Colorectal

Cancer
Presented by:
Anas jolani amiral aiman ahmed fathi

Epidemiology ..
It is a disease with a known geographical
variation.
Incidence varies from 4/100,000 to
40/100,000.
Mean age in the west is 63. Here in Jordan, it is
61.
In Jordan, 13% of cases are below 45 years,
while 6% in the west.
Nearly equal incidence in both sexes. Some

Screening at
age of 50

10 years, involving the

whole colon

Ulcerativ
e colitis

Polyps

Age

Alcohol
&
smoking

Risk
Factors

Hereditar
y
conditions

FAP
HNPCC

Low
Low fiber
fiber
diet,
diet,
refined
refined
carbs,
carbs, high
high
animal
animal fat
fat

Family
history

Polyps [Adenoma]

Descriptive
Descriptive
term
term for
for any
any
elevation
elevation in
in
the
the mucosa.
mucosa.
>95%
>95% of
of colon
colon
cancer
cancer occur
occur
on
on top
top of
of
polyps.
polyps.
>>
>>
Adenomatous
Adenomatous
polyps
polyps are
are
PREPREMALIGNANT!
MALIGNANT!

Clinical
Clinical
presentation:
presentation:
-Mostly
-Mostly
incidental
incidental
-Rectal
-Rectal
bleeding
bleeding
-Change
-Change in
in
bowel
bowel habit
habit
-Pain,
-Pain, N&V
N&V >
>
obstruction
obstruction

Described
Described
grossly:
grossly:
-Sessile
-Sessile
-Pedunculated
-Pedunculated
Described
Described
pathologically:
pathologically:

-Tubular
-Tubular
-Villous
-Villous
-Tubulovillous
-Tubulovillous

Tubular adenoma
-more common than
villous
-usually pedunculated

Villous
adenoma

-less common than tubular

-usually sessile
-appear as velvety or
cauliflower-like projections
-maybe up to 10 cm in
diameter
-much more likely to
harbour invasive carcinoma
(about 40%)

Factors that increase the risk of

transformation into malignancy:

1- Size
2- Histology
3- Dysplasia

Villous

*Why do they become malignant?

Mutations (inherited, environmental)
>Inactivation of suppressor gene: APC, mismatch
repair
>Activation of oncogene: K-ras

*Management: polypectomy by
endoscopy or surgically if too large.

Familial Adenomatous
Polyposis
-Autosomal dominant
-Clinically defined by the presence of more
than 100 colorectal adenomas
-Accounts for less than 1% of colorectal cancer
-Risk of colorectal cancer is 100%!
*80% with +ve family history. 20% arise from
new mutations in APC gene.

Patients start to develop polyps early in

teenage.
By the 4th decade, ALL patients have
colorectal cancer!

Management:
In the past: Colectomy with ileorectal
anastomosis

>carries risk of cancer in the rectum

Now:
Restorative proctocolectomy with ileoanal
anastomosis

Hereditary NonPolyposis
Colorectal Cancer (HNPCC)
-Lynch syndrome
-Autosomal dominant
-Mean age of diagnosis is 44 years
-5-6% of colorectal cancer
-Lifetime risk of colorectal cancer is 80%
-Caused by mutation in one of the DNA mismatch
repair genes
-Most cancers develop in the proximal colon
-High incidence of synchronous &
metachronous tumors (colon, endometrium,
ovary, stomach)

HNPCC can be diagnosed by genetic testing, or

Amsterdam criteria II:
-Three or more family members with an HNPCCrelated cancer, one of whom is a first-degree
relative of the other two.
-Two successive affected generations.
-One or more of the HNPCC-related cancers
diagnosed before the age of 50 years.
-Exclusion of FAP.

Colon Cancer
The most common GI cancer
>98% is Adenocarcinoma
2%: carcinoid, leiomyosarcoma, lymphoma
Grossly:

Fungating lesion

Ulcerating lesion

Stenosing lesion: left colon > intestinal obstruction

Mass lesion: cecum & ascending colon

Fungating, mass
lesion

Stenosing lesion

Mass lesion with

ulceration

A gradual shift toward right-sided or proximal colon cancers has been

observed both in the United States and internationally

Symptoms
Asymptomatic: discovered by screening

Change in bowel habit ( constipation, diarrhea, alteration )

Rectal bleeding ( any type : fresh , altered, drops, clots, black )

Abdominal discomfort, weight loss and tiredness (anemia)

{ more with Rt. colon CA }

20% of cases present as Emergency: intestinal obstruction,

peritonitis due to perforation, massive bleeding
*Any colonic bleeding >40 years require complete investigation
of the colon.

Signs
Pallor.
Abdominal mass.
PR mass.
Jaundice.
Nodular liver
Ascitis.

Investigations
Confirm diagnosis.
Evaluation of the whole colon.
Evaluation of the extent of the disease.

Investigations
o CBC, LFT
o Fecal occult Blood test.
o Barium enema.
oCT colongraphy (virtual colonography)
o Lower Endoscopy/ colonoscopy/ sigmoidoscopy
oEndorectal US for rectal Ca
oCEA Tumor marker. Follow up & recurrence
oCT, MRI, Chest X-ray, PET scan metastasis

Fecal occult blood test

We look for occult blood in the stool.
The advantages of this test are that it is simple and not
expensive.
Both the sensitivity and specificity of this test are low.
Other diseases produce blood like hemorrhoids, anal
fissures and peptic ulcers.
Therefore this test is not a diagnostic test.

