Rectal cancer

Rectal Cancer

Rectal cancer Part 1

What T stage rectal tumors can have sphincter sparing surgery versus abdominoperineal resection for
distal rectal cancer?

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T1 or T2

Rectal cancer Part 1
Rectal cancer

How many cm above the anal verge does the distal rectum comprise?

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6 cm

Rectal cancer
Rectal cancer

Which portions of the rectum can be managed with low anterior resection?

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Upper and middle 1/3

Rectal cancer
Rectal cancer

When can a short course of radiotherapy be considered prior to neoadjuvant concurrent chemoradiotherapy ?

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Bulky disease and metastatic debulking

Rectal cancer
Rectal cancer

Hoe does FOLFOX compared to FOLFOX + radiotherapy in the neoadjuvant setting?

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FOLFOX is inferior

Rectal cancer
Rectal cancer

What is the role of bevacizumab in the neoadjuvant setting for rectal cancer?

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No role

Rectal cancer
Rectal cancer

What is the role of irinotecan in the neoadjuvant setting for rectal cancer?

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No proven benefit

Rectal cancer
Rectal cancer

Which trials with 5-FU / oxaliplatin / Xeloda with or without radiotherapy have shown any benefit in the
neoadjuvant setting?

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ACCORD 12/0405 PROIGE2:
Pre-op FOLFOX/XRT – no change in outcomes
PETACC-6: pre- and post-op FOLFOX/XRT – no change in outcomes
NSABP trial R-04
XELOX vs FOLFOX vs Xeloda vs 5-FU pre-op + XRT = no change in outcomes

Rectal cancer
Rectal cancer

What is the role of oxaliplatin for neoadjuvant rectal cancer treatment?

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No role as there is no change in pathologic CR or change in APR conversion rate

Rectal cancer
Rectal cancer

What dose of Xeloda is used for concurrent chemoradiotherapy?

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825 mg/m2 every 12 hours 5/7 days per week for 6 weeks

Rectal cancer
Rectal cancer

Which 5-FU modality is best for concurrent chemoradiotherapy in rectal cancer?

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Infusional 5-FU is much better than bolus

Rectal cancer
Rectal cancer

Which chemotherapy is recommended alongside radiotherapy for rectal cancer?

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Cis-platinum or 5-FU

Rectal cancer
Rectal cancer

What are the long-term side effects of radiotherapy after TME surgery?

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High fecal incontinence, low sphincter pressure, low sexual function, sacral insufficiency fracture

Rectal cancer
Rectal cancer

How long should you wait after concurrent chemoradiotherapy before proceeding with surgery?

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6-8 weeks
After about 20 weeks, there is less of a correlation with overall survival

Rectal cancer
Rectal cancer

What is the difference in outcomes for concurrent chemoradiotherapy preoperatively versus
radiotherapy alone or chemotherapy alone for rectal cancer?

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Concurrent chemoradiotherapy is superior to both With regards to recurrence risk, sphincter sparing potential, and pathologic complete response rates

Rectal cancer
Rectal cancer

Which 2 postoperative variables determine recurrence risk of rectal cancer?

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Tumor regression grade (TRG) and lymph node status

Rectal cancer
Rectal cancer

Which study group showed the superiority of preoperative chemoradiotherapy in rectal cancer?

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German rectal cancer study group

Rectal cancer
Rectal cancer

What is the role of observation after concurrent chemoradiotherapy rather than surgery?

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Retrospective studies show same efficacy in some patients but no randomized trials therefore NCCN
recommendeds surgery

Rectal cancer
Rectal cancer

What are the adjuvant chemotherapy treatment options for rectal cancer?

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FOLFOX, 5-FU + leucovorin, Xeloda

Rectal cancer
Rectal cancer

What options do patients with initial lower one third rectal tumors have to avoid abdominoperineal
resection?

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Preoperative concurrent chemoradiotherapy to try and convert to LAR

Rectal cancer
Rectal cancer

Which rectal cancer lesions can be treated with local excision only?

