dr. Amer Odobašić

1. Surgical treatment of colon cancer
Amer Odobašić, MD
University Clinical Center Tuzla
Bosnia and Herzegovina
Bosnian- Herzegovinian American Academy of Arts and Sciences
7. BHAAAS days in B&H; Brcko District, 22-26 April, 2015

2. What is
Colon Cancer?

3. Facts
• 2nd leading cancer killer in the U.S.
– Every 9.3 minutes, a person in the U.S. dies of
colon cancer
• Survival depends on early detection
– 90% five-year survival rate in early detected
cases

4. • Estimated new cases and deaths from colon
cancer in the United States in 2015:
 New cases: 93,090 (colon cancer only).
 Deaths: 49,700 (colon and rectal cancers
combined)
• American Cancer Society: Cancer Facts and Figures 2015. Atlanta, Ga: American Cancer Society, 2015. Available online.
Last accessed January 7, 2015.

5. Republic of Korea had the highest rate of colorectal
cancer, followed by Slovakia and Hungary.
About 54 per cent of colorectal cancer cases occurred
in more developed countries.
The highest incidence of colorectal cancer was in
Oceania and Europe and the lowest incidence in
Africa and Asia.
Source: Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F.
GLOBOCAN 2012 v1.1, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France:
International Agency for Research on Cancer; 2014. Available from: http://globocan.iarc.fr, accessed on 16/01/2015.

6. How Can Reduce Risk For Colon Cancer?

7. • Know risk
• Maintain a healthy weight throughout life
• Be physically active
• Eat a healthy diet
• Limit consumption of alcoholic beverages
• Do not use tobacco products

8. Groups at an increased risk:
– Those age 50 and older
– Individuals with a personal or family history of
colon cancer, non-cancerous olon ps, or Irritable
Bowel Syndrome (IBS)

9. Hereditary Colorectal Cancer
• Familial adenomatous polyposis
– FAP account for <1% of all colorectal cancers
– Due to mutation of the adenomatosis polyposis coli (APC) gene
– Numerous adenomas appear as early as childhood and virtually
100% have colorectal cancer by age 50 if untreated
• Hereditary non-polyposis colorectal cancer / Lynch syndrome
– More common than FAP and account for ~1-5% of all colonic
adenocarcinomas
– Due to a mutation in one of the mismatch repair genes
– Earlier age onset of colorectal cancer and predominantly involve
the right colon
– HNPCC also increases the risk of
• Endometrial, ovarian, breast ca
• Stomach, small bowel, hepatobiliary ca
– Renal pelvis or ureter ca

10. The best way to reduce risk is by getting screened.

11. • Common Screening Options:
– Colonoscopy
– Virtual colonoscopy (computerized tomographic
colonography or CTC)
– Sigmoidoscopy
– Fecal occult blood test (FOBT)
– Fecal immunochemical test (FIT)
Screening Options

12. A colonoscopy is the most effective screening
method.
It can reduce the average person's risk of dying from
colon cancer by 90%.

13. What is the better ?

14. Clinical Presentation
Depends on location of cancer
• Locations
– ⅔ in descending colon and rectum
– ½ in sigmoid colon and rectum (i.e. within reach of
flexible sigmoidoscope)
• Caecal and right sided cancer
– Iron deficiency anaemia (most common)
– Distal ileum obstruction (late)
– Palpable mass (late)

15. Clinical Presentation
• Left sided and sigmoid carcinoma
Change of bowel habit
• Alternating constipation + diarrhoea
• Tenesmus
• Thin stool
PR bleeding, mucus
• Bowel obstruction
• Metastasis
o Liver (hepatic pain, jaundice)
o Lung (cough)
o Bone (leucoerythroblastic anaemia)
o Regional lymph nodes
o Peritoneum
o Others

