Colorectal cancer

COLORECTALCOLORECTAL
CANCERCANCER
Prof . Amer Eltwati Ben Irhuma FRCS
Consultant Surgeon
Sebha Medical College

QuoteQuote
To repeat what others have said, requiresTo repeat what others have said, requires
education .. to challenge it, requires brainseducation .. to challenge it, requires brains
MARY PETTIBONE POOLEMARY PETTIBONE POOLE

Lecture ObjectivesLecture Objectives
 Lecture objectives ……Lecture objectives ……
 ReviewReview the anatomy of colon and rectumthe anatomy of colon and rectum
 KnowKnow the disease epidemiologythe disease epidemiology
 IdentifiesIdentifies the etiologies and risk factorsthe etiologies and risk factors
 UnderstandUnderstand the pathology of colorectal cancerthe pathology of colorectal cancer
 RecognizeRecognize different types of clinical featuresdifferent types of clinical features
 InvestigateInvestigate the Diseasethe Disease
 understandunderstand the treatment options for various typesthe treatment options for various types
of colorectal cancer including preventive measuresof colorectal cancer including preventive measures

INTRODUCTIONINTRODUCTION
 Cancer of the colon & rectum is theCancer of the colon & rectum is the secondsecond
most common cancer after the lung cancer inmost common cancer after the lung cancer in
the western world, it is there fore contributesthe western world, it is there fore contributes
considerably to morbidity and mortality.considerably to morbidity and mortality.
 Until the last decade treatment has beenUntil the last decade treatment has been
limited tolimited to excisional surgeryexcisional surgery, the generally, the generally
poor outcome showed little signs ofpoor outcome showed little signs of
improvement .improvement .

INTRODUCTIONINTRODUCTION
 New information fromNew information from epidemiological studiesepidemiological studies,,
molecular biologymolecular biology,, imagingimaging together withtogether with
surgical innovationsurgical innovation andand trials of adjuvanttrials of adjuvant
therapytherapy offer possibilities foroffer possibilities for preventingpreventing somesome
cancers,cancers, diagnosingdiagnosing others earlier &others earlier & improvingimproving
both quality and duration of survival for majorityboth quality and duration of survival for majority
of patient whileof patient while avoidingavoiding unnecessaryunnecessary
mutilation for those with no prospect of cure.mutilation for those with no prospect of cure.
 A through understanding of the disease and theA through understanding of the disease and the
options available for management areoptions available for management are
therefore more necessary than ever.therefore more necessary than ever.

EPIDEMIOLOGYEPIDEMIOLOGY
 The incidence of colorectal cancer varies betweenThe incidence of colorectal cancer varies between
and within theand within the countries suggesting environmentalcountries suggesting environmental
factorsfactors
 The peak incidence appear in theThe peak incidence appear in the seventh decadeseventh decade ofof
lifelife
 The ratio between male & female is almost equalThe ratio between male & female is almost equal
 it is common in western world but rare in Asia &it is common in western world but rare in Asia &
Africa the difference among racial & groupsAfrica the difference among racial & groups
within different areas of country suggestingwithin different areas of country suggesting
genetic or cultural factors are importantgenetic or cultural factors are important
 Life style play very important role in etiology ofLife style play very important role in etiology of
cancerscancers

AnatomyAnatomy
 The colon is 150 cm long and is subdivided into the The colon is 150 cm long and is subdivided into the
cecum,cecum,  ascendingascending, , transversetransverse, , descendingdescending, and , and
sigmoidsigmoid colon. The ileocecal valve forms the junction  colon. The ileocecal valve forms the junction
between the small and large bowel and demarcates between the small and large bowel and demarcates
the cecum from the ascending colon. the cecum from the ascending colon.
 The The transverse transverse andand sigmoid colons sigmoid colons have a mesentery  have a mesentery
and are entirely intraperitoneal. The ascending and and are entirely intraperitoneal. The ascending and
descending colons are partially extraperitoneal. descending colons are partially extraperitoneal.
 The The superior mesenteric arterysuperior mesenteric artery supplies the colon  supplies the colon
between the ileocecal valve and the splenic flexure. between the ileocecal valve and the splenic flexure.
The The inferior mesenteric arteryinferior mesenteric artery supplies the colon  supplies the colon
distal to the splenic flexure. distal to the splenic flexure.

AnatomyAnatomy
 The colonic wall comprises 4 The colonic wall comprises 4
layers, including the :layers, including the :
– MucosaMucosa
– submucosasubmucosa
– muscularis propriamuscularis propria (inner circular layer  (inner circular layer
and outer longitudinal layer, and outer longitudinal layer,
comprising 3 narrow bands comprising 3 narrow bands tenia Coli)tenia Coli)
– and and serosaserosa

AETIOLOGYAETIOLOGY
The exact cause/s of theThe exact cause/s of the
colorectal cancer iscolorectal cancer is unknownunknown

Colorectal Cancer: Who's at Colorectal Cancer: Who's at
RiskRisk??
 Age Age
 DietDiet
 PolypsPolyps
 Personal Medical HistoryPersonal Medical History
 Family Medical HistoryFamily Medical History
 Genetic factors Genetic factors
 Inflammatory bowel diseaseInflammatory bowel disease
 Irradiation Irradiation

RISK FACTORS for Colon CancerRISK FACTORS for Colon Cancer
 Age.Age.
 Colorectal cancer is more likely to occur as Colorectal cancer is more likely to occur as
people get older. This disease is more people get older. This disease is more
common in people over the age of 50. common in people over the age of 50.
 However, colorectal cancer can occur at However, colorectal cancer can occur at
younger ages, even, in rare cases, in the younger ages, even, in rare cases, in the
teens. teens.