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Clinical T1 with pathologic T1 and no evidence of lymphovascular invasion, involved margins, or other
high risk features

Rectal cancer
Rectal cancer

How centimeters from the anal verge defines lower one third for an abdominoperineal resection?

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5 cm

Rectal cancer
Rectal cancer

Does CEA monitoring matter for rectal cancer?

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Yes

Rectal cancer
Rectal cancer

What imaging is required preoperatively for rectal cancer?

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Ultrasound or MRI even for a polyp

Rectal cancer
Rectal cancer

With tumor size for rectal cancer confers poor prognosis?
5 cm

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Rectal cancer
Rectal cancer

Does the 5-fluorouracil plus radiotherapy regimen for neoadjuvant rectal cancer management include a
bolus?

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No

Rectal cancer
Rectal cancer

What is the role of oxaliplatin for rectal cancer?

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None

Rectal cancer
Rectal cancer

What did the German clinical trial show for neoadjuvant versus adjuvant concurrent chemoradiotherapy
for rectal cancer?

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Recurrences 6% with neoadjuvant versus 13% with adjuvant

Rectal cancer
Rectal cancer

What neoadjuvant approach is used in Europe for rectal cancer?

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5 x 5 radiotherapy.

Rectal cancer
Rectal cancer

Which 5-fluorouracil regimen is used for neoadjuvant rectal cancer?

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Xeloda plus radiotherapy

Rectal cancer
Rectal cancer

Does neoadjuvant treatment for rectal cancer change overall survival?

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Reduces local recurrence but no change in overall survival

Rectal cancer
Rectal cancer

Which regimen is used for neoadjuvant rectal cancer management?

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Nightly 5-fluorouracil plus radiotherapy

Rectal cancer
Rectal cancer

How much radiotherapy is given with rectal cancer treatment?

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45 Gy +5 Gy boost

Rectal cancer
Rectal cancer

What neoadjuvant option is used in Europe for rectal cancer?

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Short course of radiotherapy without chemotherapy
In the United States concurrent chemotherapy and radiotherapy

Rectal cancer
Rectal cancer

Which rectal cancer patients should get neoadjuvant concurrent chemoradiotherapy?

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Distal 1/3 tumors with plan to convert to low anterior resection even if it’s cT2

Clinical T3 and clinical T4
Presence of N1 or N2 disease

Rectal cancer
Rectal cancer

Which surgery is used for rectal cancers with local bowel or organ invasion?

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Pelvic exoneration

Rectal cancer
Rectal cancer

What are 2 options for rectal cancer patients with lower 1/3 tumors who don’t want abdominoperineal
resection?

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Local excision if it’s a small tumor
Neoadjuvant chemoradiotherapy or isolated radiotherapy to down stage

Rectal cancer
Rectal cancer

What preoperative CEA level confers a worse prognosis for rectal cancer?

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Greater than 5 ng/mL

Rectal cancer
Rectal cancer

How do you manage a clinical T1 rectal cancer that ends up being pathological T2,3,4?

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Pathological T2 – surgery if no evidence of distant spread
Pathologic T3 or T4 – consider adjuvant chemotherapy +/- radiotherapy

Rectal cancer
Rectal cancer

What criteria for rectal polyps allow for endoscopic resection without further surgical intervention or
chemotherapy / radiotherapy?

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Pathologic T1 only, no poorly differentiated features, negative margins, no lymphovascular invasion, no
invasion past submucosa, not sessile polyp

Rectal cancer
Rectal cancer

How do you manage squamous cell carcinoma of the rectum?
Same as anal cancer, surgery was is required as first-line treatment, concurrent chemotherapy
radiotherapy

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Rectal cancer
Rectal cancer

Is there a role for surgery in metastatic rectal cancer?

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Yes

Rectal cancer
Rectal cancer

If patients get low anterior resection first without chemotherapy, is there still a role for adjuvant
chemotherapy?

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Yes

Rectal cancer
Rectal Cancer Part 2

Is CEA elevated in squamous cell rectal cancer ?

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Rarely, 25% pre-op

Rectal Cancer Part 2
Rectal Cancer

Does SCC of the rectum have better median OS versus anal SCC ?

