Colorctal ca - MANAGEMENT -CURRENT STAUTS

1. Dr Ashutosh Mal(2nd yr PGT)

2. CRC MANAGEMENT
& RECENT UPDATES
• SCREENING
• STAGING
• DIAGNOSIS
• TREATMENT OPTIONS
SURGERY
CHEMOTHERAPY
Targeted therapy
Immunotherapy
Radiotherapy

3. SCREENING
• ThegoalofScreeningistodetectpreinvasive polyporearlyinvasivecancer.
• Neoplastic polypincluding tubular adenoma ,villousadenoma,tubulo-
villous adenomaareprecursorsofcoloncancer.
• MostCRCarisefrompre-existing polyps.
• Thecumulativelifetime riskofdeveloping CRCinunitedstatesisabout6%.
• TheAmericanCancerSociety(ACS)andtheunitedstatespreventative
servicetaskforcerecommendedscreeninginaverage-riskindividualsstarting
attheageof50.

4. ACS advocates for tests that detect adenomatous
polyp & cancer as follows:
• Double contrast barium enema every 5 yrs
• CT colonography every 5 yrs
• Flexible sigmoidoscopy every 5yrs
• Colonoscopy every 10 yrs
• Guaiac-based fecal occult blood ,fecal immunohistochemical and
stool DNA test may be performed for CRC ,but not polyp detection.

5. Cont…
• In high risk pts more intensive surveillance is recommended.
• Individual with FAP initiate annual sigmoidoscopy or colonoscopy
beginning at the age of 10 to 12 yrs. until the age of 35 to 40 if
negative
• Pt with HNPCC initiate annual screening at the age of 20 to 25 yrs
or 10 yr prior to earlest familial CRC diagnosis.
• Pt with IBD should initiate screening with colonoscopy 8 to 10 yrs
after initial diagnosis.

6. Who are at High Risk ?
• Pt with adenomatous polyp.
• H/O CRC
• First degree relative diagnosed with CRC or Adenomas
• IBD
• Genetics:
Overexpression of K-RAS ,PI-3-K,RAF oncogene
APC gene mutation
MYH-Gene
DCC & TGF-Beta -mutation
Mutation in TP53 gene
Inactivation of PTEN Gene

9. Diagnostic Workup
•Complete history
•Physical examination /DRE-size , location, distance from
verge , mobile or fixed & sphincter function
•Pelvic examination in women
•Routine exam-CBC,LFT & KFT.
•Confirmatory biopsy
•Gold standard-Colonoscopy+Biopsy
•CT –colonography ?

10. COLONOSCOPY STILL THE GOLD STANDERD
Different Techniques:
• Dye Spray Techniques
• Narrow Band Imaging
• SPOT marking
• Quality colonoscopy
• Training evolution

11. DYE SPRAY TECHNIQE
• Use of Dye ( indigo carmine or methylene blue ) to enhance images of
flat lesions at colonoscopy
• Decrease “miss” rate of small and flat lesions

12. NARROW BAND IMAGING

15. CT- COLONOGRAPHY
• Computerized tomography is used to recreate
‘VIRTUAL’- colonoscopy
• It is helical CT 3 dimensional intraluminal colon
imaging.
• It needs bowel preparation , air insufflation , CT
imaging.
• Role - in the screening programs & regular imging in
future.

16. CT Colonography

17. Staging workup
• CXR OR CECT CHEST
• Barium enema ( double-contrast)
• Colonoscopy-to evaluate extent of the tumor
• USG-W/A
• CECT-Abdomen+Pelvis, the Sensitivity of CT Scan is-50% to
80%,Specificity-30% to 80%
• MRI Liver-is the Test Of Choice for the assessment of Liver
Metastasis
• PET-CT-has emerging role

18. Barium Enema
Figure-69.25 : Barium enema showing a carcinoma of the sigmoid colon.It may
have an ‘apple core’ appearance i.e. a short, irregular stenosis with sharp
shoulders at each end.

19. For rectal Malignancies
• Endoscopic ultrasound(EUS)-Transrectal EUS is more helpfull
for staging.
• EUS is 80% to 95 % accurate in tumor staging & 70 to 85 %
accurate in mesorectal LN staging.
• MRI
• MRI techniques have high accuracy in defining the extent of
rectal cancer to mesorectum & in determining location and
stage of the tumor.
• Another advantage of MRI is that it can detect LN status.

