Appendix to Anus Flashcards

Question

Causes of pseudoobstruction

Answer 1

Opiates Neuroleptic meds Retroperitoneal haematoma Autonomic disruption (true Ogilvie's) DM Severe metabolic illness Electrolyte disturbance Hyperparathyroidism Parkinsonism Scleroderma Systemic lupus erythematosis Uraemia

Answer 2

Signs and symptoms consistent with a large bowel obstruction without mechanical cause. Multiple underlying aetiologies and often multifactorial. Results ultimately from an imbalance of sympathetic and parasympathetic nervous supply to the colon. Likely related to sympathetic overactivity vs parasympathetics.

Answer 3

First: Neostigmine * 2.5mg IV over 3 mins * Bradycardia- cardiac monitoring on and atropine ready Second: Spinal epidural * Block sympathetics- effective Third: Colonoscopy * Caution re: insufflation and perforation, * Higher recurrence rates Operate if needed or unable to resolve

Answer 4

Clinical features * Bleeding and diarrhoea more prominent than Crohn's * Perianal disease rare Microscopy * Inflammation of mucosa and submucosa only * Crypt abscesses (also seen in Crohn's and infection) Endoscopic * Continuous * Hyperaemic friable mucosa * (ulceration is actually rare)

Answer 5

Prolonged UC (0%\<10 years, 60%\>20 years) Proximal to splenic flexure LBO

Answer 6

Joints * Arthritis * Ankylosing Spondylitis Skin * Erythema Nodosum * Pyoderma Gangrenosum Eyes * Primary * episcleritis * uveitis * Secondary * cataracts (steroid) Hepatic * Primary Sclerosing Cholangitis Manifestations which may respond to surgical management of the affected bowel: * Skin * Eye * Arthritis Manifestations which do not respond to surgical management affected bowel: * Ankylosing spondylitis * PSC * colitis often less severe with PSC associated phenotype but colon cancer risk is 5x that of UC alone

Answer 7

Mild-moderate proctitis- * 5ASA, topical, * If resistant add oral 5ASA initially More proximal involvement- * enema and oral Refractory- steroids, cyclosporin, biologics Severe colitis- * Steroid for 3 days- * if no/inadequate response- either cyclospirin, infliximab or surgery * if rescue therapy given then surgery if no/inadequate response by further 4-7 days NB methotrexate is out

Answer 8

* Bloody diarrhoea at least 6x per day AND any of: * Pulse \>90 * Temp\> 37.8 * Hb \<105 * ESR \>30 * CRP\>30

Answer 9

Acute * Toxic megacolon * Non response to therapy * Bleeding Chronic * Dysplasia * Stricture (presume malignancy) * Cancer

Answer 10

Smoking Jewish descent Away from the equator (Scotland, Scandinavia) Prev. Abx use OCP FHx Mycobacterium paratuberculosis?

Answer 11

Anti TNF-a

Answer 12

Antibiotic use (esp Clinda) Hospitalisation Age Comorbid illness Acid suppression IBD Cirrhosis GI surgery Immunosuppression Obesity

Answer 13

Gram positive spore forming, toxin producing anaerobic bacillus

Answer 14

Interruption of normal flora Colonisation Toxin production * Toxin A (enterotoxin) and B (cytotoxin) enter colonocytes and interrupt Rho GTPases * Toxin A also direct neutrophil recruitment and activation of macrophages Colonocyte death and direct toxin A effects lead to inflammation * mediated by IL-1,6,8, TNF, substance p causing: Further colitis and colonocyte death. Toxin B is a potent cytotoxin, ? necessary to pathogenesis

Answer 15

By depth and cause Partial thickness * transient * stricturing Full thickness with gangrene Occlusive Non occlusive

Answer 16

Normal Colonocyte * APC/Beta-catenin (tumour suppressor) Tumour Initiation (abnormal crypt foci and early adenoma) * KRAS Adenoma formation and growth * DCC/SMAD4/SMAD2 Late adenoma * p53 Carcinoma

Answer 17

Tumour suppressor gene Chromosome 5q21 APC mutation leads to increased intracytoplasmic pool of Beta Catenin and Wnt signalling pathway disruption It is the underlying genetic mutation in FAP and the initial mutation in the sporadic adenoma-carcinoma pathway in 80%

Answer 18

Original description is FAP with extraintestinal manifestations * Mandibular osteomas * Desmoids * Periampullary neoplasms More recently recognised associations * papillary thyroid cancer * medulloblastoma * gastric fundic gland polyps