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No, inferior

Rectal Cancer
Rectal Cancer

Is SCC of the rectum more common in men or women ?

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Women

Rectal Cancer
Rectal Cancer

Is there a role for surgery in metastatic rectal cancer?

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Yes

Rectal Cancer
Rectal Cancer

If patients get low anterior resection first without chemotherapy, is there still a role for adjuvant
chemotherapy?

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Yes

Rectal Cancer
Rectal Cancer

What options do patients with initial lower one third rectal tumors have to avoid abdominoperineal
resection?

View Answer
View Question

Preoperative concurrent chemoradiotherapy to try and convert to LAR

Rectal Cancer
Rectal Cancer

Which rectal cancer lesions can be treated with local excision only?

View Answer
View Question

Clinical T1 with pathologic T1 and no evidence of lymphovascular invasion, involved margins, or other
high risk features

Rectal Cancer
Rectal Cancer

How many centimeters from the anal verge defines lower one third for an abdominoperineal resection?

View Answer
View Question

5 cm

Rectal Cancer
Rectal cancer

Does CEA monitoring matter for rectal cancer?

View Answer
View Question

Yes

Rectal cancer
Rectal cancer

What imaging is required preoperatively for rectal cancer?

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Ultrasound or MRI even for a polyp

Rectal cancer
Rectal cancer

What tumor size for rectal cancer confers poor prognosis?

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5 cm

Rectal cancer
Rectal cancer

Does the 5-fluorouracil plus radiotherapy regimen for neoadjuvant rectal cancer management include a
bolus?

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View Question

No

Rectal cancer
Rectal cancer

What is the role of oxaliplatin for rectal cancer?

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View Question

None

Rectal cancer
Rectal cancer

What did the German clinical trial show for neoadjuvant versus adjuvant concurrent chemoradiotherapy
for rectal cancer?

View Answer
View Question

Recurrences 6% with neoadjuvant versus 13% with adjuvant

Rectal cancer
Rectal cancer

What neoadjuvant approach is used in Europe for rectal cancer?

View Answer
View Question

5 x 5 radiotherapy.

Rectal cancer
Rectal cancer

Does neoadjuvant treatment for rectal cancer change overall survival?

View Answer
View Question

Reduces local recurrence but no change in overall survival

Rectal cancer
Rectal cancer

Which regimen is used for neoadjuvant rectal cancer management?

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View Question

Daily 5-fluorouracil plus radiotherapy

Rectal cancer
Rectal cancer

How much radiotherapy is given with rectal cancer treatment?

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45 Gy +5 Gy boost

Rectal cancer
Rectal cancer

When can one consider induction chemotherapy prior to neoadjuvant chemoradiotherapy for rectal
cancer?

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To debulk if there is a high chance of having R1 resection

Rectal cancer
Rectal cancer

What surgery is required if patients have local organ invasion?

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Multi-visceral resection AKA pelvic exoneration

Rectal cancer
Rectal cancer

What are the local excision techniques for rectal cancer?

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Transanal excision
Transanal endoscopic microsurgery

Rectal cancer
Rectal cancer

What is ideal chemoradiotherapy / surgical approach for metastatic rectal cancer with resectable
metastases?

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Any variation should be attempted as long as it is feasible

Rectal cancer
Rectal cancer

What percentage of lymph nodes are positive despite pathologic T0 assessment status post concurrent
chemoradiotherapy?

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12%

Rectal cancer
Rectal cancer

What is the role of local excision versus abdominoperineal resection in rectal cancer after
chemoradiotherapy?

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No randomized trials therefore recommend full surgery

Rectal cancer
Rectal cancer

Why is the dentate line important?

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Changing nerve and vascular supply above and below the line

Rectal cancer
Rectal cancer

What difference is there between the skin above and below the anorectum?

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Above – without hair follicles
Below – presence of hair follicles

Rectal cancer
Rectal cancer

Which surgical approach can spare patient the complications of a low anterior resection?

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Total mesorectal excision

Rectal cancer
Rectal cancer

Which structures can rectal cancer adhere to?