20. Transrectal EUS

21. Others-
• STOOL CYTOLOGY
• CEA
• IHC Marker-Keratin
• Moleculer Marker-Oncogene
• DNA Flow Cytometry
• Immunoscintigraphy

22. TREATMENT OPTIONS
SURGERY
CHEMOTHERAPY
Targeted therapy
Immunotherapy
Radiotherapy

23. SURGERY
• SURGERY is The GOLD STANDARD & Principal Therapy of Primary
& Non Metastatic CA Colon.
•Curative
•Palliative
•Accurate disease staging
•Guides adjuvant treatment

24. PRINCIPLE:standardtreatment
wideresectionoftheinvolvedsegmentincludingtheLymphatic
drainageareas+mesocolon+ en-blockresectionofneighbouring
involvedorgan
AIM:
• To excise the primary lesion with adequate margin-5cm of
normal bowel proximal an distal to the tumor
• To reconstitute bowel continuity
• To avoid complications
• To inspect the other viscera and LN for mets

25. TYPES OF SURGICAL RESECTIONS
• Right Hemicolectomy
• Extended Rt Hemicolectomy
• Lt Hemicolectomy
• Segmental Resection
• Total abdominal colectomy : UC,FAP
Sx approach dictated by the Lesion Size & Location.
Location determines which region of bowel is removed & the
extent of its resections dictated by its vascular and lymphatic supply.
Minimum of 12 to 15 LN should be removed.

26. CHEMOTHERAPY
Adjuvant : AIM 1)To Destroy microscopic Metastatic disease
2)preventing death from metastasis after Sx
Metastatic setting / Palliative
Adjuvant Chemotherapy:
Benefit of Adj. Chemo is for Stage –III pts ,whereas benefit of
Stage –II pts is controversial.
Prospective randomized trial have shown that addition of 5
Fluorouracil (5FU) & Leucovorin (LV) improves survival for
resected Stage-III pts.

27. CHEMOTHERAPY
• INDICATIONS:
Positive Nodes
T4 Lesions
Venous (microscopic) spread
Signet cell type
Poorly differentiated tumor/anuploidy
Changes in CEA Level

28. CHEMOTHERAPY as adjuvant in CRC
• Oxaliplatin + 5-FU + Leucovorin ( mFOLFOX7 ):
• oxaliplatin : 100 mg/m2 IV on D1
• 5-FU : 3000 mg /m2 IV continuous infusion on D1& D2 for 46 hrs
• Leucovorin: 400 mg/ m2 IV on D1 as a 2 hour infusion before 5-FU
• Repeat cycle every 2 weeks
• Irinotecan + 5-FU + Leucovorin ( FOLFIRI Regimen ):
• Irinotecan : 180 mg/m2 IV on D1
• 5-FU : 400 mg/m2 IV bolus on D1,followed by 2400 mg/m2 IV continuous
infusion for 46 hrs
• Leucovorin : 200 mg/m2 IV on D1 as a 2 hrs infusion prior to 5-FU
• Repeat cycle every 2 weeks
• Capecitabine :
• Capecitabine 1250 mg/m2 PO BD D1 to D14
• Repeat cycle every 21 days for a total of 8 cycles

29. Cont….
• Capecitabine + Oxaliplatin (XELOX):
• Capecetabin:1000 mg/m2 PO BD on D1 - D14
• Oxaliplatin : 130 mg/m2 IV on D1
• Repeat cycle every 21 days
• Capecitabine + Irinotecan ( XELIRI ):
• Capecetabine : 1000 mg/m2 PO BD on D1 - D14
• Irinotecan : 250mg/m2 IV on D1
• Repeat cycle every 21 days

30. Neoadjuvent chemoradiotherapy
• Here chemoradiotherapy is given preoperatively as a short
course over 5 days with immediate surgery 7 -10 days later
• 1)sterilise the operative field in cancers with suspected
lympho vascular involvement
• 2)Down stage the locally invasive advanced cancer with
threatened circumferential resection margin

31. RADIOTHEARPY
Indications for RT:
• incomplete excision / Residual disease
• Locally advanced tumor , infiltrating Psoas major muscle or lat Abd
wall , Lft sided colonic growth.
• Positive resection margins
• B2,B3,C2 Arising in immobilised bowel with closed CRM(<1 cm)
• T-3,T-4 or N-1
• Fixed Tumors i.e. caecal & sigmoidal CA
• Tumors A/W perforation , obstructions , fistula , abscess
• Inoperable recurrent tumor
RT decreases Local Recurrence rates in advanced cases of
Rectal Cancer

32. Techniques of irradiation
• Generally, an initial dose of 45 Gy in 25 fractions @ 1.8 Gy
per fraction is delivered through larger field to primary
tumour & risk tissues.
• Critical normal (dose limiting) tissues
• Small intestine : max 45 Gy ( 30 Gy by WART)
• Liver : 2/3 of liver should not get>30 Gy
• Kidney : 2/3 of one kidney should not get>20 Gy
• Spinal cord : maximum dose should be < 45Gy

33. NEWER RT Technique
• IORT – Radiation boosting for dose intensification
• T4 tumor with uncertain margin / Invading adjacent structures
• Preop EBRT + 5-FU based CCT followed by resection with or without
IORT and post op systemic therapy.
• Advantages-
• Visual contrast of target volume
• Homogeneous treatment of controlled thickness of tissue with tumor
• Protection of mobile uninvolved normal tissue
• Disadvantages –
• Increase incidence of late normal tissue complications
• Dose –With 9-15 Mev Electron,10-20 Gy normalised at 90%