 Diet.Diet.
 Colorectal cancer seems to be associated with Colorectal cancer seems to be associated with
diets that are diets that are high in fat and calorieshigh in fat and calories and and low in low in
fiber. fiber. diet low in indigestible fibers , high in diet low in indigestible fibers , high in
animal fatanimal fat
 increased fecal bile salt- postcholecystectomyincreased fecal bile salt- postcholecystectomy
 selenium deficiencyselenium deficiency
 high anaerobic bacterial count in feceshigh anaerobic bacterial count in feces

 PolypsPolyps..
 PolypsPolyps are benign growths on the inner wall of the colon andare benign growths on the inner wall of the colon and
rectum. They are fairly common in people over age 50. Some typesrectum. They are fairly common in people over age 50. Some types
of polyps increase a person's risk of developing colorectal cancerof polyps increase a person's risk of developing colorectal cancer
 polyppolyp::
Colonic polyp is well known cause of colorectal cancer. the risk ofColonic polyp is well known cause of colorectal cancer. the risk of
malignant change in benign polyp depend on many factorsmalignant change in benign polyp depend on many factors
including:including:
- - size, number of polypsize, number of polyp
-- histological typehistological type,, the risk of cancerthe risk of cancer
development is more common indevelopment is more common in villous typevillous type
of adenomas than inof adenomas than in tubular type.tubular type.
also presence of epithelial dysplasia increase thealso presence of epithelial dysplasia increase the
risk of cancerrisk of cancer

 Personal Medical History.Personal Medical History.
– Research shows that women with a history of cancer Research shows that women with a history of cancer
of the ovary, uterus, or breast have a some what of the ovary, uterus, or breast have a some what
increased chance of developing colorectal cancer. increased chance of developing colorectal cancer.
Also, a person who has already had colorectal cancer Also, a person who has already had colorectal cancer
may develop this disease a second time.may develop this disease a second time.
 Family Medical HistoryFamily Medical History..
– First-degree relatives (parents, siblings, children) of a First-degree relatives (parents, siblings, children) of a
person who has had colorectal cancer are somewhat person who has had colorectal cancer are somewhat
more likely to develop this type of cancer themselves, more likely to develop this type of cancer themselves,
especially if the relative had the cancer at a young age. especially if the relative had the cancer at a young age.
If many family members have had colorectal cancer, If many family members have had colorectal cancer,
the chances increase even more.the chances increase even more.

 Genetic factors:Genetic factors:
– Play small but very important role in etiology of Play small but very important role in etiology of
Colonic cancerColonic cancer
– The familial syndromes with increased risk of The familial syndromes with increased risk of
colorectal carcinoma includes:colorectal carcinoma includes:

RISK FACTORS for Colon Cancer RISK FACTORS for Colon Cancer
Genetic factorsGenetic factors
- Familial adenomatous polyposis Familial adenomatous polyposis
- HNPCCHNPCC
- Lynch syndrome I & iiLynch syndrome I & ii
- Turcot,s syndrome Turcot,s syndrome
- Peutz-jeghers syndromePeutz-jeghers syndrome

Hereditary Colorectal Cancer Hereditary Colorectal Cancer
Syndromes: FAPSyndromes: FAP
 Familial adenomatous polyposis (FAP) accounts for 1%
of colorectal cancer cases
 People with FAP typically develop hundreds to
thousands of colon polyps; the polyps are initially
benign , but there is nearly a 100% chance that the
polyps will develop into cancer if left untreated
 Colorectal cancer usually occurs by age 40 in people
with FAP
 Mutations (changes) in the APC gene cause FAP;
genetic testing is available
 Yearly screening for polyps is recommended
 Attenuated familial adenomatous polyposis (AFAP) is
related to FAP; people have fewer polyps

Hereditary Colorectal Cancer Hereditary Colorectal Cancer
Syndromes: HNPCCSyndromes: HNPCC
 Hereditary non-polyposis colorectal cancerHereditary non-polyposis colorectal cancer
(HNPCC), sometimes called(HNPCC), sometimes called Lynch syndromeLynch syndrome,,
accounts for approximately 5% to 10% of allaccounts for approximately 5% to 10% of all
colorectal cancer casescolorectal cancer cases
 The risk of colorectal cancer in families withThe risk of colorectal cancer in families with
HNPCC is 70% to 90%, which is several times theHNPCC is 70% to 90%, which is several times the
risk of the general populationrisk of the general population
 People with HNPCC are diagnosed with colorectalPeople with HNPCC are diagnosed with colorectal
cancer at an average age of 45cancer at an average age of 45
 Genetic testing for the most common HNPCCGenetic testing for the most common HNPCC
genes is available; measures can be taken togenes is available; measures can be taken to
prevent development of colorectal cancerprevent development of colorectal cancer