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Prostate, bladder, sacrum, pelvic sidewall

Rectal cancer
Rectal cancer

What 2 surgeries are performed for rectal cancer?

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Low anterior resection and abdominoperineal resection

Rectal cancer
Rectal cancer

What determines if there will be a benefit to adjuvant chemotherapy if patients are given concurrent
neoadjuvant chemoradiotherapy?

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Pathologic T0, T1, T2 will show an improvement in overall survival while pathologic T3 and T4 do not
shown any improvement in overall survival

Rectal cancer
Rectal cancer

How many weeks before surgery should bevacizumab be held for rectal cancer?

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6 weeks

Rectal cancer
Rectal cancer

What adjuvant treatment should be offered when rectal cancer patients are upstaged after initial
surgery without neo-adjuvant chemoradiotherapy?

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Concurrent chemoradiotherapy

Rectal cancer
Rectal cancer

What distinguishes a T2 from a T3 rectal cancer?

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T2 = muscularis propria invasion
T3 = past the muscularis propria

Rectal cancer
Rectal cancer

What adjuvant therapy is needed for a pathologic T2 N0 M0 rectal cancer?

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None

Rectal cancer
Rectal cancer

What are some palliative options for symptomatic rectal cancer?

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Diverging stoma, palliative resection, stent placement, laser ablation, electrofulgration

Rectal cancer
Rectal cancer

What are the criteria for superficial excision of clinical T1 lesions?

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No lymphovascular invasion, no poorly differentiated features, only submucosal invasion, no evidence of
distant metastases, up to 3 cm in diameter, mobile, non-fixed, greater than a 3 mm margin, less than
30% bowel lumen circumference

Rectal cancer
Rectal cancer

When can you consider neoadjuvant chemotherapy without radiotherapy for rectal cancer?

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Never

Rectal cancer
Rectal cancer

What neoadjuvant option can be considered for bulky T4 tumors?

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2 rounds of FOLFOX and then concurrent chemotherapy radiotherapy

Rectal cancer
Rectal cancer

What 3 criteria are evaluated with secondary imaging such as RUS/MRI for rectal cancer?

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Lymph node involvement, circumferential resection margins, depth of tumor invasion

Rectal cancer
Rectal cancer

What imaging modality is required pre-operatively for rectal cancer?

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MRI or rectal ultrasound

Rectal cancer
Rectal cancer

Is there a role for CEA monitoring in rectal cancer post-operatively?

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Yes, post-operative elevation is concerning for persistent disease

Rectal cancer
Rectal cancer

Which fascia is considered high risk and should also prompt concurrent chemoradiotherapy for rectal
cancer?

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Mesorectal fascia within 1-2 mm

Rectal cancer
Rectal cancer

If patients have T1-T2 rectal cancer and highly suspicious lymphadenopathy, is the treatment option
surgery or concurrent chemoradiotherapy?

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Concurrent chemoradiotherapy

Rectal cancer
Rectal cancer

What is the most important determinant in TNM staging for predicting recurrence of rectal cancer?

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Depth of extramural invasion greater than or equal to 5 mm

Rectal cancer
Rectal cancer

Should clinical T3 N0 patients receive radiotherapy during chemotherapy?

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Yes because high percentage are under-staged because of imaging limitations

Rectal cancer
Rectal cancer

What are the features of T3 and T4 rectal cancer?

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T3 tumors pass the muscularis propria and invade into the peri-colorectal tissue
T4 tumor penetrate to the surface of the visceral peritoneum

Rectal cancer
Rectal cancer

What are some reasons why abdominoperineal resection is so morbid?

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Permanent colostomy bag, sexual dysfunction, bladder dysfunction

Rectal cancer
Rectal cancer

What are some indications for concurrent chemoradiotherapy for distal rectal cancer?

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T3 and T4 disease
T1 and T2 with notable lymph nodes on MRI or ultrasound
Other clinical features that make abdominoperineal resection necessary

Rectal cancer
Rectal cancer

What is another option for abdominoperineal resection for distal rectal cancer?

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Concurrent chemoradiotherapy with or without sphincter sparing surgery

Rectal cancer
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