16. Three elements:
• T = Tumor
– How large is the tumor?
• N = Node
– Are cancer cells in the
lymph nodes?
• M = Metastases
– Has the cancer spread
to other organs?
Four stages:
• Stage 0
• Stage I
– Spread to the middle layers
of the colon or rectum
• Stage II
• Stage III
• Stage IV
– Advanced disease, spread to
other organs
STAGING OF COLON CANCER

17. STAGE GROUPING
STAGE T N M DUKES MAC
0 TIS NO MO - -
I T1 NO MO A A
T2 NO MO A B1
IIA T3 NO MO B B2
IIB T4 NO MO B B3
IIIA TI-T2 NI MO C CI
IIIB T3-T4 NI MO C C2/C3
IIIC ANY T N2 MO C C1/C2/C3
IV ANY T ANY N MI D

18. STAGING OF COLON CANCER
PRIMARY TUMOR REGIONAL NODES DISTANT METASTASES
TX-CANNOT ASSESS NX-CANNOT ASSESS MX CANNOT ASSESS
TO- NO PRIMARY TUMOR NO-NO METS RN MO- NO DISTANT METS
TIS- TUMOR IN SITU N1-METS 1-3 RN M1- DISTANT METS
T1- INVADES SUBMUCOSA N2- METS >3 RN
T2- INVADES MUSCULARIS
T3- INVADES THROUGH MUSCULARIS PROPIA INTO SUBSEROSA OR ONTO NON-
PERITONIALISED PERICOLIC OR PERIRECTAL TISSUES
T4-DIRECTLY INVADES OTHER
ORGANS OR STRUCTURES
AND/OR PERFORATES
VISCERAL PERITONEUM

19. Colon anatomy

21. Stage 0 Colon Cancer Treatment
Stage 0 colon cancer is the most superficial of all the
lesions and is limited to the mucosa without invasion of
the lamina propria.
Because of its superficial nature, the surgical procedure
may be limited.
Standard treatment options for stage 0 colon cancer
include the following:
• Local excision or simple polypectomy with clear
margins.
• Colon resection for larger lesions not amenable to
local excision.

22. Stage I Colon Cancer Treatment
Because of its localized nature, stage I colon cancer has
a high cure rate.
Standard treatment options for stage I colon cancer
include the following:
• Wide surgical resection and anastomosis.
The role of laparoscopic techniques [1] [2] [3] [4] in the treatment of
colon cancer was examined in a multicenter, prospective,
randomized trial (NCCTG-934653, now closed) comparing
laparoscopic-assisted colectomy (LAC) with open colectomy.

23. Stage II Colon Cancer Treatment
Standard treatment options for stage II colon cancer
include the following:
• Wide surgical resection and anastomosis.
Evidence (laparoscopic techniques):
The role of laparoscopic techniques [1] [2] [3] [4] in the treatment of
colon cancer was examined in a multicenter, prospective,
randomized trial (NCCTG-934653, now closed) comparing
laparoscopic-assisted colectomy (LAC) to open colectomy.

24. Stage III Colon Cancer Treatment
Stage III colon cancer denotes lymph node involvement.
Studies have indicated that the number of lymph nodes
involved affects prognosis; patients with one to three
involved nodes have a significantly better survival than
those with four or more involved nodes.
Standard treatment options for stage III colon cancer
include the following:
• Surgery - wide surgical resection and anastomosis.
• Adjuvant chemotherapy.

25. Stage IV and Recurrent Colon Cancer
Treatment
Stage IV colon cancer denotes distant metastatic disease.
Treatment of recurrent colon cancer depends on the sites of
recurrent disease demonstrable by physical examination
and/or radiographic studies.
Such approaches have not led to improvements in long-term
outcome measures such as survival.