Answer 19

Autosomal recessive polyposis and cancer Mutation in MYH gene encodes oxidative repair of DNA genes Mutation promotes APC mutation MAP phenotype is variable

Answer 20

Tumour Supressor gene Induces either: * Apoptosis or: * G1 cell cycle arrest allowing DNA repair- in response to cellular injury

Answer 21

Lynch syndrome Autosomal dominant, 80% penetrance Accounts for 3% of colon cancers Mutation in DNA MMR genes * MLH1, PMS2, MSH2, MSH6, EPCAM * MLH1 and MSH2 account for 90% of detected known mutations 50% of clinical Lynch syndrome (on family history) will not have an identifiable genetic mutation MMR defects induce microsatellite instability * Errors in S phase of DNA replication- resulting in vast increase in rate of mutation Associated malignancies- * Classically * Colon * ovarian * endometrial * urothelial * gastric. * Others * HPB * gliomas * sebaceous skin cancers * Breast cancers * in some studies but this finding is variable

Answer 22

Breach of the muscularis mucosae

Answer 23

Use pure carbon black Polyps \>1cm- 1 spot Worrisome polyp (suspect malignancy)- 3 spots Cancer- 3 spots Not usually caecum/ascending (caecum is reliable endoscopic landmark) or rectum

Answer 24

Haggit 4 SM2-3 Positive margin LVI + Width of cancer \>4mm Depth of cancer \>2mm Tumour budding Cribriform Poor differentiation

Answer 25

100% penetrance Autosomal Dominant Average age of presentation with new diagnosis 29 Average age of Malignancy 39

Answer 26

No firm guidelines, initial endoscopy at ~30 years Suggest endoscopy based on Spigleman stage * Stage 0: Every four years * Stage I: Every two to three years * Stage II: Every one to three years * Stage III: Every 6 to 12 months * Stage IV: In the absence of surgery (duodenectomy), surveillance every six months

Answer 27

Rare Autosomal dominant Phenotypic variant of HNPCC At least: * 1 sebaceous skin tumour and: * 1 visceral tumour * colon * endometrial * urothelial * ovarian Same Mutations as HNPCC * MLH1 * PMS2 * MSH2 * MSH6

Answer 28

Results from hypermethylation of MLH1 promoter region and is strongly associated with the BRAF V600E mutation. * Detection of BRAF V600E almost completely excludes lynch syndrome

Answer 29

True Lynch have favourable stage for stage prognosis MSI high (MMR deficient) cancers are resistant to 5-FU based chemotherapy and there is no or little survival advantage MSI high cancers may be sensitive to irinotecan, mytomycin and checkpoint inhibitors e.g pembrolizumab

Answer 30

Rare autosomal dominant syndrome Congenital hamartomatous polyposis of GI tract and hyperpigmentation of buccal mucosa, lips and digits STK11 tumour supressorgene 2-10% GI cancer risk (panenteric) Associated cancers * GI * Breast * Cervix * Testicle * Ovary * Pancreas

Answer 31

Rare Autosomal dominant High penetrance SMAD4 tumour suppressor Variable phenotype Predominantly hamartomas but also adenomas and increased colorectal cancer risk Colonic and extraintestinal cancers

Answer 32

T1: tumor invades submucosa T2: tumor invades muscularis propria T3: tumor invades through the muscularis propria into the pericolorectal tissues T4: * T4a: tumor invades through the visceral peritoneum * including gross perforation of the bowel through tumor * T4b: tumor directly invades or adheres to other adjacent organs or structures

Answer 33

* CEA * MSI * Tumour deposits * Satellite deposits (? obliterated LN's) * Tumour regression grade * CRM * Resection margin * Perineural invasion

Answer 34

Multiple scoring systems, AJCC advocates/uses the: * Modified Ryan tumour regression score * 0- No viable tumour cells (complete response) * 1- Single cells or rare small groups of cells (near complete response * 2- Residual cancer with evident regression (desmoplastic response) * 3- No evident response

Answer 35

From SEER 1998-2005 I- 90% II- 75% III- 50% IV- \<5% One suspects outcomes have improved from these though