 Inflammatory bowel disease:Inflammatory bowel disease:
- Ulcerative colitis:- Ulcerative colitis:
Patient with extensive colitis and for long            Patient with extensive colitis and for long
            duration are at high risk of developing colorectal  duration are at high risk of developing colorectal
            cancer cancer
- Crhon,s disease :- Crhon,s disease :
            is also associated with increased risk of is also associated with increased risk of cancercancer
 Irradiation & immunosuppresion:Irradiation & immunosuppresion:
– Irradiation is well known carcinogenic,
– patient on immunosuppression drugs or disease
are at increased risk of developing colorectal cancer
RISK FACTORS for Colon Cancer RISK FACTORS for Colon Cancer

))CRC) Risk of ColorectalCRC) Risk of Colorectal
CancerCancer
0 20 40 60 80 100
General populationGeneral population
Personal history ofPersonal history of
colorectalcolorectal
neoplasianeoplasiaInflammatoryInflammatory
bowel diseasebowel disease
HNPCC mutationHNPCC mutation
FAPFAP
5%5%
15%15%––20%20%
15%15%––40%40%
70%70%––80%80%
<<95%95%
Lifetime riskLifetime risk)%()%(

PATHOLOGYPATHOLOGY
 Adenoma-carcinoma sequence
– Between 70-90 %Between 70-90 % of colorectal cancer arise fromof colorectal cancer arise from
adenomatous polyp.adenomatous polyp.
– the adenoma- carcinoma sequence is multi-stepthe adenoma- carcinoma sequence is multi-step
process involving sequential mutations orprocess involving sequential mutations or
deletions of genesdeletions of genes
– Polyp with tubular histological pattern have thePolyp with tubular histological pattern have the
least malignant potential , whereas villousleast malignant potential , whereas villous
adenomatuos polyp have the highest malignantadenomatuos polyp have the highest malignant
potentialpotential
– The larger the polyp ) more than 2cm in diameterThe larger the polyp ) more than 2cm in diameter

PATHOLOGYPATHOLOGY
Adenoma-carcinoma sequenceAdenoma-carcinoma sequence

PATHOLOGYPATHOLOGY
The distribution of colorectal cancers is as follows:The distribution of colorectal cancers is as follows:
 rectum 14%rectum 14%
 ssigmoid colon 35%igmoid colon 35%
 descending colon 4%descending colon 4%
 Splenic flexure 3%Splenic flexure 3%
 transverse colon 10%transverse colon 10%
 Hepatic flexure 10%Hepatic flexure 10%
 ascending colon 12%ascending colon 12%
 Ceacum 22%Ceacum 22%
 3% of the tumors are3% of the tumors are
synchronoussynchronous
 3% of the tumors are3% of the tumors are
metachrounousmetachrounous

Macroscopically:Macroscopically:
colorectal cancers may appear to the naked eye as:colorectal cancers may appear to the naked eye as:
-- Exophytic cauliflower-typeExophytic cauliflower-type of growthof growth
-- Ulcerating lesionUlcerating lesion penetrating through the bowelpenetrating through the bowel
wallwall
-- Annular constrictingAnnular constricting growthgrowth
- or as the rare- or as the rare colloid mucus-colloid mucus- secreting tumorssecreting tumors
Microscopically:Microscopically:
almost all colorectal cancers are aalmost all colorectal cancers are adenocarcinomadenocarcinoma, but, but
their histologic appearance is differenttheir histologic appearance is different
Grade I : well differentiatedGrade I : well differentiated
Grade II : moderately differentiatedGrade II : moderately differentiated
Grade III : poorly differentiatedGrade III : poorly differentiated
PATHOLOGYPATHOLOGY

MacroscopicMacroscopic
appearance of colorectalappearance of colorectal
cancercancer

Spread of the cancerSpread of the cancer
generally speaking it is comparatively slow growing tumorgenerally speaking it is comparatively slow growing tumor
 local spread:local spread:
the growth is limited to the bowel for considerable time,the growth is limited to the bowel for considerable time,
it spreads round the intestinal wall & to a certain extentit spreads round the intestinal wall & to a certain extent
longitudinally. when it invades the bowel wall it affectlongitudinally. when it invades the bowel wall it affect
the near structures like bladder, uterus, ovaries, etc..the near structures like bladder, uterus, ovaries, etc..
where it may cause a fistula , or perforate intowhere it may cause a fistula , or perforate into
peritoneal cavity, or to the pelvic wallperitoneal cavity, or to the pelvic wall
 lymphatic spread:lymphatic spread:
to epicolic group of lymph nodes then toto epicolic group of lymph nodes then to
paracolic group then to main groups of lymphparacolic group then to main groups of lymph
nodes arranged around the main arteriesnodes arranged around the main arteries

