Information about Colorectal cancer by Dr Dhaval Mangukiya. Details of Colorectal cancer, Epidemiology, Risk Factors, Protective Factors, Pathology, Prognostic Determinants, Clinical Presentation, Rectal Cancer, Dignosis, Differential Diagnosis, Staging and Management etc. https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/

1. Colorectal Cancer
Dr DHAVAL MANGUKIYA
Surgical Gastroenterologist
SIDS Hospital

2. • Epidemiology
• Risk factors
• Protective factors
• Pathology
• Prognostic factors
• Clinical presentation
• Dignosis
• Differential diagnosis
• Staging
• Management

3. Epidemiology
• Third most commonly diagnosed cancer in
males and the second in females
• Highest incidence rates are in Australia and
New Zealand, Europe, and North America
• Lowest rates are found in Africa and South-
Central Asia
• Third most lethal cancer
• India – incidence-6.09 / mortality rate-4.59

4. Risk factors
Factors that currently influence screening
recommendations
• Hereditary CRC syndromes (FAP, Lynch
syndrome)
• Personal or family history of sporadic CRCs or
adenomatous polyps
• Inflammatory bowel disease
• Abdominal radiation

5. Factors that may influence screening
recommendations
• Race— African Americans
• Acromegaly
• Renal transplantation
Risk factors

6. Risk factors that do not alter screening recommendations
• Obesity
• Diabetes mellitus and insulin resistance
• Red and processed meat
• Tobacco
• Alcohol
• Use of androgen deprivation therapy
• Cholecystectomy
• Other risk factors
– The presence of coronary heart disease
– Ureterocolic anastomoses after extensive bladder surge
Risk factors

7. PROTECTIVE FACTORS
• Physical activity
• Diet high in fruits and vegetables
• Fiber
• Folic acid and folate
• Vitamin B6 (pyridoxine)
• Calcium and dairy products
• Vitamin D
• Magnesium
• Garlic
• Fish consumption
• Drugs (NSAID & Aspirin)
• Postmenopausal hormone therapy
• Statins (pravastatin and simvastatin)
• Antioxidants
• Bisphosphonates
• Angiotensin II inhibition

8. Pathology
Gross appearance
• proximal or right colon - polypoid or fungating
exophytic masses
• distal or left colon - annular or encircling
lesions that produce an "apple-core" or
"napkin-ring" appearance
• Synchronous colon cancers
• Metachronous colon cancers

9. Double-contrast barium enema shows an
eccentric mass arising from the anterior wall of
the rectum (arrow).
Double contrast barium enema shows an
apple-core lesion surrounding the lumen of
the descending colon.

10. • Histology and immunohistochemistry
Pathology
Immunohistochemistry — Cytokeratin 20
(CK20) and caudal-type homeobox 2 (CDX2)

11. PROGNOSTIC DETERMINANTS
Pathologic features
• Local tumor extent - depth/size (>4.5cm)
• Regional nodes
• Nodal micrometastases
• Mesenteric nodules
• Lymphovascular invasion
• Perineural invasion
• Circumferential (radial) margin
• Residual tumor

12. Pathologic features
• Histologic type, grade of differentiation, and
presence of mucin
• Tumor regression after neoadjuvant therapy
• Tumor border
• Microvessel density
• Peritumoral fibrosis and inflammatory response
• Focal neuroendocrine differentiation
PROGNOSTIC DETERMINANTS

13. • Clinical features
• Preoperative serum CEA (CEA levels
≥5.0 ng/mL )
• Bowel obstruction and/or perforation
• Molecular factors
– Mismatch repair deficiency
– RAS and BRAF
– 18q deletions
PROGNOSTIC DETERMINANTS

14. CLINICAL PRESENTATION
• Suspicious symptoms and/or signs
• Asymptomatic individuals discovered by
routine screening
• Emergency admission with intestinal
obstruction, peritonitis, or rarely, an acute
gastrointestinal (GI) bleed

15. Symptoms and manifestations
• hematochezia or melena, abdominal pain,
otherwise unexplained iron deficiency
anemia, and/or a change in bowel habits
• Rectal cancer can cause tenesmus, rectal pain,
and diminished caliber of stools
CLINICAL PRESENTATION