Lower Endoscopy
The lower endoscopy
includes both colonoscopy
and sigmoidoscopy.
It can be both diagnostic
and therapeutic since the
doctor can remove a polyp
if he finds one.
colonoscpy is the
investigation of choice for
colorectal cancer

Barium Enema
The barium blocks X-rays, causing the
barium-filled colon to show up clearly on
the X-ray picture.
We look for filling defects in the
presence of colorectal cancer.
Characteristic apple core appearance

Staging
- TNM
- Dukes
- modified Dukes

TNM staging
T : tumor
N : lymph nodes involved
M : metastasis

Dukes classification
A: tumor within the wall.
B: tumor through the whole wall.
C: involvement of lymph nodes (C1,C2)
D: metastatic spread.

Mode of spread
Direct spread to adjacent structures (may cause fistula)
Lymphatic.
Vascular (commonest sites: liver, lung, bone, brain)
Transcoelomic (shedding into peritoneal cavity leading
to ascites)

Treatment
*** The treatment is individualized..
Surgery
Chemotherapy (systemic, chemoembolization)
(before (neoadjuvant) or after (adjuvant) surgery
Radiotherapy (external, internal) (before or after
surgery)
Combination chemotherapy and radiotherapy

Surgery
The primary treatment.
Curative or palliative.
Resection & re- anastomosis as one
stage.
Stoma

Types of surgeries
Right hemicolectomy
Left hemicolectomy
Total colectomy
sigmoidectomy
Anterior resection ( removal of the rectum )
Abdominoperineal resection (removal of the rectum and
the anal canal )
Put colostomy (permanent or temporary )
Put ileostomy
Put any other stomy

Right Hemicolectomy and ileocolic anastomosis

for Cecal / Right Colon Cancer

Left Hemicolectomy and anastomosis of

colon and rectum for Left Colon Cancer

Sigmoid Colectomy and anastomosis of

colon and rectum for Sigmoid Cancer

Total colectomy needs to be considered for multiple tumors

Prognostic factors
Stage ( most important factor )
Pathology (differentiation, vascular & perineural invasion)
DNA content ( aneuploidy or diploidy )
Mucin secreting tumour or not
Technique and surgeon experience
Perforation.
Co-morbidity and general condition of the
patient

Prognosis
5-year survival rate:
Stage I: 90%.
Stage II: 60-80%.
Stage III: 20-50%.
Stage IV: < 5%.

Rectal tumors

- Symptoms mainly:
Hematochezia (fresh blood), mucus with stool,
tenesmus and feeling of incomplete evacuation,
Alteration in bowel habit : Early morning
diarrhoea. Urinary symptoms
- Signs:
by PR examination >> mass, can give
information on the size, fixation, ulceration, local
invasion, and lymph node status

Types of carcinoma spread

1- Local spread:
Local spread occurs circumferentially rather than in a longitudinal
direction.
If penetration occurs anteriorly, the prostate, seminal vesicles or
bladder become involved in the male; in the female, the vagina or
the uterus is invaded. In either sex, if the penetration is lateral, a
ureter may become involved, while posterior penetration may reach
the sacrum and the sacral plexus.
2- Venous spread, liver, lungs, adrenals.
3-Lymphatic spread.
4-Peritoneal dissemination

Staging
Dukes classified carcinoma of the rectum into stages :
A : The growth is limited to the rectal wall (15%): prognosis excellent.
B : The growth is extended to the extrarectal tissues, but no metastasis
to the regional lymph nodes (35%): prognosis reasonable.
C : There are secondary deposits in the regional lymph nodes (50%).
These are subdivided into C1, in which the local pararectal lymph
nodes alone are involved, and C2, in which the nodes accompanying
the supplying blood vessels are implicated up to the point of division :
prognosis is poor.
D : stage D is often included, which was not described by Dukes. This
stage signifies the presence of widespread metastases, usually
hepatic.

Investigations
Rigid or flexible sigmoidoscopy.
Biopsy : Using biopsy forceps via a sigmoidoscope, a
portion of the edge of the tumor can be removed. If
possible, another specimen from the more central part
of the growth should also be obtained.
Barium Enema
Trans-rectal ultrasonography has an accuracy of
approximately 75% for T stage and 65% for N stage; it
should be an integral part of the staging of rectal
tumors.

Endorectal US
It shows us the layers of the rectal wall
and to see the depth of invasion through
mucosa
it can help to reach the diagnosis

Surgical Treatment
goals: to remove cancer with adequate margins and
perform an anastomosis only if theres:
1- good blood supply,
2- absence of tension, and
3- normal anal sphincters.
*** If any of these conditions cannot be met, the entire
rectum must be removed and the patient left with a
permanent colostomy.

Colostomy

Surgical option depends on:

The height of the lesion,
The condition of the sphincters,
The condition of the patient.

Options we have:
Low anterior resection: is the operation of choice for
tumors that can be resected with an adequate distal
margin
Abdominoperineal resection:
is performed for tumors that cannot be resected with a
2-cm distal margin or if sphincter function is
questionable.
Colonic J-pouch or coloplasty:
may also be constructed to recreate the reservoir
function of the rectum

Anterior resection and anastomosis of colon and rectum

for upper and middle rectal tumors

Abdominoperineal resection resection of anus rectum and part

of segmoid colon and leave a permanent colostomy for lower
rectal tumors

Adjuvant therapy
for rectal cancer should routinely be considered to
reduce local recurrence and possibly improve overall
survival.

Preoperative radiotherapy
Neoadjuvant chemoradiation,
including chemotherapy with a 5fluorouracilbased regimen.

THE END! :)