Spread of the cancerSpread of the cancer
 haematogenous spread :haematogenous spread :
through the venous system ( inferior & superiorthrough the venous system ( inferior & superior
mesenteric veins) mainly to the liver, it alsomesenteric veins) mainly to the liver, it also
goes to lung, bones, etc…goes to lung, bones, etc…
 spread by implantationspread by implantation
 transperitoneal spreadtransperitoneal spread

Staging of the tumorStaging of the tumor
the most simple & practical system of staging is:the most simple & practical system of staging is:
thethe Modified Duke classificationsModified Duke classifications
Duke stagesDuke stages
A - Tumor is confined to bowel mucosaA - Tumor is confined to bowel mucosa
B1 - Tumor involved the muscle wall butB1 - Tumor involved the muscle wall but
not completelynot completely
B2 - Tumor involve the serosaB2 - Tumor involve the serosa
C1 - Tumor involve the muscle wall but notC1 - Tumor involve the muscle wall but not
completely, local L.Ns involvedcompletely, local L.Ns involved
C2 - Involves the serosa & local LNsC2 - Involves the serosa & local LNs

The Dukes’ Staging System

The TNM Staging System

Stage GroupingsStage Groupings
Using the TNM criteria colorectal cancers are
placed in to 4 stages:
 Stage I: T1 N0 M0; T2 N0 M0
 Stage II: T3 N0 M0; T4 N0 M0
 Stage III: any T, N1-2, M0
 Stage IV: any T, any N, M1
http://homepage.ntlworld.com/watson-jones/portfolio/illustration-08.html

Prognosis of the colorectal cancersPrognosis of the colorectal cancers
 The prognosis of colorectal cancers dependThe prognosis of colorectal cancers depend
mainly on themainly on the stage of the diseasestage of the disease but there arebut there are
many factors considered to have prognosticmany factors considered to have prognostic
significance independent of stage, it includes :-significance independent of stage, it includes :-
– the degree of differentiationthe degree of differentiation
– the presence of veins invasionthe presence of veins invasion
– character of invasive marginscharacter of invasive margins
– peri-tumoral lymphatic infiltrationperi-tumoral lymphatic infiltration
– the number of nodes involvedthe number of nodes involved
– the presence or absence of apical lymphthe presence or absence of apical lymph
node metastasisnode metastasis

Prognosis of the colorectal cancersPrognosis of the colorectal cancers
Dukes Classification (modified by Turnbull) and 5-year SurvivalDukes Classification (modified by Turnbull) and 5-year Survival**
StageStage DescriptionDescription 55--year Survivalyear Survival
AA Limited to theLimited to the
bowel wallbowel wall
9090
BB Extension toExtension to
pericolic fat; nopericolic fat; no
nodesnodes
7070
CC Regional lymphRegional lymph
node metastasesnode metastases
3030
DD DistantDistant
metastases )liver,metastases )liver,
lung, bonelung, bone))
1010

CLINICAL FEATURESCLINICAL FEATURES

The colorectal cancers have wide range ofThe colorectal cancers have wide range of
presentation whichpresentation which ddepend on theepend on the
-- Site of the tumorSite of the tumor
-- Presence of complications like obstruction orPresence of complications like obstruction or
perforation or hemorrhageperforation or hemorrhage
-- The presence of metastasisThe presence of metastasis

 Carcinoma of the right sideCarcinoma of the right side
 it present in several guises:
- RIF pain
- anemia: sever & unyielding to treatment is
frequent features
- mass in the right iliac fossa
- melena in ulcerative form
- loss of weight
- nausea, vomiting, anorexia
- fainting, & dyspnea
- appendicities

CLINICAL FEATURES:CLINICAL FEATURES:
 Carcinoma of the left side:Carcinoma of the left side:
- alteration of bowel habit- alteration of bowel habit
- bleeding per rectum- bleeding per rectum
- loss of weight- loss of weight
- lower & LIF abdominal pain- lower & LIF abdominal pain

CLINICAL FEATURESCLINICAL FEATURES::
• Rectal cancer;Rectal cancer;
- bleeding per rectum- bleeding per rectum
- palpable mass on rectal examination- palpable mass on rectal examination
- spurtial diarrhea- spurtial diarrhea
- loss of weight- loss of weight
- tenesmus (sensation of incomplete- tenesmus (sensation of incomplete
evacuation)evacuation)
- sacral perineal pain- sacral perineal pain

Colorectal Cancer
Clinical features
Right colon Rectum Left colon
Change in bowel habit
Diarrhea Tenesmus Constipation
Anemia “Blood & mucus Bleeding
Discharge” PR

