findings on physical examination and imaging results it would supplement our working diagnoses. Just to quote, " 25% CEA were elevated in Dke's A and B ) while 85-90% in Duke's D" (Oxford Textbook of Surgery, 2nd Ed.) pp 1634.   As tumour markers are not available for the in-patients at the hospital that I am working in, we have to send it to private laboratories and hence we are required to explain to the patients the reason for requesting these tests.

 

Reference:

1) Annika LindblomAnnelie Liljegren, Clinical Review: Tumour Markers in Malignancy, BMJ 2000;320:424-427 (12 February)

2) Gobbi PG, Valentino F, Beradi E et al, New insight into the role  of age and carcinoembryonic antigen in the prognosis of colorectal cancer; British Journal of Cancer 2008; 98(2);328-34

.

James EDWARDS

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I agree with the general consensus regarding this patient's management, and that CT (especially given this acute presentation) is the most appropriate next investigation.

 

Regarding tumour markers: when is the most appropriate time to request these tests?  Most texts I have read say that they are best used in monitoring after treatment.  In a case such as this (where we strongly suspect cancer) should we be fishing for answers by requesting tumour markers or is there a formal role for them?  Anyone with any thoughts?

 

Information giving - There are ways of avoiding questions that we don't want to answer or that we think would best be discussed at another time.  For instance, the explanation/discussion about small bowel obstruction is relatively benign (pardon the pun!).  We can give plenty of information (If requested) on that, especially as it is the acute presentation and we know what we are going to do.  Questions regarding the underlying cause (cancer) can be defused somewhat by stating that you will be doing some investigations to identify the cause later on, but then returning the conversation to the present by saying what you are going to do now to relieve the patients symptoms and make her comfortable.

Deborah SANDHU

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I agree with Karen's management plan, and maybe consider an anti-emetic if nausea is persistent. I would also do a PV as gynae malignancy is in my differential diagnosis. I will definitely obtain more history - diarrhoea? constipation? PV bleeding? family history? A CT scan would be my next line of radiological investigation as well.

 

From what's been described, it seems that the patient herself is not perturbed by her symptoms. This could be because she doesn’t think they are serious, or it could be because she knows it is serious and is avoiding the doctors. I would first establish what they understand and find out what they want to know. At this stage I will explain the 'I have found fluid in the abdomen' and that her 'bowels are obstructed'. How much more information I would offer will depend allot on how much they want to know.

Robert SMITH

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I think something else to look for in on examination is evidence of scars, no scars in this sort of patients probably means that she has cancer.

 

We have a diagnosis of small bowel obstruction so the usual treatments as Karen described.

 

You would be worried about a pelvic tumour just as Karen decribed.  Associated with peritoneal mets

 

I think a CT would help find the cause of her obstruction as well as giving you a staging at the same time.  I would explain the diagnoses of small bowel obstruction to the family, explain that there are lots of reasons for this and we would require a scan to what was happening.  If they don't ask about cancer I would never tell. 

 

Just something extra, if she's already dry and has a Hb of 10 I would Group and save her just in case she needs transfusion due to a dilutional drop in her Hb.

Karen WHITE

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1. Immediate Actions

 - canula and IVF to cover maintenance and loses

 - catheter to help with fluid management

 - urine dip, if not yet done: infection?, blood?

 - PR if not yet done

 - more hx if possible: renal system, bowels esp.

 - ? needs NGT: dependent on volume vomiting

 - PRN analgesia (not needing at present)

 - blood form for morning - check U+Es

2. Provisional dx

Incomplete distal small bowel obstruction

Secondary to pelvic tumor (likely in light of non-specific symptoms - fatigue, weight loss, ascites)

3. Tests

 - Bloods for tumour markers

 - CT Scan - ? cause obstruction (chest/ abdo/ pelvis - staging)

Stephen Boyce

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Hi

 

That's a good point about staging David.

 

In colorectal cancer adjuvant chemotherapy should be considered in anyone with involved lymph nodes (Dukes C) and those with poor prognosis Dukes B tumours, such as lymphovascular invasion by the tumour.

 

Agents used commonly in adjuvant treatment for colon cancer include 5-FU and oxaliplatin given IV or capecitabine given orally. Capecitabine has a much lower side effect profile and can be taken at home.

 

Your answers to this scenario have been excellent so let’s move on to a more challenging clinical scenario.

 

An 82 year old woman who lives independently and is a fanatical gardener is admitted by her GP with painless abdominal distension. She is accompanied by her daughter, who does her mother’s shopping and lives nearby, seeing her every day. The daughter describes a slow deterioration over the last six months and she thinks her mother looks thin. The patient is annoyed with all the fuss but admits to feeling very tired and feels her abdomen is swollen. Over the last three days she describes some colicky abdominal pain and vomiting after meals. She is passing flatus but not stool. On examination she is thin though the abdomen is distended. You feel fullness in the SP region, centrally the abdomen is tympanic but dull in the flanks, and you demonstrate shifting dullness. The AXR shows dilated small bowel loops on the background of a ground glass appearance to the film. While you are reviewing the film the patient vomits 600mls of bile stained fluid. Blood tests show Hb is 10, she has mild pre renal failure.