Answer 36

Stage 2 and above with at least 1 poor prognostic factor should be considered * Treatments are 5F-U based * Either infusiional 5-FU or capecitabine * Capecitabine may infact be superior as it is activated by an enzyme universally overexpressed by tumour cells * addition of Oxaliplatin (FOLFOX) or Irinitecan (FOLFIRI) or both (FOLFIRINOX) is beneficial in stage III and IV disease * possibly in stage II also Consider MoABs * Bevacizumab- VEGF inhibitor * Cetuximab- EGFR inhibitor * Not in RAS gene mutations * Not in BRAF mutations Checkpoint inhibitors * Pembrulizumab, nivolumab * Only in dMMd/MSI-h cancers

Answer 37

Heald et al descrided tumour deposits 4cm distal to the cancer, more contemporary series show 3cm. 5cm is consider the appropriate distal margin

Answer 38

Pubococcygeus Ileococcygeus Puborectalis

Answer 39

Anal resting and squeeze pressures * Manometry Anal reflexes Pudendal nerve conduction velocities electromyographic muscle fibre recruitment

Answer 40

Age Female gender (6:1) Chronic constipation More common in young institutionalised psychiatric men also Parity deserves a mention but may not actually be that important (35% nulliparous)

Answer 41

Concentric mucosal rings vs deep radial grooves

Answer 42

Anteriorly based 4-12cm from anal verge 1/3 related to fullthickness rectal prolapse * Respond well to surgery If related to mucosal prolapse- less well Topical 5ASA, pelvic floor physio and dietary management resolve most episodes

Answer 43

Rare Protozoan parasite disease *Trypanosoma Cruzi* South america Denervation of both myenteric (Auerbach) and submucosal (Meissner) plexuses secondary to immune mediated cross reactivity Oesophageal (differential for Achalasia) and colonic (progressive dilatation, megacolon and slow transit) are the most common manifestations of the gut Also causes cardiomyopathy

Answer 44

Suction or punch biopsy 3cm (in adults) above the dentate line (below this is usually aganglionic anyway) Histology by ACh shows an increased number of large brown nerve fibres

Answer 45

4cm in length, variable shorter in multiparity Tube within a cone * External sphincter continuous with levator ani * Skeletal muscle * S2, Pudendal, somatic innervation * Internal sphincter continuous thickened portion of internal circular muscular layer of colon * Visceral smooth muscle * Sympathetic fibres maintain contraction (pelvic plexus L1,2) * Parasympathetics relax (pelvic sphlancnic)

Answer 46

divided by the dentate (pectinate line) approx 1/3 from anorectal margin and intersphincteric groove inferiorly * Above dentate line: * GRADUAL transition between columnar rectal mucosa and stratified squamous epithelium * up to 12 anal columns * at the base of these are the anal valves transversely which constitute the visual dentate line * Anal sinuses above valves, between columns * Anal glands open into sinuses * Pecten extends from dentate line to intersphincteric groove * stratified squamous epithelium * Non keratinising * No follicles or sweat glands * Below intersphincteric groove is histologically typical skin * keratinizing squamous epithelium * sebaceous, sweat glands and hair follicles present

Answer 47

Arterial * Upper part from superior rectal artery from IMA * lower part from inferior rectal artery from internal pudendal from internal iliac Venous * correspond to arteries but partake in the rectal venous plexus (which is actually anal) * Internal venous plexus form cusions at 3,7,11 * Contributes to continence and development of haemorrhoids Watershed "as per the vascular supply" in lasts but not totally correct * Upper part usually drains with the internal pudendal supply to the internal iliacs * lower part via anastomoses with superficial external pudental (from femoral) to the medial superficial inguinal group

Answer 48

Pressure differential between rectum and anus * anus ~90cm H2O Haemorrhoidal cushions Anorectal angle * 75-90º at rest * Angle opens out with relaxation of puborectalis

Answer 49

Medical * Konsyl D- Bulking * Loperamide- Decrease transit Physiotherapy * Pelvic floor physiotherapy * Biofeedback training Surgery * Sphincter repair * Prostheses- * Bulking (collagen, silicone) * Artificial sphincter * Sacral nerve stimulation * Diversion * Dynamic graciloplasty

Answer 50

2cm anterior to the anterior line of the anal canal on DPG

Answer 51

Lifestyle * Water supplementation * Fibre supplimentation Office procedures (best suited for grade 1-2, consider in 3) * Banding * Failure predicted by \>4 bandings * Sclerotherapy Surgery * Open (Milligan-Morgan) * Closed (Fergusson) * Use of an energy device probably decreases post operative pain. * Stapled * Increased recurrence rate

Answer 52

Urinary retention 30% Faecal incontinence 2% Infection 1% Haemorrhage 1% Stricture 1%