CLINICAL FEATURESCLINICAL FEATURES::
 Emergency presentation;Emergency presentation;
patient may present as an emergencypatient may present as an emergency
case in the form ofcase in the form of
- acute intestinal obstructionacute intestinal obstruction
- perforation result in fecal peritonitis- perforation result in fecal peritonitis
- sever per rectal bleeding or melena- sever per rectal bleeding or melena
Metastasis presentation includes:Metastasis presentation includes:
jaundice, fistulae, coughjaundice, fistulae, cough

INVESTIGATIONSINVESTIGATIONS
 Digital Rectal Examination (DRE):Digital Rectal Examination (DRE):
is essential & many rectal cancers can be identifiedis essential & many rectal cancers can be identified
as craggy ulcerated massas craggy ulcerated mass
 fecal occult blood (FOBfecal occult blood (FOB)) for screeningfor screening
 blood & electrolytesblood & electrolytes examination will shows;examination will shows;
AAnemianemia of iron deficiency type especially in rightof iron deficiency type especially in right
side cancerside cancer
 ESRESR will increase but not specificwill increase but not specific
 Electrolytes disturbanceElectrolytes disturbance may be evident as resultmay be evident as result
of, diarrhea obstruction, vomiting, inadequate fluidof, diarrhea obstruction, vomiting, inadequate fluid
intake, urea may increase as result of dehydrationintake, urea may increase as result of dehydration
 Carcino-embryonic antigen (CEA)Carcino-embryonic antigen (CEA) can be detectedcan be detected

INVESTIGATIONSINVESTIGATIONS imagingimaging
 plain X-rayplain X-ray will show signs of obstruction &dilated bowelwill show signs of obstruction &dilated bowel
 CXRCXR for lung metastasisfor lung metastasis
 Barium enemaBarium enema carcinoma of the colon as a constant,carcinoma of the colon as a constant,
irregular, filling defect ( apple core deformity) on theirregular, filling defect ( apple core deformity) on the
other hand negative radiography by no means excludeother hand negative radiography by no means exclude
the carcinomathe carcinoma
 USSUSS is essential tool of investigations, it can detect theis essential tool of investigations, it can detect the
mass, and presence of metastasis in the liver or pelvicmass, and presence of metastasis in the liver or pelvic
organsorgans
 Intrarectal USS:-Intrarectal USS:-
new tool of investigations with great help of diagnosisnew tool of investigations with great help of diagnosis
and staging of the cancer especially the rectal cancerand staging of the cancer especially the rectal cancer
 CT-scanCT-scan is needed for evaluation of resectabilityis needed for evaluation of resectability
 MRIMRI has lower sensitivity and higher specificity than CThas lower sensitivity and higher specificity than CT
scan in T staging. The techniques have a similar overallscan in T staging. The techniques have a similar overall
accuracyaccuracy in T staging.in T staging.

Chest X-rayChest X-ray
 Chest radiograph -Chest radiograph -
pulmonarypulmonary
metastases frommetastases from
colonic carcinomacolonic carcinoma

InvestigationsInvestigations
 Double contrast barium enemaDouble contrast barium enema
– Does not require sedationDoes not require sedation
– Avoids risk of perforationAvoids risk of perforation
– More limited in detecting small lesionsMore limited in detecting small lesions
– All lesions need to be confirmed by colonoscopyAll lesions need to be confirmed by colonoscopy
and biopsyand biopsy
– Performed with sigmoidoscopyPerformed with sigmoidoscopy
– Second line in patients who failed / cannotSecond line in patients who failed / cannot
undergo colonoscopyundergo colonoscopy

Double contrast Ba. enemaDouble contrast Ba. enema
 Colon Annular carcinomaColon Annular carcinoma
of the sigmoid colon.of the sigmoid colon.
The lumen of the sigmoidThe lumen of the sigmoid
is narrowed severely byis narrowed severely by
the circumferential massthe circumferential mass
with mucosal destructionwith mucosal destruction
and the overhangingand the overhanging
edges or shouldering atedges or shouldering at
the tumor marginsthe tumor margins..

CT scan of colonic cancerCT scan of colonic cancer
 Contrast-enhancedContrast-enhanced
CT showing liverCT showing liver
metastases.metastases.
 Several low-densitySeveral low-density
metastases from themetastases from the
colonic primarycolonic primary
tumor involve bothtumor involve both
lobes of the liver.lobes of the liver.

CT scan of colonic cancerCT scan of colonic cancer
 Preoperative CT -Preoperative CT -
cecal wallcecal wall
thickening andthickening and
infiltration of theinfiltration of the
pericolic fatpericolic fat

EndoscopiesEndoscopies
 SigmoidoscopySigmoidoscopy:: rigid sigmoidoscope reach to only therigid sigmoidoscope reach to only the
distaldistal 30 cm of the colon, but flexible sigmoidoscope30 cm of the colon, but flexible sigmoidoscope
can reach up to 60 cm where 70% of tumor cancan reach up to 60 cm where 70% of tumor can
detected.detected.
 Sigmoidoscope is important investigation & shouldSigmoidoscope is important investigation & should
be performed in cases of bleeding & mucusbe performed in cases of bleeding & mucus
discharged from the rectum also biopsy can bedischarged from the rectum also biopsy can be
taken for histological studiestaken for histological studies
 colonoscopecolonoscope:: should be carried in all cases as inshould be carried in all cases as in
3% of cases there will be synchronous tumor3% of cases there will be synchronous tumor

