K 17 Colorectal Carcinoma

SURGICAL TREATMENT FOR
COLORECTAL CANCER
PROF. PANKAJ G. JANI, ASSOCIATE PROFESSOR, DEPARTMENT

OF SURGERY, UNIVERSITY OF NAIROBI
COLORECTAL CANCER(CR)
MANAGEMENT IS BY A
MULTIDISCIPLINARY TEAM
 C.R. SURGEONS
 ONCOLOGISTS
 RADIOTHERAPISTS
 DIAGNOSTIC RADIOLOGISTS
 NURSE SPECIALISTS
 HISTOPATHOLOGISTS
COLORECTAL CANCER
 SURGERY REMAINS THE MAIN STAY

OF TREATMENT, EVEN IN
METASTATIC DISEASE
PATHOLOGY
 MOST COMMON & CLINICALLY
SIGNIFICANT CANCER OF THE BOWEL
 COMMONEST CAUSEE OF CANCER

RELATED MORBIDITY & MORTALITY
IN THE WEST {>35000 NEW CASES / YR
(UK)}
DISTRIBUTION OF COLON CA
 RIGHT COLON ♎ 20%
 TRANSVERSE COLON ♎ 10%
 LEFT COLON ♎ 5%
 RECTOSIGMOID ♎ 55%
 OTHER SITES ♎ 10%

RECTAL CANCER
GOALS OF THERAPY FOR
RECTAL CARCINOMA
 DECREASE LOCAL RECURRANCE
 OPTIMISE Q.O.L. AVOID

COLOSTOMY
ANATOMY OF RECTUM
 CHANGED FROM TRADIOTIONAL 22

CMS FROM ANAL VERGE TO 15 CMS
 ABOVE THAT IS NOW ALL COLON

CA. RECTUM (ESP. LOWER
TUMORS)
 SHOULD BE DIAGNOSED EARLY

(DRE)
 SHOULD GIVE GOOD RESULTS WITH

EARLY THERAPY
SYMPTOMS
 RECTAL BLEEDING
LOWER RECT.
 TENESMUS
 ALT. OF BOWEL HABITS

UPPER.
 ANY G.I. SxS (dyspepsia)
SURGICAL CHALLANGES
 I - STAGING
 II - USE OF CH/RT
 III - SURGICAL TECHNIQUE

STAGING
MODIFIED DUKES
TNM
DUKES STAGING SYSTEM
FOR COLORECTAL CANCER
Dukes Definition Approximate five year
stage cumulative survival (%)
A Tumour confined to the mucosa 95
B1 Tumour invading the muscularis propria but 90

not the serosa
B2 Tumour invading the serosa but no lymph 60

node involvement
C1 Tumours with metastasis to regional lymph 40

nodes
C2 Tumours with metastasis to regional and/or 10

apical lymph node involvement
D Distant metastases present <10

STAGING
DECIDES –TRANS ANAL LOCAL

EXCISION  APR
.
- NEOADJUVANT CH/RT
TRADITIONAL STAGING
 DIGITAL RECTAL EXAMINATION
 CT SCANS
NEWER STAGING
METHODS
 DRE
 ERUS – NODES
 CT
RECENT ADVANCES
 DRE
 ERUS
 MRI
STAGING
DRE FOR ADVANCED TUMORS

STAGING
 ERUS
 T STAGE ACCURACY 60 – 90%
 N STAGE ACCURACY 60 – 90%
 MRI
 T STAGE ACCURACY 60 – 90%
 N STAGE 40 --- 80%
 ( NODES > 5mm)
RECENT ADVANCES ERUS
 ERUS
------ BEST FOR NODAL STATUS
( OPERATOR DEPENDANT)
CHALLANGE
 PICK UP < NODES < 5mm (33%OF ALL

<NODES)
 PICK UP MICRO METS
 USE OF CH/RT
STAGING MRI
 HIGH RESOLUTION THIN SLICE (<1mm)
 DEPTH OF EXTRAMURAL SPREAD ACCURATELY

IDENTIFIED (AIDS CIRCUMFERENTIAL
RESECTION MARGIN)
 TRADITIONAL
- PROXIMAL RESECTION MARGINS
- DISTAL IMPORTANT
 RECENT ADV. – CIRCUMFERENTIAL RESEC.

