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Rectal Cancer Patient Summary and Treatment

This document summarizes a 49-year-old female patient with a rectal cancer. She has a uT3N1Mo mid-rectal cancer and comorbidities including arthritis. Her treatment plan involves pre-operative chemoradiation with Xeloda and intensity-modulated radiation therapy to the rectum and pelvic lymph nodes. She is experiencing some minor side effects but is tolerating the treatment well. Rectal cancer has risks of spreading locally and metastasizing to distant sites like the liver and prognosis depends on disease stage.

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231 views35 pages

Rectal Cancer Patient Summary and Treatment

This document summarizes a 49-year-old female patient with a rectal cancer. She has a uT3N1Mo mid-rectal cancer and comorbidities including arthritis. Her treatment plan involves pre-operative chemoradiation with Xeloda and intensity-modulated radiation therapy to the rectum and pelvic lymph nodes. She is experiencing some minor side effects but is tolerating the treatment well. Rectal cancer has risks of spreading locally and metastasizing to distant sites like the liver and prognosis depends on disease stage.

Uploaded by

api-448999672
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  • Patient Summary: Provides an overview of patient demographics and current treatment details.
  • Past Medical History: Lists patient's previous medical conditions and diseases.
  • Familial History: Discusses the family medical history, including genetic risks.
  • Past Social History: Examines patient's social habits and lifestyle factors affecting health.
  • Rectum Anatomy and Physiology: Details the anatomical structure and physiological function of the rectum.
  • Signs and Symptoms: Describes common symptoms and signs on presentation.
  • Diagnosis: Outlines diagnostic procedures and tests conducted for rectal cancer.
  • Colo-Rectal Epidemiology: Presents epidemiological data concerning colorectal cancer.
  • Rectum Etiology: Explores causes and risk factors associated with rectal cancer development.
  • Rectum Lymph Drainage: Discusses lymphatic drainage paths related to rectal cancer.
  • Rectal Histopathology: Reviews histological findings typical in rectal cancer cases.
  • Rectal Staging: Explains the staging systems used in categorizing rectal cancer progression.
  • Treatment Options: Outlines the various treatment strategies available for rectal cancer.
  • Patient Treatment Plan: Contains detailed information on the patient's individualized treatment regimen.
  • Treatment Parameters: Specifies the technical and procedural parameters for treatment delivery.
  • Potential Side Effects: Lists potential and observed side effects from treatments administered.
  • Prognosis and Survival: Details statistical projections for survival based on stages of cancer.
  • Metastatic Risks: Explores risks and characteristics of metastatic spread in rectal cancer.
  • References: Lists the academic references and sources consulted in creating the document.
  • Questions: This page invites any potential queries or discussions related to the presentation.

Rectal CA

Ryan Kisamore
Patient Summary
• Female Patient aged 49 with a uT3N1Mo rectal cancer.
 Tumor Location: Mid-Rectum

• Treatment Site: The James Vault

• Current Medications:
 Outpatient: Calcium Carbonate-Vitamin D, Capecitabine
 Before RT: Etanercept, Fluticasone, Ibuprofen, Multi-Vitamin, Omega-3 Fatty Acids

• No Abnormal Physical Findings.

• Tumor found after Colonoscopy.

• Unable to Palpate Tumor during DRE


Past Medical History
• Inflammatory Arthritis

• Osteoarthritis

• Rheumatoid Arthritis

• Sjogren’s Disease
Familial History
• Mother:
 History of Caner, unspecified.

• Father:
 Diabetes
 Hypertension
 Lipid Disorder

• No significant history from brother.


Past Social History
• History of Smoking; Quit around 27 years ago.
 1.25 Packs per Year

• Patient claims no use of smokeless tobacco.

• Drinks Socially; about 3.0 oz weekly

• No drug use.
Rectum Anatomy and Physiology
• Begins at around the 3rd Sacral Vertebrae at the termination of the Sigmoid
Colon.

• Consists of 3 Valves; Tumor location in these valves plays ae huge role in


treatment options.
 Superior
 Middle
 Inferior

• Terminates at the Anal Canal, which is the terminal inch of the GI Tract.
Signs and Symptoms
• Common:
 Rectal Bleeding
 Any abnormal change in bowel habits
 Pencil Thin Stool
 Constipation
 Diarrhea
 Tenesmus

• Patient Presented with Rectal Bleeding at time of diagnosis.

• Karnofsky Scale 100

• Denies any other issues.


Diagnosis
• Digital Rectal Exam • Patient’s tumor found following
• Sigmoidoscopy presentation of rectal bleeding which
prompted at colonoscopy.
 Bowel MUST be empty
• Colonoscopy found localized polypoid
• Colonoscopy mass 5cm from the anal verge.
 Allows for removal of Polyps and for
pictures to be taken. • Tumor was not palpable during DRE.
• Virtual CT Colonoscopy • Biopsy showed fragments of
 Good for Visualization of entire colon but adenocarcinoma.
you are unable to remove any Polyps
• Surgical Resection on tumor in
• Barium Enema February after Chemo-Radiation
Course.
• Standard CT Scan
Colo-Rectal Epidemiology
• Colo-Rectal Cancer is the 3rd most common cancer seen in the United States
 It is also the 3rd leading cause of death (depending on where you look this could be
2nd).