InvestigationsInvestigations
 ColonoscopyColonoscopy
– Can visualize lesions < 5mmCan visualize lesions < 5mm
– Small polyps can be removed or at a later stageSmall polyps can be removed or at a later stage
by endoscopic mucosal resectionby endoscopic mucosal resection
– Performed under sedationPerformed under sedation
– Consent: bleeding, infection, perforation (1 inConsent: bleeding, infection, perforation (1 in
3000), missed diagnosis, failed procedure,3000), missed diagnosis, failed procedure,
anaesthetic/medical risksanaesthetic/medical risks
– Warn: bowel prep, abdominal bloating/discomfortWarn: bowel prep, abdominal bloating/discomfort
afterwards, no driving for 24 hoursafterwards, no driving for 24 hours

Colonoscope images ofColonoscope images of
colorectal cancercolorectal cancer

BiopsyBiopsy
No body have cancer until the pathologist say soNo body have cancer until the pathologist say so
• BiopsyBiopsy - Evaluation for cancerous- Evaluation for cancerous
changes of tissue samples removedchanges of tissue samples removed
during test procedures .during test procedures .

Medical TeamMedical Team
 Successful treatmentSuccessful treatment
requires a multidisciplinaryrequires a multidisciplinary
team of CRC specialists:team of CRC specialists:
– Surgical OncologistSurgical Oncologist
– Medical OncologistMedical Oncologist
– Radiation OncologistRadiation Oncologist
– RadiologistRadiologist
– PathologistPathologist
– Oncology NurseOncology Nurse
SpecialistSpecialist
– Social WorkerSocial Worker
– NutritionistNutritionist
– PharmacistPharmacist
 choice of a medical teamchoice of a medical team
depends on preferences:depends on preferences:
– RecommendationsRecommendations
– ExpertiseExpertise
– Style of communicationStyle of communication
– LocationLocation
– Type of institutionType of institution
(private practice,(private practice,
community hospital,community hospital,
cancer center)cancer center)
– InsuranceInsurance

Goals of TreatmentGoals of Treatment
Goals of Treatment forGoals of Treatment for
Early DiseaseEarly Disease
 Remove cancer cellsRemove cancer cells
 Kill cancer cellsKill cancer cells
 Keep the cancer cellsKeep the cancer cells
from returningfrom returning
Treatment is defined by stage and type of cancer present
Every person responds differently to treatment, so communication is key!
Goals of Treatment for
Advanced Disease
• Slow or stop the growth of
cancer cells
• Manage quality of life
concerns

TREATMENTTREATMENT
 Surgical treatment :Surgical treatment :
Surgery provides the only hope for cureSurgery provides the only hope for cure
of the cancer, and for palliation ofof the cancer, and for palliation of
incurable cancer.incurable cancer.
– Resection of the tumor with adequateResection of the tumor with adequate
margins & including the regionalmargins & including the regional
lymph nodes is indicated when thelymph nodes is indicated when the
diagnosis is confirmed.diagnosis is confirmed.

ManagementManagement
 Pre-operativePre-operative
– Bowel prep – picolax, go lytely, fleetBowel prep – picolax, go lytely, fleet
 Normally 1 day priorNormally 1 day prior
 Partial obstruction – 2~3 days priorPartial obstruction – 2~3 days prior
 Complete obstruction – intra-operative lavageComplete obstruction – intra-operative lavage
– Antibiotics prophylaxis (up to 24 hours post-op)Antibiotics prophylaxis (up to 24 hours post-op)
 AmpicillinAmpicillin
 MetronidazoleMetronidazole
 GentamicinGentamicin
– DVT/PE prophylaxisDVT/PE prophylaxis

TREATMENTTREATMENT
 Surgical procedures;Surgical procedures;
general principle include :general principle include :
– early ligation of the vascular pedicleearly ligation of the vascular pedicle
– no-touch techniqueno-touch technique
– avoidance of contamination by bowelavoidance of contamination by bowel
content.content.

 Caecum or ascending colon
– Right hemicolectomy
– Vessels divided – ileocaecal and right colic
– Anastamosis between terminal ileum and
transverse colon
 Transverse colon
– Close to hepatic flexure  right hemicolectomy
– Mid-transverse  extended right hemicolectomy
(up to descending) + omentum removed en-bloc
with tumour
– Splenic flexure  subtotal colectomy (up to
sigmoid)

 Descending colon
– Left hemicolectomy
– Vessels divided – inferior mesenteric, left colic,
sigmoid
 Sigmoid colonSigmoid colon
– High anterior resection
– Vessels ligated – inferior mesenteric, left colic
and sigmoid
– Anastomoses of mid-descending colon to upper
rectum