16. Metastatic disease
• The presence of right upper quadrant pain,
abdominal distention, early satiety,
supraclavicular adenopathy, or periumbilical
nodules
• Sites – Liver and Lung
CLINICAL PRESENTATION

17. Unusual presentations
• Fistula formation into adjacent organs, such as
bladder (resulting in pneumaturia) or small
bowel
• Fever of unknown origin
• Unknown primary sites (6%)
• Liver metastases that are detected incidentally
CLINICAL PRESENTATION

18. DIAGNOSIS
• Colonoscopy
• Barium enema
• CT colonography
• Tumor markers

19. Normal sigmoid colon

20. Endoscopic appearance of multiple polyps in
familial adenomatous polyposis

21. DIFFERENTIAL DIAGNOSIS
• Disseminated Kaposi Sarcoma
• Primary non-Hodgkin lymphoma
• Colonic carcinoid tumors
• Metastases from other primary cancers
(Ovary)
• Diverticular disease

22. STAGING
• TNM/AJCC

24. STAGING

27. Clinical staging evaluation
• CT scan
• Liver MRI
• PET scans
• Locoregional staging for rectal cancer
– Digital rectal examination (DRE)
– Rigid sigmoidoscopy
– Rransrectal ultrasound
– Transrectal endoscopic ultrasound
– Pelvic MRI
STAGING

28. MANAGEMENT OF LOCALIZED
DISEASE
• Surgical resection
• Regional lymphadenectomy
• Resection margins

29. Arterial circulation to the large bowel

30. Idealized representation of the peritoneal and
mesenteric relationships at various levels of
the colon and rectum

31. COLON RESECTION

32. Right colectomy for malignancy

33. Extended right colectomy for malignancy

34. Colectomy for mid transverse colon cancer

35. Left colon resection for a splenic flexure lesion

36. Sigmoid resection for tumor

37. Total colectomy for cancer

38. Rectal Cancer
Male pelvis - Sagittal section

39. Rectal Cancer
Presacral venous plexus - Fascial relationship

40. Rectal Cancer
Lateral ligament of the rectum

41. Management
Mangement of carcinoma in a polyp
• Colonoscopic removal
• Surgery
– Poorly-differentiated histology
– Lymphovascular invasion
– Cancer at the resection or stalk margin
– Invasion into the muscularis propria of the bowel wall (T2
lesion)
– Invasive carcinoma arising in a sessile (flat) polyp with
unfavorable features (eg, lower third submucosal
penetration, lymphovascular invasion, poorly
differentiated

42. Management
Locally advanced primary lesions
• Multivisceral resection is an appropriate
option for locally advanced, potentially
resectable primary colon cancers.

43. Management
Neoadjuvant chemoradiotherapy or
chemotherapy
• Neoadjuvant (preoperative)
chemoradiotherapy rather than initial surgery
is a common approach for locally advanced
rectal cancer.

44. Management
• Adjuvant chemotherapy
– FOLFOX
– CAPOX

45. Management
METASTATIC DISEASE
• Potentially resectable metastases in liver or lung -
an aggressive surgical approach
• Unresectable metastatic disease - according to
their severity, and the medical condition of the
patient.
• Asymptomatic primary unresectable metastatic
disease - conservative

46. MANAGEMENT OF LOCALLY
RECURRENT DISEASE
• Multimodality therapy may include
chemotherapy, chemoradiotherapy, or
intraoperative radiation therapy (RT), in
addition to surgery

47. COMPLICATED DISEASE
• Colonic perforation
• Colonic obstruction

48. PALLIATION OF ADVANCED DISEASE
symptomatic colon or rectal cancer with
incurable metastatic disease
• Resection of cancer and primary anastomosis
• Diverting end colostomy with mucous fistula
• Bypass procedure

49. MANAGEMENT OF RECTAL CANCER
• Local excision
• Sphincter-preserving procedures
• Abdominal perineal resection (APR)

50. Left colectomy for malignancy Left hemicolectomy for a benign diseases

51. Que