MARGINS IMP.
RECENT ADVANCE MRI
INDICATORS OF MALIGNANT NODAL
INVOLVEMENT
L. NODES
IRREGULAR BORDER
MIXED SIGNAL INTENSITY OF NODE

RECENT ADVANCE MRI
 DETECTS EXTRAMURAL VENOUS

INVASION (EMVI)
 POOR PROGNOSIS WITHOUT CH/RT

IF EMVI PRESENT
II USE OF CH/RT
(NEOADJUVANT/ADJUVANT)
 PTS WITH POOR HISTOLOGY
 PTS WITH EXTRA MURAL SPREAD (MRI)
 PTS WITH INVOLVED NODES (ERUS)
 PTS WITH EMVI (MRI)

III SURGICAL TECHNIQUE
TRADITIONAL
PROCTECTOMY PERFORMED
-- In the DARK
-- Using BLUNT Dissection
-- Without attention to ANATOMIC Detail
RESULTED in
-- Bloody operation
-- Increased -- Autonomic Nerve injury
-- APR rates
-- Local Rec.
SURGERY - TRADITIONAL
 ANT. RESECTION – UPPER ⅓ RECTAL CA

 LOW ANT.RESCETION- MID ⅓ RECTAL CA
 A.P.R. - LOWER ⅓ RECTAL CA
 ANY TUMOR 10cms FROM ANAL VERGE-

APR
.
RECTAL CA. RECENT ADVANCES
Dangerous Practices
RECTAL CARCINOMA
RECENT ADVANCES
 >100 YEARS SINCE MILES DESCRIBED

ABDOMINO-PERINEAL-RESECTION
 >25 YEARS SINCE HEALD DESCRIBED

TOTAL MESORECTAL EXCISION
III SURGICAL TECHNIQUE
RECENT ADV.
TOTAL MESORECTAL EXISION
( EXICISION OF FASCIA ENVELOPING

THE FAT PAD AROUND THE RECTUM.)
SAUSAGE APPEARANCE
SURGERY – RECENT
ADVANCES
 LOW-ANT RESECTION – UPTO ≏ 6cms

FROM ANAL VERGE
 APR – ONLY IF SPHINCTOR

FUNCTION COMPROMISED
RECTAL CANCER –
RECENT ADVANCES
CAREFUL ASSESSMENT OF SxS

- PROCTOSCOPY
EARLY DIGNOSIS WITH - SIGMOIDOSCOPY

- DRE
ACCURATE STAGING - ERUS
- MRI

CH/RT - FOR SELECTED PTS
RECTAL CANCER –
RECENT ADVANCES
 CH/RT - FOR SELECTED PTS
 TRANSANAL RESECTION
SURGERY - (TEM)
- LOW ANT RESECTION
 - APR
RESTAGE
(With Histology)

ADTUVANT CH/RT
CHEMOTHERAPY
 INJ KYTRIL 3mg Ksh 2,250/-
 INJ DEXAMETHAZONE 8mg Ksh 385/-
 INJ FLUOUROURACIL 5500mg Ksh 12,053/-
 INJ OXALIPLATIN 200mg Ksh 187,600/-
 INJ LEUCOVORIN 100mg Ksh 1,809/-
 INJ AVASTIN 400mg Ksh 213,806/-
Kshs417903/-
RADIOTHERAPY
 EUROPEAN APPROACH  AMERICAN APPROACH
 (25G/5CYCLES)  (45 – 54G/28 CYCLES)
 SHORT COURSE – LOW  PROLONGED COURSE –
DOSE – IMMEDIATE HIGH DOSE – DELAYED
SURGERY
SURGERY
 NO CHANGE IN PATH
STAGING  BETTER SURGICAL
 LOWER COST TOLERANCE
 BETTER COMPLIANCE  MORE TUMOR
 DOSE EQUIVALENT TO 30- REGRESSION
33G  EXPECT >80% REDUCTION
 EXPECT 66% REDUCTION IN LOCAL RECURRENCE
IN LOCAL RECURRENCE
A GOOD SET OF REGULAR BOWEL
MOVEMENTS IS BETTER THAN ANY
AMOUNT OF BRAINS
COLON CANCER
SOME DIFFERENCES FROM

RECTAL CANCER
DIAGNOSIS
 COLONOSCOPY
SIGI. --- FLEXIBLE ( LIMITED

COLONOSCOPY)
--- RIGID
DOUBLE CONTRAST BA. ENEMA
COLORECTAL CANCER
DIAGNOSIS – MISSED LOCALLY
 PATIENTTS WITH UNDIAGNOSED
DYSPEPSIA
 PATIENTS WITH UNDIAGNOSED IRON

DEFECIENCY ANAEMIC
 PATIENTS WITH POSITIVE FAECAL

OCCULT BLOOD
ELECTIVE SURGERY FOR
COLON CANCER
 ♎ 70% OF COLON CA PRESENT
ELECTIVELY
PRE-OP. THOROUGH STAGING IS NOT

AS ACCURATE AS FOR RECTAL CANCER
TUMOR AND NODE STAGED POST OP.