Answer 53

Consider esp if atypical position (non midline) TB Crohns HIV Syphillis Carcinoma

Answer 54

Parks Classification 1. intersphincteric 2. Trans-sphincteric 3. suprasphincteric 4. extrasphincteric

Answer 55

up to 40% Am. J. Surg. 2019 metanalysis showed reduction in fistula from 25% to 16% with an oral 5-10 day post operative antibiotic course but that study was pretty shit, a retrospective cohirt study was included and the 2 RCTS actually showed quite different outcomes and the better one trended toward harm

Answer 56

Male sex Ages 18-45 Obesity Trauma Sedentary lifestyle Deep natal cleft Hirsuit Family history

Answer 57

deroofing and curretage is superior to simple excision Pit excision is not beneficial Depilation decreases recurrence and number of procedures with laser, wax, creams- razor may increase recurrence

Answer 58

Secondary intention has long healing times but lower recurrence rates For primary closure, off midline procedures are superior to midline Thats pretty much it

Answer 59

Simple excision with primary or secondary intention healing Bascome 1 (pit picking) Bascome cleft lift Rhomboid flap (inferiorly based) Karydakis flap

Answer 60

Anal canal * Not visible externally or incompletely with light external traction Perianal * completely visible, arising within5cm of the anal opening Skin * \>5cm from the anus

Answer 61

Benign condyloma * HPV-6, HPV-11 Dysplasia and increased cancer risk * HPV-16, HPV-18

Answer 62

AJCC recommends the use of Squamous Intraepithelial Lesion (SIL) rather than Anal Intraepithelial neoplasia (AIN) * Low-grade squamous intraepithelial lesions (LSIL) * AIN I, low grade * High-grade squamous intraepothelial lesions (HSIL) * AIN II, moderate grade * AIN III, high grade

Answer 63

LSIL * May spontaneously regress * HSIL may be found but likely arises seperately * Biopsy anything concerning or excise for symptoms (e.g condylomata) but does not specifically need treatment * Follow up every 6/12 HSIL * Recommend treatment * Unlikely to regress * ablate the tissue somehow * cautery, excision, imiquimod, 5-FU * Surveillance required- high recurrence rate

Answer 64

Giant condylomata accumenatum Verrucous carcinoma

Answer 65

Anal canal 5x more common than perianal disease Risk factors include: * HPV * HSIL * HIV * Receptive anal intercourse * Smoking * Lifetime number of sexual partners

Answer 66

Squamous derived * Benign * Condylomata accumenatum * Premalignant * LSIL/HSIL * Malignant * SCC * BCC * Melanoma * Extramammary Paget's disease Columnar derived * Adenocarcinoma Soft tissue * Sarcoma

Answer 67

CT CAP MRI Pelvis CT PET for T2 (2cm) or greater or node positive disease

Answer 68

Definitive chemorads * 5-FU and Mitomycion C. * 45Gy initially, up to 59 if needed as second dose or in high risk disease * Continued response for 6 months, therefore: * Initial assessment at 10 weeks * Complete response * Monitor every 3-6 months for 2 years then less frequent * Partial response * Monitor out to 6 months then salvage if persistent disease beyind that * Progressive disease * Get histological confirmation before considering salvage * Salvage is with APR

Answer 69

Rare Very poor prognosis Often amelanotic Manage by obtaining R0 resection, more aggressive surgery i.e APR doesn't seem to improve survival

Answer 70

NZ uses Faecal Immunochemical Test * Age 60-75 * Single test (c/w Guaic acid-3 days)- highest uptake * every 2 years Screening has been shown in RCTs to decrease mortality Most international guidelines recommend screening from age 50 Other screening options range from stool based tests to CTC, to flex sig to colonoscopy Main risks are psychological and related to colonoscopy

Answer 71

Melanosis coli Benign Pigmentation of colon (and small bowel) caused by lipofuscin deposition in macrophages Associated with long term laxative use/abuse

Answer 72

ESMO guidelines recommend not resecting either the small bowel or appendix High rates of abscess and fistula from appendicectomy small bowel can be treated medically if crohns but the differential would still be broad.

