John is a 60 year old man who presents to his gp with a 4 week history of frequent and profuse passage of fresh blood per rectum. This is associated with a mucoid discharge. Rectal examination and sigmoidoscopy reveal an ulcerating tumour in the mid-rectum. Biopsy confirms this to be a moderately differentiated adenocarcinoma. 1. Apart from polyps, state Two risk factors for colorectal carcinoma. (2 marks) John then under goes ct of the abdomen and MRI of the pelvis. This confirms the diagnosis and the tumour is identified as being T3. N0.M0 2 discuss why both CT and MRI were used to stage johns disease. Using evidence from published research, evaluate the contribution of each modality to the diagnostic process. (20 marks) 3, During John’s CT scan a radiographic contrast agent was administered. This resulted in john developing some wheezing and urticaria. Out line the physiological mechanism which leads to these two effects (10 marks) John’s case is discussed at the multi-disciplinary team meeting. His treatment and subsequent care are of particular concern as he is the main carer for his teenage son. 4, Evaluate the role of the following members of the MDT when discussing a case such as Johns i) Clinical Oncologist ii) Gastrointestinal surgeon iii) Macmillan Nurse iv) Social Worker (12 marks) John receives a week of intensive pre-operative radiotherapy and subsequently undergoes a total mesorectal excision with immediate re-anastomosis. Histopathological review confirms a moderate/poorly differentiated adenocarcinoma that penetrates through the full thickness of the rectal wall but has a clear circumferential resection margin and clear margins of excision proximally and distally. There is no involvement of the peri-rectal fat or other pelvic lymph nodes but there is some evidence of venous invasion. John goes on to receive 6 months of adjuvant 5-flourouracil (5FU) / Folinic Acid Chemotherapy 5, Post surgery, John is experiencing some severe pain and is prescribed morphine as an analgesic. Explain the action of morphine and discuss its action in the pain pathway. Discuss the side effects that are associated with morphine and precautions taken to minimise them. (20 marks) Part way through john’s cycle of chemotherapy, a blood test reveals the following. RBC 5.7x10 12/1 Hb 14.6 g Plts 85x10 9/1 WBC 2.1x10 9/1 Neutrophils 0.4x10 9/1 Lymphocytes 0.9x10 9/1 6, List the side effects commonly associated with this chemotherapy regime. In light of the blood results given what precautions would you put in place before john visited your department for a 30 minute appointment? (16 marks) John remains well on routine follow up until 3 years later when a routine pre-clinic CEA estimation is found to be 12 times the upper limit of normal at 48ug/1. This triggers restaging, and CT reveals the presence of liver metastases. Over the next 18 months, John undergoes additional treatments, until he finally receives a terminal prognosis. He struggles to come to terms with this news, and eventually his son contacts johns GP to discuss additional support and pain relief as john has been very uncomfortable and distressed. 7, discuss the support that could be offered through the palliative care team, and evaluate the difference which could be made to Johns care. Your answer should include the concept of ‘total pain’ and identify strategies to alleviate some of John’s physical symptoms. (20 marks)