• A typical age at presentation is 60, this could possibly be due to genetics and
the lifestyle wears that come with age.

• Incidence has been steadily declining since 1980 in both men and women
over the age of 50.

• Can be divided into cancers of the Colon, Rectum, or Anus


Rectum Etiology
• A diet high in fat and low in fiber increases patient risk.
• Genetic Potential
 Familial Adenomatous Polypsosis (FAP) seen in a first degree relative shows
increased risk of development of Rectal CA.
 Presents due to a mutation in the APC Gene on chromosome 5 or MUTYH on chromosome 1

• Adenomatous Polyps
 Growths that arise from the mucosal lining and protrude into the lumen of the
bowel.

• Inflammatory Bowel Disease


 Chronic Ulcerative Colitis
 Crohn’s Disease

• Hereditary Nonpolyposis Colorectal Syndrome


 Aka Lynch Syndrome
Rectum Lymph Drainage
• Tumor location along the rectum will show a variance of where lymph will drain.
PET CT may be utilized to confirm any drainage.
• Superior Half
 Peri-Rectal
 Sacral
 Sigmoidal
 Inferior Mesenteric

• Inferior Half
 Peri-Rectal
 Internal Iliac
 Hypogastric
 External Iliac

• If Tumor is low or has anal involvement the inguinal nodes may also be
involved.
Rectal Histopathology
• Over 90% of Rectal Cancers will present as Adenocarcinoma

• Other types seen include:


 Carcinoid
 Leiomyosarcoma
 Lymphoma
 Squamous Cell Carcinoma
 As you get more distal within the rectum the chance for squamous cell increases.

• Rectal CA has a possibility of directly invading adjacent pelvic structures


 Systemic drainage to Lung is also possible

• It is common for cancer of the colon and rectum to spread to the Liver via
Portal Drainage.
Rectal Staging
• Duke’s Staging is most commonly used.
 A – tumor invades submucosa or muscularis propria (T1 & T2)
 B – tumor invades through muscularis propria into subserosa or perforates the visceral
peritoneum or invades other organs (T3 & T4)
 C – Mets to pericolic or perirectal lymph nodes or pelvic lymph nodes

• AJCC System is also used along side Duke’s.

• Patient Stage
 uT3 N1 M0
 Duke’s Stage 3
Duke’s Staging vs AJCC
Treatment Options
• Stage I
 Local Excision

• Stage II
 Local excision with adjuvant Chemoradiation.

• Stages II and III if tumor is resectable


 Pre-Op Chemotherapy, 5-FU, with Radiation Therapy. Follow with a
transabdominal resection can continuation of adjuvant 5-FU Chemotherapy.

• Stage III unresectable


 5-FU Chemotherapy along with Radiation Therapy
Patient Treatment Plan
• Technique: 3D Conformal: 3 Fields, 1 Reduced Field, Dynamic Wedges; 10-
OUT and 60-IN

• Prescription Dose: 45 Gy; 50.4 Gy in


 25 Fractions at 180 cGy per fraction.
 Boost of 540 cGy in 3 fractions at 180 cGy per fraction.
 Total Dose of 5040 cGy.

• Primary RT is timed with chemotherapy using Xeloda. (BID)

• Machine energy: Mixed Mode for Primary and Boost

• Imaging:
 CBCT for the first 3 days, followed by twice weekly
 If shifts greater than 1.2 cm, MD must be called.
Treatment Parameters
• Patient Prone on Belly Board
 Indexed @ H4B and F1B
 Board Number: 23
 Head Rest: 11

• Knee Sponge used for Ankle Support

• Patient must have empty Bowel and Rectum daily.

• Field Design and arrangement( what we are treating and blocking)


 Number of fields and their angles

• Organs at Risk
 Large Bowel, Small Bowel, Bladder, Heads of the Femurs.
Potential Side Effects
• Acute • Patient Presented with:
 Diarrhea  Persistent Mild Fatigue
 Abdominal Cramping and Bloat  Minor Bleeding during Bowel Movements.
 Bloody and Mucous Discharge  Intermittent Nausea
 Dysuria  Minor Skin Erythema
 Fatigue  Occasional Discomfort with Urination

• Chronic • She tolerated treatment very well.


 Persistent Diarrhea
 Proctitis
 Urinary Incontinence
 Damage to Small Bowel → leads to enteritis
 Adhesions
 Obstuction
Prognosis and Survival
Metastatic Risks
• Tumors can spread via direct extension, lymphatics, and hematogenous
spread.
 Direct extension is most often in a radial fashion into the bowel wall.
 Hematogenous Spread is often to the liver followed by the lung.

• If tumor extends past the bowel wall and into the abdominal cavity spread
via Peritoneal Seeding may also occur.

• Tumor Cells may also implant themselves during surgery.

• Patient showed no incidence of Metastatic Growth outside of Tumor Volume


and Nodal Involvement.
References
• Bussman-Yeakel L., In: Washington, CM & Leaver, D. Principles and
Practice of Radiation Therapy. 4th Edition. St. Louis, MO: Elsevier, Inc;
2016:822-836.

• Hackworth, Ruth. Colorectal CA. Present at: RADSCI 3574 - Applied


Radiation Oncology 2; January 2018; Columbus, Ohio
Questions?

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