Question 1

Doctors at a first-level hospital see colorectal cancer patients but must refer them to the next level, and even the highest level available locally often cannot treat them. What should a doctor in this position do?

Dr. Kaushal Kishor Yadav · Accepted Answer

Many African patients who reach India face the same problem: evaluation, diagnosis and the route to treatment take a very long time, they do not get a proper line of management early, and by the time they present to us the disease is already advanced. That translates into longer treatment in India, and in stage four the options are limited. What a primary-care doctor can do is recognise the warning signs and act on them. Patients under 40, even in their 20s and 30s, are not spared, because habits and lifestyles are changing everywhere. Whenever these symptoms are present and abdominal symptoms are not settling, the patient should have a colonoscopy or a CT scan so that any doubt can be confirmed. Even at that initial level, the doctor can contact us to describe the patient, the symptoms and what initial investigations should be done.

Question 2

Where MRI quality is poor, as in Ethiopia, CT is used even for rectal tumours instead of the textbook MRI of the pelvis. Is that acceptable?

Dr. Kaushal Kishor Yadav · Accepted Answer

MRI is most helpful when the cancer is very low in the rectum. There it shows whether the pelvic muscles are free of tumour, and therefore whether the patient will need a stoma or can keep normal bowel passage. In the rest of the cases a CT scan is good enough.

Question 3

Is intersphincteric resection really possible even for distal rectal cancer?

Dr. Kaushal Kishor Yadav · Accepted Answer

Yes. A tumour lying low in the rectum is not the problem; the question is whether the cancer can be removed completely. Guidelines have shown that even a minimal distal margin of 1 cm is adequate, and an intraoperative frozen section can check that all microscopic cancer cells have been removed. This is possible because of the 'holy plane': rectal cancer rarely spreads downwards within the bowel wall by more than a centimetre; it spreads upwards along its natural embryological lymphatic supply and embryological planes. Staying strictly within those planes allows the surgeon to go between the internal and external sphincter of the anal canal, provided that plane is free. If it is, a coloanal anastomosis is possible even in the most distal part of the rectum.

Question 4

In a setup where frozen section is not available, how can a surgeon be sure of free margins, and how should the patient be followed after surgery?

Dr. Kaushal Kishor Yadav · Accepted Answer

Follow the natural avascular surgical plane, doing sharp dissection between the internal and external sphincter. On gross examination, aim for about one centimetre of margin at the lowest extent of the tumour, or three to five centimetres higher up depending on where the tumour is located. Stay within the correct surgical plane and the margin should come back clear; the final histopathology report, once it arrives, confirms this.

Question 5

In a region with very low healthcare infrastructure, where the paraclinical tests described are not available, what should doctors do to help their patients?

Dr. Kaushal Kishor Yadav · Accepted Answer

Do whatever is genuinely achievable under your own control. If something cannot be done locally, it is better to refer the patient to a centre where it can be done with precision, because cancer gives only one real chance to get the treatment pathway right.

Question 6

What is the name of the colon cancer technique just described?

Dr. Kaushal Kishor Yadav · Accepted Answer

Complete mesocolic excision with central vascular ligation, abbreviated as CME with CVL.

Question 7

How should a patient with sigmoid colon cancer and peritoneal or liver metastases be managed, and what is the place of neoadjuvant chemotherapy?

Dr. Kaushal Kishor Yadav · Accepted Answer

If there is only liver metastasis and it is limited, perhaps one, two or three lesions, liver metastasectomy can be done at the time of the primary surgery or as a second stage, provided all of it can be removed completely. If the liver is studded with disease in both lobes, there is no role for curative surgery, only palliative chemotherapy. Similarly, if there are only peritoneal seedings and no other site, cytoreductive surgery with HIPEC gives a survival advantage of about 50 percent in colorectal cancer and is a good option, but the disease should be limited and the surgery combined with chemotherapy before and after. On neoadjuvant treatment: in stage one to three colon cancer there is no role for neoadjuvant chemotherapy; surgery comes first. In lower rectal cancer our practice is neoadjuvant chemotherapy and radiotherapy for T3 disease, when the cancer has grown through the muscle wall, or when lymph nodes are involved. Early T1 or T2, N0 disease goes directly to surgery; advanced disease receives neoadjuvant chemotherapy and radiotherapy followed by surgery. In stage four most treatment is chemotherapy alone, and in limited liver or peritoneal disease we give three months of chemotherapy, then surgery, followed by three months of chemotherapy.

Question 8

Will the session recording and the presentation be shared with participants?

Accepted Answer

Yes. The session was recorded and a link to the webinar recording will be provided. Dr. Yadav has also shared his presentation, in English, which will be shared as well.

Live Discussion with Dr. Kaushal Kishor Yadav