26. 1. Surgical resection of locally recurrent cancer.
2. Surgical resection and anastomosis or bypass of obstructing
or bleeding primary lesions in selected metastatic cases.
3. Resection of liver metastases in selected metastatic patients
(5-year cure rate for resection of solitary or combination
metastases exceeds 20%) or ablation in selected patients. [2]
[3] [4] [5] [6] [7] [8] [9] [10] [11]
4. Resection of isolated pulmonary or ovarian metastases in
selected patients. [12]
5. Palliative radiation therapy.
6. Palliative chemotherapy.
7. Targeted therapy.
8. Clinical trials evaluating new drugs and biological therapy.
9. Clinical trials comparing various chemotherapy regimens or
biological therapy, alone or in combination.

27. Survival rates for colon cancer, by stage:
Stage 5-year Relative Survival Rate
I 92%
IIA 87%
IIB 63%*
IIIA 89%*
IIIB 69%
IIIC 53%
IV 11%
*These numbers are correct : patients with stage IIIA or IIIB cancers have better
survival than those with stage IIB cancers.
These statistics are based on a previous version of the staging system. In that
version, there was no stage IIC (those cancers were grouped considered stage IIB).
Also, some cancers that are now considered stage IIIC were classified as stage IIIB,
while some other cancers that are now considered stage IIIB were classified as
stage IIIC.

28. Malignant large bowel obstruction

29. • Malignant bowel obstruction needs:
– Individualised approach
– Team work (oncology, surgery, radiology, specialist
palliative care team and other health care
professionals)
• Communication:
– Treatment options, expectations & limitations,
discharge plan and preferred place of care….the
earlier you discuss with patient and family, the better
coping and the less of unnecessary anxiety and fear
of uncertainty

30. • Advantages:
– Alternative option for patients unfit for surgery or do not
want to have surgery
– A quick fix while waiting for surgery
– High success rate for left sided colonic obstruction
– Quicker recovery & shorter hospital stay
• Less successful:
– Rapidly progressive cancers
– Multifocal bowel obstruction
– Diffuse carcinomatosis
Colonic stenting

31. • What surgery
– Resection/debulking….primary anastomosis
– Bypass surgery
– Defunctioning colostomy/ileostomy

32.  OBSTRUCTING CANCERS
ON THE RIGHT SIDE.
RESECTION, ANASTOMOSIS ... STOMA
ON THE LEFT SIDE
DIVERTING STOMA, RESECTION, OR INTRA-OP COLONIC
LAVAGE WITH ANASTOMOSIS
 PERFORATING CANCERS
CAN BE FROM EROSION OR PERFORATION SECONDARY TO
OBSTRUCTION.
WASHOUT, RESECTION AND ANASTOMOSIS IF FEASIBLE.
STOMA

33. • Safe
• Return of early bowel function
• Less postoperative pain
• Better pulmonary postoperative
function
• Shorter hospital stay
• Smaller incision
LAP Surgery for Colon Cancer

34. Skilled surgical team
• With experience in colorectal and
laparoscopic surgery
• Laparoscopic specialized equipment
• Laparoscopic resection is feasible and safe

35. Robotic surgery for Colon Cancer
The robotic system provides excellent ergonomics,
tremor stabilization, enhanced ambidextrous capability,
motion scaling, and instruments capable of moving with
multiple degrees of freedom.

36. While robotic surgery for colon and rectal cancer appears
feasible and safe, in the absence of long-term oncologic outcome
studies, no clear recommendation can be made.

38. Surgical principles of D1, D2, and D3 resection for both (A) right-sided colon cancers
and (B) left-sided colon cancers.
Nicholas P. West et al. JCO 2012;30:1763-1769
©2012 by American Society of Clinical Oncology
Complete Mesocolic Excision / Central Vascular Ligation

39. D3 LN dissection for colon cancer.
Hideki Ueno et al. Jpn. J. Clin. Oncol. 2014;44:547-555
© The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions,
please email: journals.permissions@oup.com

40. D3 resection in Japan.
Kentaro Nakajima et al. Jpn. J. Clin. Oncol. 2014;44:799-
806
© The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions,
please email: journals.permissions@oup.com

42. Current possibilities
Questions to be answered:
• Radicality
• Benefits
• Security

43. Thanks for Your attention