 Obstructing colon carcinomaObstructing colon carcinoma
– Right and transverse colonRight and transverse colon – resection and primary– resection and primary
anastomosisanastomosis
– Left sided obstruction
 Hartmann’s procedure – proximal end colostomy (LIF)Hartmann’s procedure – proximal end colostomy (LIF)
+ oversewing distal bowel + reversal in 4-6 months+ oversewing distal bowel + reversal in 4-6 months
 Primary anastamosis – subtotal colectomy (ileosigmoidPrimary anastamosis – subtotal colectomy (ileosigmoid
or ileorectal anastomosis)or ileorectal anastomosis)
 Intraoperative bowel prep with primary anastomosisIntraoperative bowel prep with primary anastomosis
(5% bowel leak)(5% bowel leak)
 Proximal diverting stoma then resection 2 weeks laterProximal diverting stoma then resection 2 weeks later
 Palliative stentPalliative stent

Rectal CancerRectal Cancer
 OptionsOptions
– Low anterior resectionLow anterior resection
– Transanal local excisionTransanal local excision
– Abdomino-perineal resectionAbdomino-perineal resection
– Palliative procedurePalliative procedure
 Factors influencing choiceFactors influencing choice
– Level of lesion – distance from dentate line, <5cm requiresLevel of lesion – distance from dentate line, <5cm requires
abdomino-perineal resection to obtain adequate marginabdomino-perineal resection to obtain adequate margin
 Note: only 3% of tumours spread beyond 2cmNote: only 3% of tumours spread beyond 2cm
– Grade – poorly differentiatedGrade – poorly differentiated  larger marginlarger margin
– Patient factors – incotinencePatient factors – incotinence
– Mesorectal node status – resect if LN metsMesorectal node status – resect if LN mets

Rectal CancerRectal Cancer
 Hartmann’s procedureHartmann’s procedure
– Acute obstructionAcute obstruction
– PalliativePalliative
 Transanal local exisionTransanal local exision
– Early stageEarly stage
– Too low to allow restorative surgeryToo low to allow restorative surgery
 En block resectionEn block resection – for locally advanced colorectal– for locally advanced colorectal
carcinoma (remove adherent viscera and abdominal wall)carcinoma (remove adherent viscera and abdominal wall)
 Palliative proceduresPalliative procedures
– Diverting stomaDiverting stoma
– RadiotherapyRadiotherapy
– ChemotherapyChemotherapy
– Local therapy – laser, electrocoagulation, cryosurgeryLocal therapy – laser, electrocoagulation, cryosurgery
– Nerve blockNerve block

TREATMENTTREATMENT
 Post-operative carePost-operative care
post-operative treatment includes thepost-operative treatment includes the
administration of antibiotic to guardadministration of antibiotic to guard
against possible infection of theagainst possible infection of the
anastmosis areaanastmosis area
 fluid are not given by mouth until flatusfluid are not given by mouth until flatus
is passedis passed

TREATMENTTREATMENT
 Adjuvant TherapyAdjuvant Therapy
 Adjuvant (Latin:Adjuvant (Latin: adad- to,- to, juvarejuvare- help) therapy is- help) therapy is
commonly used as a broad term encompassing allcommonly used as a broad term encompassing all
types of treatment used in conjunction with surgery.types of treatment used in conjunction with surgery.
 Two terms are commonly used in this context.Two terms are commonly used in this context.
-- Neoadjuvant therapyNeoadjuvant therapy: This can be defined as any: This can be defined as any
form of treatment the patient receives prior to definitiveform of treatment the patient receives prior to definitive
surgical intervention, with the aim of limiting the scopesurgical intervention, with the aim of limiting the scope
of surgery required.of surgery required.
-- Adjuvant therapyAdjuvant therapy: Those treatments that are given: Those treatments that are given
following the definitive surgery are described asfollowing the definitive surgery are described as
'adjuvant'. These are given with the aim of reducing the'adjuvant'. These are given with the aim of reducing the
risk of survival of micro-metastases after curativerisk of survival of micro-metastases after curative
surgery has been undertaken.surgery has been undertaken.

Adjuvant therapyAdjuvant therapy
 Adjuvant radiotherapyAdjuvant radiotherapy
there is now good evidence that adjuvantthere is now good evidence that adjuvant
radiotherapy given either pre or post-operativelyradiotherapy given either pre or post-operatively
reduces local recurrence rate and may increasereduces local recurrence rate and may increase
the survivalthe survival
 Adjuvant chemotherapy:Adjuvant chemotherapy:
there is now evidence that patient with Duke’sthere is now evidence that patient with Duke’s
colon cancer benefit from adjuvant chemotherapycolon cancer benefit from adjuvant chemotherapy
with 5-flurouracil (5-FU) and levamisol or folinicwith 5-flurouracil (5-FU) and levamisol or folinic
acid .acid .

Adjuvant therapy
Management of advanced cases:
Liver metastasis :
- hepatic resection
- systemic or intra-arterial
chemotherapy
disseminated metastasis: use of
chemotherapy.

