BeyHealth Quarterly Journal (BHQJ) BHQJ 2018: 001:1 (May 2018) - Page 28

CLINICAL UPDATE • • • • • • Radiotherapy CPD UPDATE approach, as this permits selection of patients Adjuvant radiotherapy has no benefit in colon The exact cause of bowel cancer with rapidly progressive disease who are cancer. It is given in rectal cancer to reduce the is unknown but most arise from unlikely to benefit from surgery. rate of local recurrence or possibly ‘downstage’ benign polyps or adenomas that the disease (down-sizing to increase the have undergone genetic mutation Radiofrequency Ablation (RFA) chances of successful surgical clearance). It triggered by environmental factors Radiofrequency energy has emerged as a may be given pre or post-operatively, either as 90% of colorectal cancers are useful modality to ablate in-situ liver metastases a short (5 days) or long (4-6weeks) course ‘sporadic’ or of unknown cause. where the lesions are considered irresectable treatment. There is good evidence from FAP polyps typically progress to or in selected cases, in combination with liver randomised cancer in the early twenties and resection. preoperative radiotherapy for rectal cancer administered percutaneously under general anaesthesia and radiological control by expert trials that short-course This form of treatment is cause death before age 30 significantly reduces local recurrence and Patients with FAP require surgery improves survival, but toxicity attributed to to remove the whole colon once radiologists in highly specialised units. Current therapy has reduced its popularity. Long course these polyps appear evidence indicates that RFA alone does not pre-operative radiotherapy is advocated for Treatment modalities for colorectal provide survival benefit comparable to liver patients with locally advanced rectal cancers cancer include surgery, radiotherapy resection. for the purpose of ‘downstaging’ the disease. and chemotherapy depending on Long course post-operative radiotherapy the type, site and stage of disease Palliative Care where there are bad prognostic indicators for Screening for colorectal cancer Patients with disseminated colorectal cancer, local recurrence (lymphovascular invasion, prevents disease progression and irresectable primary tumours unresponsive to poorly differentiated tumours and positive improves prognosis chemoradiation are referred to the palliative circumferential margins) following curative care team. Symptom relief with a variety of resection with the proviso that patient did NOT drugs is the primary goal of palliation. receive pre-operative radiotherapy. Infrequently, surgery is indicated in the form of a debulking or bypass procedure. Chemoradiotherapy Combination therapy in the form of Screening chemo-radiation is based on the Screening for colorectal cancer offers the concept that cytotoxic agents opportunity to prevent the disease developing sensitise tumour cells to or to improve prognosis by treating the downstaging by radiation. This premalignant (polyps) and early stage disease. form of neo-adjuvant therapy There is good evidence from randomised trials (given pre-operatively) is expected that screening for colorectal cancer with faecal to increase in popularity particularly occult blood testing saves lives and amounts with the development of newer to a 15-18% reduction in cumulative mortality. more Furthermore, 43% survival benefit was shown effective chemotherapy agents. Fig 4: anastomosis for left sided lesion using Sphincter saving operation for low rectal cancer with colo-pouch anal 28 flexible sigmoidoscopy. However, Liver R esection colonoscopy remains the gold standard and Hepatectomy for colorectal liver should metastasis is associated with a gastroenterologist / gastrointestinal surgeon five-year survival of about 30%. trained to complete the examination (caecal Generally, four intubation with photographic evidence) and to metastases confined to one lobe of recognise normal from abnormal findings. An the liver may be amenable to incomplete surgical catastrophic for the patient, so it is important less than resection, but this be undertaken examination by is qualified potentially indication has been extended in to interrogate the operator regarding their the hands of experienced liver experience, how many procedures they have surgeons. However, the timing of performed previously and their complication surgery Fig 5: in the screened population of a randomised trial Left hemicolectomy and colo-rectal remains controversial, rates. It is not customary in Nigeria to question whether hepatectomy should be a so-called “expert”. However, in view of the synchronous with resection of the high stakes involved, I would advise that the bowel primary or, perhaps delayed clinician for three months prior to re-staging addresses your concerns without resorting to that calmly (and satisfactorily) of the disease. In Europe, most irritation, anger or self-justification ought indeed surgeons to be the doctor of choice. favour a delayed | MAY 2018 | Issue 1