 

What are you going to do for the patient in the next thirty minutes?

 

What is your provisional diagnosis?

 

What tests are you going to do?

 

What are you going to tell the patient and the daughter?

Daniel ROBINSON

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Adjuvant chemotherapy has proved to increase survival rates in addition to the surgical resection for the tumour. The range of side effects depends on the type of chemo agents used but side effects would include malaise, alopecia, bone marrow supression or even neutropenic sepsis

David SAMURA

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A quick point about the staging systems before i read up on chemotherapy.  They are also useful for communication between centers in audit and research.  Results and treatments can be compared between units across the world and classification systems permit "standardisation" of disease.

Stephen Boyce

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Excellent Ruth, you certainly got the main points, pre op radiotherapy can reduce rates of local recurrence and may improve survival.

 

Sexual dysfunction is also an important side effect of radiotherapy in addition to the others you mentioned.

 

OK, so you advise your patient of what you consider to be the best course of action, he undergoes pre operative radiotherapy, then an anterior resection with total mesorectal excision (TME).

 

The patient does very well under your expert care! He recovers well from surgery. The pathology demonstrates a T3N1 tumour. His case is discussed again at the MDT and the oncologists suggest he may benefit from adjuvant chemotherapy.

 

What are the potential benefits of such treatment in colorectal cancer for the patient and what are the commonest side effects?

Ruth CHAO

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T3N1 - tumour invades subserosa or beyond without other organs involved. N1 - local nodes involved. By AJCC criteria this is IIIb is 3 or less nodes involved, IIIc if 4 or more.

 

Radiation therapy in rectal cancer reduces recurrence and improves long-term outcomes predominantly through its effects on local and regional disease. One of the largest initial studies was Kapiteijin et al Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. New England Journal of Medicine (2001) 345(9):638-46 - though there was little difference in two year survival local recurrence was reduced from 8.2% to 2.4 %. It can also alter the procedure used by down staging the tumour allowing low anterior resection rather than AP resection (although in this case an anterior resection is already planned).

 

Disadvantages: Proctitis with diarrhoea, PR bleeding pain and occasionally faecal incontinence. Bladder and urethra may be affected. Perianal skin may become red, dry, and tender. patients are usually fatigued. Dysmotility may occur, even leading to psuedoobstruction and this may persist after treatment ceases. Other long term side effects include scarring.

 

Stephen Boyce

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Excellent!

 

I think your answers complement each other well.

 

Histological confirmation is essential, biopsy can be performed in the clinic or at the time of colonoscopy. Colonoscopy can help with tumour assessment and determine whether there are synchronous lesions.

Further staging will involve both CT and MRI. CT of the chest and abdomen will determine if there is metastatic spread. MRI of the pelvis is a better modality for staging the rectal tumour itself. The fixity of the tumour, that is how tethered the tumour is in the pelvis is an important characteristic, determined by the surgeon prior to surgery, this can be gauged in the clinic, some surgeons prefer to examine the patient and assess the tumour with the patient under anaesthetic. Blood tests may reveal the presence of anaemia or liver involvement.

 

As regards counselling the patient my own belief is that the patient always has the right to know. It is important the patient understands the implications of your findings. Often the news of cancer can be devastating so when breaking such news to a patient the presence of their family can be very helpful. Remember you do not have all the information yet, you must confirm the diagnosis and staging will allow you to give the patient more infomation about their disease, their prognosis and the treatment you propose.

 

The patient has a biopsy proven adenocarcinoma of the mid rectum. Colonoscopy does not show any other tumours. CT does not show any metastatic disease. The tumour feels mobile. The patient's case is discussed at the colorectal cancer multidisciplinary meeting. The tumour is staged radiologically at T3N1.What does this mean?

 

The oncologists propose giving the patient a short course of radiotherapy prior to you performing an anterior resection of the rectum. You see the patient in clinic and he is concerned, and puzzled, as to why he needs radiotherapy. What is your explanation? What are the advantages, and disadvantages for the patient?

Karen WHITE

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Fully investigating the tumour will provide information to allow the best management course to be planned as James describes below.

However we also need to remember to inform the patient +/- family.

The patient needs to understand what we have found and why we are still investigating - not only as it is their right, but also to ensure the possible outcome of not attending, and so letting the disease progress.

Ultimately the patient (or other) will need to consent for treatment.

Fully investigating will allow us to fully inform patient of prognosis of operating/ not as well as what the options we would offer.

This is not as relevant to this gentleman as he is fit and well, however with another patient with co-morbidities, they may decide not to have an intervention offered. As such at some point it would maybe be appropriate to stop investigating.