New Therapies:New Therapies:
Antiangiogenesis TherapyAntiangiogenesis Therapy
 ““Starves” the tumor by disrupting its bloodStarves” the tumor by disrupting its blood
supplysupply
 This therapy is given along with chemotherapyThis therapy is given along with chemotherapy
 Bevacizumab (Avastin)Bevacizumab (Avastin) was approved by thewas approved by the
U.S. Food and Drug Administration (FDA) inU.S. Food and Drug Administration (FDA) in
2004 for the treatment of stage IV colorectal2004 for the treatment of stage IV colorectal
cancercancer ®)®)

New Therapies:New Therapies:
Targeted TherapyTargeted Therapy
 ““Treatment designed to target cancer cellsTreatment designed to target cancer cells
while minimizing damage to healthy cellswhile minimizing damage to healthy cells
 Cetuximab (Erbitux)Cetuximab (Erbitux) was approved by thewas approved by the
FDA in 2004 for the treatment of advancedFDA in 2004 for the treatment of advanced
colorectal cancercolorectal cancer

Recommendations for PreventionRecommendations for Prevention
of Colorectal Cancerof Colorectal Cancer
 DietDiet: low in fat, high in fruits: low in fat, high in fruits
and vegetables and fiberand vegetables and fiber
 SupplementsSupplements: Vitamin A,: Vitamin A,
E,C, folate, selenium,E,C, folate, selenium,
calciumcalcium
 Life habitsLife habits: activity, normal: activity, normal
body weight, avoid smoking,body weight, avoid smoking,
and excessive alcoholand excessive alcohol
 Medications:Medications: Aspirin andAspirin and
other NSAIDs,other NSAIDs,
postmenopausal hormonalpostmenopausal hormonal
replacement, HMG-CoAreplacement, HMG-CoA
inhibitorsinhibitors
CCohort study:ohort study:
proctosigmoidoscopyproctosigmoidoscopy
screening reduced incidencescreening reduced incidence
of rectal cancer by 85%*of rectal cancer by 85%*
Case control studies:Case control studies:
endoscopy and polypectomyendoscopy and polypectomy
reduced mortality from distalreduced mortality from distal
caancer by 50% to 79%**caancer by 50% to 79%**
Prospective trialProspective trial ofof
colonoscopy, polypectomycolonoscopy, polypectomy
and surveillance: reducedand surveillance: reduced
incidence of colorectalincidence of colorectal
cancer by 76% to 90%***cancer by 76% to 90%***
Primary Prevention
Secondary:
resection of colorectal adenomas

Screening Methods for ColorectalScreening Methods for Colorectal
CancerCancer
 Colonoscopy (currently the best way toColonoscopy (currently the best way to
prevent and detect colorectal cancer)prevent and detect colorectal cancer)
 Virtual colonographyVirtual colonography
 SigmoidoscopySigmoidoscopy
 Fecal occult blood testFecal occult blood test
 Double contrast barium enemaDouble contrast barium enema
 Digital rectal examinationDigital rectal examination

TO REMEMBERTO REMEMBER
 More than one-third of colorectal cancer deathsMore than one-third of colorectal cancer deaths
could be avoided if people over the age of 50 hadcould be avoided if people over the age of 50 had
regular screening tests; 92% of cases occur inregular screening tests; 92% of cases occur in
people 50 and older.people 50 and older.
 Most colorectal cancers begin as polyps.Most colorectal cancers begin as polyps.
People who have polyps or colorectal cancer doPeople who have polyps or colorectal cancer do
not always have symptoms, so it’s possible to havenot always have symptoms, so it’s possible to have
either and not know it.either and not know it.

TO REMEMBERTO REMEMBER
 Colorectal cancer is one of the most preventableColorectal cancer is one of the most preventable
cancers. Screening tests can help preventcancers. Screening tests can help prevent
colorectal cancer by finding pre-cancerous polypscolorectal cancer by finding pre-cancerous polyps
so they can be removed before they turn intoso they can be removed before they turn into
cancer.cancer.
 Screening tests can find colorectal cancer early,Screening tests can find colorectal cancer early,
when treatment works best. When colorectal cancerwhen treatment works best. When colorectal cancer
is detected in the earliest stage of the disease, theis detected in the earliest stage of the disease, the
survival rate is 96%.survival rate is 96%.
 Both men and women are at risk. Some peopleBoth men and women are at risk. Some people
think that women are not at risk for colorectalthink that women are not at risk for colorectal
cancer; this isn’t true. Anyone may develop it.cancer; this isn’t true. Anyone may develop it.

CONCLUSIONCONCLUSION
 Colorectal cancer is the third most commonColorectal cancer is the third most common
cancer in both men and women.cancer in both men and women.
 Tremendous strides are made regularly in theTremendous strides are made regularly in the
prevention, diagnosis, and treatment ofprevention, diagnosis, and treatment of
colorectal cancer, posing a challenge to thecolorectal cancer, posing a challenge to the
clinician who must stay abreast of the mostclinician who must stay abreast of the most
recent advancesrecent advances

Colorectal cancer

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