34. TARGATED THERAPY
• Anti -VEGF monoclonal antibody:
• Bevacizumab
• Ziv-aflibercept ( VEGF-trap)
• Rigorafenib ( multikinase inhibitor)
• Anti- EGFR moAb:
• Cetuximab
• Panitumumab

36. SURGICAL PROCEDURE OF PRIMARY SITE-
RECTOSIGMOID
• Wedge or segmental resection , partial proctosigmoidectomy
• partial proctosigmoidectomy + resection of contiguous organ
• Pull through with sphincter preservation
• Total proctectomy
• Total colectomy
• Total colectomy with ileostomy
• Ileorectal reconstruction
• Total colectomy with other pouch

37. Surgical procedure of primary site-Rectum
• Wedge or segmental resection , partial proctectomy
• Pull through with sphincter preservstion
• Total proctectomy.
• Total proctocolectomy WITH ileostomy ,NOS
• Total proctocolectomy with ileostomy and pouch
• Anterior resection
• Total mesorectal excision(taTME)
• Hartmann’s operation
• APR
• LAR
• Endoluminal stenting
• Palliative colostomy

38. Colorectal surgery -recent updates
• Total mesorectal excision
- transanal total mesorectal excision (taTME)
• Sphincter saving surgery
- Colonic -J -pouch
• Laparoscopic colorectal surgery.
• Colonic stent for obstructing cancer.
• Local excision
- Trans anal endoscopic microsurgery(TEM)
• Da Vinci Xi Robotic surgery

39. PLAIN OF DISSECTION FOR TOTAL MESORECTAL EXCISION

40. Colonic stents
Stent models, left to right: Colonic Z (Cook), Evolution colonic (Cook), Wallflex (Boston), D-type
colonic not covered (Taewoog), type colonic covered (Taewoong). All FDA approved stents.

41. Colonic Stents
• Treatment of malignant large bowel obstruction
-Inserted by colonoscopy under endoscopic or fluoroscopic control(or
both)
-Avoid emergency laprotomy with colostomy
• Best for left sided cancers
-Right and transverse colon cancers can have resection an anastomosis
-Rectal cancers rarely obstruct(and stent migrates out)
• Two Situations
-Palliative
-’Bridge’to definitive surgery

42. Colonic stent

43. Trans Anal Endoscopic Microsurgery(TME)

45. Colonic pouch

47. Laparoscopic Surgery for Colon Cancer
• First Laparoscopic cholecystectomy 1987(France)
• First Lap Rt Hemicolectomy 1991
• Short term post operative advantages
• At least equivalent oncologically to open colectomy
• Increasing role in colon cancer surgery
• Stage-III cancer showed the greatest benifit.
• LAC recovered faster with shorter return of gut activity,faster oral
intake time and reduced length of stay
• Cancer survival is greater in LAC

52. Da Vinci XI ROBOTIC Surgical System
A.SURGEON CONSOLE B.PATIENT CART

53. Colonic Robotic Resesction
Position - 15 degree Revrse-Trendelenburg Position
STEPS-
step -1)Splenic flexure mobilization-1)from top to bottom
OR 2)from bottom to top
step -2) Primary vascular control & mobilization of descending
c colon,sigmoid colon & section of mesocolon
step -3) TME & Rectal Resection
Finally Specimen removed & anastomosis undertaken

54. Recent Advances in Rectal CA Surgery
• Advances in Rectal surgery in last 5 yrs have continued to focus on
minimally invasive surgery & produced
• 1)NOTES- natural orifice transluminal endoscopic surgery
• 2)SILS - Single Incision Laproscopic Surgery
• 3)TME- Trans Anal Mesorectal Excision
• 4)SPLS - Single port laproscopic surgery
• 5)RALS - Robotic Assisted Laproscopic Surgery

55. FOLLOW UP
• CEA every 3 months * 1st 3 yrs ,then 6 monthly up to 5 yrs(
CEA detects 80% recurrence)
• Complete physical examination on each Follow up
• USG W/A
• CECT whole abdomen yrly * 1st 3 yrs
• Colonoscopy every 3 to 5 yrs
• FDG-PET :- rising CEA in two consecutive tests in absence of
image able disease by CT

56. TAKE HOME MESSAGE
• Incidence & death rates are declining
• Eat high fibre diet & vegetables , Exercise ,Avoid Smoking
• Highest risk observed in persons who are both physically inactive
,have high BMIs & having positive family history.
• Screening save lives
• Most people get screened because their doctor told them to do
• Advances in treatment have led to improved survival rate.
• Advances in molecular profiling of cancers has led to personalized
treatments