TNM STAGING SYSTEM FOR
COLORECTAL CANCER
TUMOUR (T) DEFINITION
T Primary tumour cannot be assessed
T0 No evidence of primary tumour
Tis Carcinoma in situ: intraepithelial or invasion into the lamina
propria with no extention through muscularis mucosae into
submucosa
T1 Tumour invades into submucosa, but not the muscularis propria
T2 Tumour invades into but not through the muscularis propria

T3 Tumour invades through bowel wall into subserosa or non-
peritonealized pericolic/perirectal tissues
T4 Tumour invades other organs and structures and/or perforates
visceral peritoneum
TNM STAGING SYSTEM FOR
COLORECTAL CANCER
NODES (N) DEFINATION
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph node metastases
N1 1-3 regional lymph node(s)
N2 4 or more regional lymph nodes
METASTASES (M) DEFINATION
Mx Metastatic disease cannot be assessed
M0 No evidence of metastatic disease
M1 Distant metastases present
SPREAD – COLON CANCER
 LOCAL EXTENSION
 VASCULAR INVASION
 TRANSCOELOMIC SPREAD
 MUSCULARIS MUCOSA – FEW
LYMPHATICS
 MUSCULARIS PROPRIA – RICH IN
LYMPHATICS
LYMPHATIC SPREAD
 EPICOLIC NODES
 PERICOLIC NODES
 INTERMEDIATE NODES
 PRINCIPLE NODES
ARTERIES OF LARGE INTESTINES
ADVANCED DISEASE
 RADIOLOGICAL EVALUATION ( CT )
 HISTOPATHOLOGICAL STAGING (T4)
 NEOVADJUVENT
CHEMORADIOTHERAPYDOWNSIZE
 SURGERY
HISTOLOGY
 TUBULAR DIFFERENTIATION
DETERMINES GRADE:-
 20% WELL DIFFERENTIATED
 20% POORLY DIFFERENTIATED
 60% MODERATELY DIFFERENTIATED

Common Problems Facing Surgery in Africa
Lack of Guidelines and

Standards
Inadequate supervision
RT.HEMICOLECTOMY
EXTENDED RT.
HEMICOLECTOMY
TRANSVERSE COLON CANCER
LT. HEMICOLECTOMY
SIGMOID COLECTOMY
RECENT ADVANCE
 LAPAROSCOPIC COLON RESECTIONS

(16 Cms RESEC. To 11Cms RESEC.)
RECENT ADVANCE
 RESECTION OF
HEPATIC/PULMONARY METASTASIS
OUR SCENARIO
 LATE PRESENTATION
 ADVANCED TUMORS
 ANATOMICAL DISTORTION
 LACK OF NEOADJUVENTS
 SURGERY MORE DIFFICULT
 RESULTS POORER
THANK YOU

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SURGICAL TREATMENT FOR

PROF. PANKAJ G. JANI, ASSOCIATE PROFESSOR, DEPARTMENT

 SURGERY REMAINS THE MAIN STAY

 COMMONEST CAUSEE OF CANCER

 TRANSVERSE COLON ♎ 10%

 OTHER SITES ♎ 10%

 DECREASE LOCAL RECURRANCE

 OPTIMISE Q.O.L. AVOID

 CHANGED FROM TRADIOTIONAL 22

 ABOVE THAT IS NOW ALL COLON

 SHOULD BE DIAGNOSED EARLY

 SHOULD GIVE GOOD RESULTS WITH

 ALT. OF BOWEL HABITS

 III - SURGICAL TECHNIQUE

B1 Tumour invading the muscularis propria but 90

B2 Tumour invading the serosa but no lymph 60

C1 Tumours with metastasis to regional lymph 40

C2 Tumours with metastasis to regional and/or 10

D Distant metastases present <10

DECIDES –TRANS ANAL LOCAL

 DIGITAL RECTAL EXAMINATION

DRE FOR ADVANCED TUMORS

 PICK UP < NODES < 5mm (33%OF ALL

 PICK UP MICRO METS

 DEPTH OF EXTRAMURAL SPREAD ACCURATELY

 RECENT ADV. – CIRCUMFERENTIAL RESEC.

MIXED SIGNAL INTENSITY OF NODE

 DETECTS EXTRAMURAL VENOUS

 POOR PROGNOSIS WITHOUT CH/RT

 PTS WITH EXTRA MURAL SPREAD (MRI)

 PTS WITH INVOLVED NODES (ERUS)

 PTS WITH EMVI (MRI)

 ANT. RESECTION – UPPER ⅓ RECTAL CA

 ANY TUMOR 10cms FROM ANAL VERGE-

 >100 YEARS SINCE MILES DESCRIBED

 >25 YEARS SINCE HEALD DESCRIBED

TOTAL MESORECTAL EXISION

( EXICISION OF FASCIA ENVELOPING

 LOW-ANT RESECTION – UPTO ≏ 6cms

 APR – ONLY IF SPHINCTOR

SOME DIFFERENCES FROM

SIGI. --- FLEXIBLE ( LIMITED

 PATIENTS WITH UNDIAGNOSED IRON

 PATIENTS WITH POSITIVE FAECAL

PRE-OP. THOROUGH STAGING IS NOT

TUMOR AND NODE STAGED POST OP.

T2 Tumour invades into but not through the muscularis propria

 HISTOPATHOLOGICAL STAGING (T4)

 20% WELL DIFFERENTIATED

 20% POORLY DIFFERENTIATED

 60% MODERATELY DIFFERENTIATED

Lack of Guidelines and

 LAPAROSCOPIC COLON RESECTIONS

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