Answer 73

JAMA surg paper 2019 RCT of interval appendicectomy vs MRI surveillance showed 20% rate of neoplasm in patients managed with perc drain for perforated appendicitis. The study was terminated early and all patients offered interval appendicectomy 33% of the MRI group had already required interval appendicectomy for recurrence

Answer 74

2019 meta-analysis showed of 5 days of cipro/metronidazole or Augmentin reduced the risk of fistula from 24% to 16% The studies included were at some risk of bias

Answer 75

N1: metastasis in 1 - 3 regional lymph nodes * N1a: metastasis in 1 regional lymph node * N1b: metastasis in 2 - 3 regional lymph nodes * N1c: no regional lymph nodes are positive but there are tumor deposits in the subserosa, mesentery or nonperitonealized pericolic or perirectal / mesorectal tissues

Answer 76

Metastasis in 4 or more regional lymph nodes * N2a: metastasis in 4 - 6 regional lymph nodes * N2b: metastasis in 7 or more regional lymph nodes There is no N3 for colorectal cancer

Answer 77

Tumour invades submucosa

Answer 78

Tumor invades muscularis propria

Answer 79

Tumor invades through the muscularis propria into the pericolorectal tissues

Answer 80

T4a * tumor invades through the visceral peritoneum * including gross perforation of the bowel through tumor T4b * tumor directly invades or adheres to other adjacent organs or structures

Answer 81

Optimal preprocedural preparation depends on timing of procedure * Morning procedures should have split dosing * Improved rates of adequate prep, adenoma detection and patient tolerance * Afternoon procedures single dose appears to be better Clear fluids should be ceased at least 2 hours prior to procedure to facilitate sedation

Answer 82

* Prior inadequate preparation * History of constipation * Use of medications associated with constipation * e.g tricyclic antidepressants and opioids * Dementia or Parkinson disease * Male sex * Low health literacy of cognitive function * Low patient engagement * Obesity * Diabetes mellitus * Cirrhosis

Answer 83

* Increase the risk of adverse events related to the procedure * Lengthen the insertion time and overall procedure time * Necessitate reducing the interval between procedures * Lower caecal intubation rates * Lower adenoma detection rates

Answer 84

MSI-high phenotype * 15-20% of CRCs * loss of DNA mismatch repair genes * Sporadic (BRAF associated) * HNPCC (~3%) Chromosomal instability (CIN) * 70-85% of CRCs * Wnt/beta-catenin pathways * Most frequently APC Global genomic hypermethylation * inactivation of tumour suppressor genes * CpG island methylator phenotype (CIMP) * Often results in MLH1 mutation leading to dMMR * Frequently associated with serrated polyps * progress to MSI-h sporadic CRC (BRAF V600E associated)

Answer 85

Most common non neoplastic polyp of the colon * Most common in rectum and rectosigmoid * Unclear if associated with increased risk of more proximal neoplasia * Guidelines * consensus of US multidisciplinary taskforce Am J gastro 2020 recommends colonoscopy in * 10 years for: * \<20 polyps in rectum and sigmoid all \<10mm * \<20 polyps proximal to rectosigmoid all \<10mm * 3-5 years for * \>10mm * 1 year for * serrated polyposis syndrome * diagnosis requires both of: * \>20 sessile polyps distributed throughout the colon * \> at least 5 proximal to the rectum of which 2 or more are \>10mm * NZ and Aus just say return to baseline screening if hyperplastic polyps * No further delineation of risk (both NZGG and Australian Cancer Council)

Answer 86

Rare syndrome (formerly called hyperplastic polyp syndrome) Genetic testing not recommended due to unknown genetics and heterogeneity Diagnosis is endoscopic (use carmine blue!) * requires both of (WHO): * \>20 sessile polyps distributed throughout the colon * \> at least 5 proximal to the rectum of which 2 or more are \>10mm Lifetime risk of cancer is ~50%

Answer 87

* R1 * G3 * Mesoappendiceal invasion \>3mm * Size \>2cm (definate) * Size 1-2cm (if high risk features) * Tumour at base of appendix (even R0) * LVI * G2

Answer 88

~1 in 1000 pregnancies * It is unclear if appendicitis is more or less common in pregnancy, if anything it is probably less common * Appendiceal rupture occurs more frequently in pregnant women especially in the third trimester

Answer 89

Operative * this is considered the standard of care in appendicitis and there is insufficient data to support non operative management in pregnant patients * A higher negative appendicectomy rate in pregnant women is generally accepted

Answer 90

This is usually from late or missed appendicitis * management depends on the clinical condition of the patient primarily * well patient * drainable- drain * not drainable- antibiotics only * the role of interval appendicectomy should be considered especially in those over 40 as there is a risk of rare but clinically important diagnoses such as NETS * Overall this risk and the risk of relapse are low * in some series the risk or relapse is up to 40% * unwell patient * operate on initial presentation