James EDWARDS

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Having performed the rigid sigi, I would send him to the phlebotomist for blood tests (most specifically looking for deranged liver function tests and abnormal calcium? mets to liver etc), and at the same time book him in for an urgent colonoscopy and biopsy.  Although we could probably biopsy this mass using a sigmoidoscope, it is important to visualise the lesion from all angles (which will also help in obtaining a satisfactory biopsy sample) and also to exclude any synchronous tumours.  Biopsy should be sent to path lab for histology and so forth.

 

Having performed the colonoscopy, the patient requires a CT chest/abdo/pelvis to image the extent of tumour invasion and identify any metastases.  However, MRI and PET CT are increasingly being used.  The advantage of MRI is that it gives high resolution images thus providing a very accurate description of local invasion.  It is most useful in identifying invasion into the mesorectal fascia, and thus is an important use of imaging prior to Total Mesorectal Excision.

 

Having got the results of Biopsy, Colonoscopy and CT/MRI, cases should be discussed at an MDT meeting to plan the most appropriate treatment course.

Stephen Boyce

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Hi Guys,

 

I am Stephen Boyce, I'll be helping Peter Lamb with the discussion board over the next two weeks.

 

You have certainly summarised the purpose of staging, that is to plan treatment and to estimate prognosis, the classification systems are general such as TMN and specific to different cancers such as Dukes'.

 

In practice how will do we go about staging suspected cancer?

 

Take the scenario of a 72 year old man referred by his GP with a history of altered blood per rectum. The patient is otherwise healthy, is not on any medication and has no relevant family history. The GP referred him urgently, concerned that he could feel a mass per rectum. You take a history, general exam is unremarkable but he has a mass 5cm from his anal verge. You visualise a tumour with the rigid sigmoidoscope.

 

What will you do next?

Deborah SANDHU

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Yes time is flying by!

 

I agree with Lisa; the purpose of staging is to determine the extent of spread of cancer. It is important because the stage is the most powerful predictor of survival, and decision on treatment is based on stage.

 

The most common staging system for solid tumours is the TMN system. It was devised in the 1940s and is well recognised globally. It is maintained by the UICC (International Union Against Cancer). To further elaborate on Lisa TAYLOR's post, the TNM system can be denoted by 'c' or 'p' before the stage ( eg. c T2N1M0).

 

'c' = clinical

'p' = pathological

 

Clinical stage is based on information gathered by clinically without histology. Pathological staging includes histology and is considered more accurate. Many cancers use TMN system routinely, including lung, bladder, prostate, breast, kidney.

 

There is also an overall staging system using Roman numerals. The staging is used slightly differently in different cancers. The bigger the number, the worse the prognosis. Stage II and III differ depending on the type of cancer.

 

Stage 0 - carcinoma in situ

Stage I - localised to one particular area only

Stage II and Stage III - locally advanced and/or involving local lymph nodes.

Stage IV - distant metastasis

 

Stage 0 and I are usually considered curable, and Stage IV is not.

 

There are other forms of staging such as Duke's staging for colorectal ca -

 

Duke A - invasion into but not through bowel wall

Duke B - through bowel wall

Duke C - involvement of lymphnodes

Duke D - metastasis

 

Other tumours adopt their own systems for prognosis; eg. FIGO for cervical and ovarian cancers, Breslow thickness for melanomas.

 

Lisa TAYLOR

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New topic already... this year is flying by...

The purpose of staging is to determine the spread of a tumour and therefore to allow an appropriate plan for treatment to be made. For example different degrees of local involvement may change the type of operation that should be performed. Local spread to nodes or distant metastases may indicate the need for adjuvant or neoadjuvant therapy such as chemotherapy or radiotherapy. Extensive disease may mean that a curative operation is not suitable and that palliative measures should be considered.

 

The most commonly used staging system for solid tumours is the TNM classifcation:

Each letter is followed by a number which denotes the extent of disease as outlined below.

 

T (1-4) - represents the size and degree of local invasion of the tumour, the exact meaning of the numbers depends on which solid tumour is being described but 1 is usually small with no invasion, while 4 would be a large tumour with local invasion.

 

N (0-3) - degree of spread to lymph nodes

N0: No lymph nodes

N1: Spread to the closest or small number of regional nodes

N2: Larger number of regional nodes

N3: Spread to distant nodes or extensive involvement of regional nodes

 

M (0/1) - presence of metastases

M0: No metastases

M1: Spread to distant organs, beyond lymph nodes

Peter Lamb

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Welcome to the discussion boards for surgical oncology. These will be run for two weeks by myself and other surgeons with an interest in surgical oncology. There has been a lot of medical oncology input into the suporting material and I hope this is helpful.

 

To start you off - What is the purpose of staging and what staging systems do you know for solid malignancies?

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