Answer 91

20% in women 30% in men Adenoma detection rates correlate with the risk of interval colorectal cancer Recent paper in the gastroenterology literature suggests that overall polyp detection rate may be a reasonable surrogate marker for ADR

Answer 92

50/1000 will obtain a positive result * 35/1000 will have adenomatous polyps * 3-4/1000 will have colorectal cancer

Answer 93

Endometrial and ovarian cancers * both have an increased risk **and** have an earlier onset in Lynch syndrome Endometrial cancer * lifetime risk is 25-70% depending on the mutation * mean age ~50 * screening: * women should be counselled for the increased risk and have dynfunctional bleeding promptly investigated * annual endometrail sampling should begin at the age of 30-35 or 5-10 years earlier than the earliest family member Ovarian cancer * lifetime risk is 10-25% depending on the underlying mutation * mean age ~45 * screening: * annual TVUS at the age of 30-35 or 5-10 years earlier than the earliest family member * CA125 every 6-12 months * all screening has a high rate of false positives and potential harm in ovarian cancer Risk reduction * ultimately prophylactic TAH and BSO from age 35-45 is warranted * it is reasonable to wait until child bearing is complete * earlier if there is a family history of early onset of cancers

Answer 94

Amsterdam II criteria * There should be at least three relatives with any Lynch syndrome-associated cancer (colorectal cancer, cancer of the endometrium, small bowel, ureter, or renal pelvis) * One should be a first-degree relative of the other two * At least two successive generations should be affected * At least one should be diagnosed before age 50 * Familial adenomatous polyposis should be excluded in the colorectal cancer case(s), if any * Tumors should be verified by pathological examination

Answer 95

The revised Bethesda guidelines 1. Colorectal cancer diagnosed in a patient who is less than 50 years of age. 2. Presence of synchronous, metachronous colorectal, or other HNPCC-associated tumors regardless of age. 3. Colorectal cancer with the MSI-H-like histology diagnosed in a patient who is less than 60 years of age 4. Colorectal cancer diagnosed in a patient with one or more first-degree relatives with an HNPCC-related tumor, with one of the cancers being diagnosed under age 50 years. 5. Colorectal cancer diagnosed in a patient with two or more first- or second-degree relatives with HNPCC-related tumors, regardless of age.

Answer 96

This depends on the genetic mutation * MLH1 and MSH2 are higher risk * 35-45% * MSH6 and PMS2 are lower risk * 15-25%

Answer 97

Divided into three anatomic classes * forniceal * enter high, through the posterior fornix of the vagina * common causes: * crohns * bowel cancer * diverticular * radiation to gynaecological cancers * post operative from bowel anastomosis * septal * pass through the rectovaginal septum (middle third of the vagina) and are suprasphincteric * common causes: * rectal cancer * crohns * radiation * cervical cancer * obstructed labour with pressure necrosis * perineal * pass through the sphincter mechanism * common causes * crypotoglandular infections * obstetric tears * crohns * surgery

Answer 98

the risk of colorectal cancer is mildly increased in patients with 1 first degree relative with bowel cancer over the age of 55 colonoscopy should begin at age 50

Answer 99

Either * 1 FDR with colon cancer under the age of 55 or * 2 FDR with colon cancer at any age Colonoscopy should begin at 50 or 10 years before the first family member

Answer 100

There are multiple risk groups in the NZGG document: * those with a known genetic mutation * taylor recommendations to that syndrome * those with polyps * 1 FDR or SDR with cancer and multiple polyps * 1 FDR with multiple polyps * those with FDR with colon cancer * 1 FDR plus 2 other FDR or SDR with cancer any age * 2 FDR and one has any of: * cancer age \<55 * multiple cancers * extracolonic cancer suggestive of a syndrome * 1 FDR \<50 * esp. if dMMR

Answer 101

Our local protocol is for short course radiotherapy only, without chemosensitization. * 25 in 5 * surgery within 1 week of cessation

Answer 102

Patients receive long course radiotherapy with 5-FU sensitization. * Post treatment surgery is based on the mercury study * MRI at 1 month * if there is progressive or non responsive disease then progression to surgery within the week * if there is response then surgery is undertaken 6-12 weeks post neoadjuvant therapy

Appendix to Anus Flashcards

(142 cards)