Lecture notes for medical students

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aetiologies.
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5. This will be an ACTIVE LEARNING SESSION x
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6. Good for self study also.
7. See notes for bibliography.

2. Learning Objectives
1.

3. Learning Objectives
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Prevention
11. Guidelines
12. Take home messages

4. Introduction & History.
•

5. Introduction & History.
• Colorectal cancer occurs in the colon or
rectum.
• The incidence and epidemiology, etiology,
pathogenesis, and screening
recommendations are common to both
colon cancer and rectal cancer.
• Rectal cancer as cancer located within 12
cm of the anal verge by rigid proctoscopy.

6. Relevant Anatomy
•

7. Relevant Anatomy
• 25% sigmoid colon
• 20% rectum
• 20% cecum
• 10% rectosigmoid junction.

8. Aetiology of Malignancy
•

9. Aetiology of Malignancy
• Idiopathic
• Risk factors
– Non modifiable
– Modifiable
• Premalignant lesions

10. Aetiology of Ca. Rectum
• Idiopathic 75%
• Risk factors
– Non modifiable
– Modifiable
• Premalignant lesions

11. Aetiology of Ca. Rectum
• Non modifiable Risk factors
–

12. Aetiology of Ca. Rectum
• Non modifiable Risk factors
– Age
– Sex
– Family history or personal history of colorectal
cancer or polyps

13. Aetiology of Ca. Rectum
• Premalignant lesions

14. Aetiology of Ca. Rectum
• Premalignant lesions
– Hereditary nonpolyposis colorectal
cancer HNPCC or Lynch syndrome
– Familial adenomatous polyposis(FAP)
– Gardner syndrome
– Inflammatory bowel disease (IBD; 1% of
all cases).

15. Aetiology of Ca. Rectum
• Modifiable Risk factors
– Diet
• A high-fat, low-fiber diet
• saturated animal fats and highly saturated vegetable
oils (eg, corn, safflower)
• Red meat
• Processed meat
– Alcohol
– Tobacco smoking
– Obesity,
– Lack of physical exercise.

16. Aetiology of Ca. Rectum
• Modifiable Risk factors
– Protective Diets
•

17. Aetiology of Ca. Rectum
• Modifiable Risk factors
– Protective Diets
• High fibre
• High fish consumption
• Intake of calcium
• Selenium, carotenoids, and vitamins A, C,
and E

18. Pathophysiology

19. Pathophysiology
• Adenoma>carcinoma sequence
1. Upto 40% have synchronous adenomas
2. Adenomatous polyposis coli ( APC) gene
adenoma-carcinoma pathway
3. Hereditary nonpolyposis colorectal cancer
(HNPCC) pathway
Inflammatory Bowel Disease
• Dysplasia>Neoplasia sequence

20. Pathology
•

21. Pathology
• Adenocarcinomas (98%)
• Carcinoid (0.4%)
• Lymphoma (1.3%)
• Sarcoma (0.3%)
• Squamous cell carcinoma -very rare

22. Staging/Classification

23. Classification
Dukes Classification -Three stages
1. Dukes A limited to the rectal wall.
2. Dukes B -extend through the rectal wall
into extra-rectal tissue.
3. Dukes C -metastases to regional lymph
nodes.
4. Dukes D- Distant metastases.

24. TNM Classification
• T

25. TNM Classification
• TX -
• T0 -
• Tis -
• T1 -
• T2 -
• T3 -
• T4 -

26. TNM Classification
• TX - Primary tumor cannot be assessed or depth of
penetration not specified
• T0 - No evidence of primary tumor
• Tis - Carcinoma in situ (mucosal); intraepithelial or
invasion of the lamina propria
• T1 - Tumor invades submucosa
• T2 - Tumor invades muscularis propria
• T3 - Tumor invades through the muscularis propria into
the subserosa or into non-peritonealized pericolic or
perirectal tissue
• T4 - Tumor directly invades other organs or structures
and/or perforates the visceral peritoneum

27. TNM Classification
• N- Regional lymph nodes

28. TNM Classification
N- Regional lymph nodes
• NX -
• N0 -
• N1 -
• N2
• N3

29. TNM Classification
N- Regional lymph nodes
• NX - Regional lymph nodes cannot be
assessed
• N0 - No regional lymph node metastasis
• N1 - Metastasis in 1-3 pericolic or perirectal
lymph nodes
• N2 - Metastasis in 4 or more pericolic or
perirectal lymph nodes
• N3 - Metastasis in any lymph node along
the course of a named vascular trunk

30. TNM Classification
M- Metastasis-
• MX -
• M0 -
• M1 -

31. TNM Classification
M- Metastasis-
• MX - Presence of metastasis cannot be
assessed
• M0 - No distant metastasis
• M1 - Distant metastasis
– M1a: metastasis confined to one organ or site
– M1b: metastases in more than one organ/site or
the peritoneum.

32. TNM Classification
• Stage I -T1-2 N0 M0
• Stage II
• A-T3 N0 M0
• B-T4 N0 M0
• Stage III
• A- T1-2 N1 M0
• B-T3-4 N1 M0
• C-T1-4 N2 M0
• Stage IV
• T1-4 N0-2 M1

33. Clinical Features
•

34. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

35. Demography

36. Demography
• Incidence & Prevalence
• Geographical distribution.
• Age
• Sex
• Socioeconomic status
• Temporal behaviour

37. Demography
• Incidence & Prevalence
• Geographical distribution.
• Age
• Sex
• Socioeconomic status
• Temporal behaviour

38. Demography
• Incidence & Prevalence

39. Demography
• Incidence & Prevalence
– Currently, colorectal cancer is the third most
common cancer and the third leading cause of
cancer deaths in both males and females in the
United States.

40. Demography
• Geographical distribution.

41. Demography
• Geographical distribution.
– High incidences in industrialized countries
– Low incidence in Asia and Africa

42. Demography
• Age
–

43. Demography
• Age
– Found in all ages
– Starts to increase after age 35 and rises rapidly
after age 50, peaking in the seventh decade.

44. Demography
• Sex
– Slightly higher in males than in females.

45. Demography
• Temporal behaviour-
–

46. Demography
• Temporal behaviour-
– Colon and rectal cancer incidence was
negligible before 1900. The incidence of
colorectal cancer rose dramatically following
economic development and industrialization.

47. Symptoms

48. Symptoms
• Bleeding is the most common symptom of
rectal cancer, occurring in 60% of patients.
• Asymptomatic
• Change in bowel habits
– diarrhea;
– the caliber of the stool may change;
– feeling of incomplete evacuation
– tenesmus.
• Occult bleeding
• Abdominal pain
• Back pain

49. Symptoms
• Urinary symptoms
• Malaise
• Pelvic pain
• Weight loss
• Emergencies such as peritonitis from
perforation (3%) or jaundice, which may
occur with liver metastases.

50. Prognosis

51. Prognosis
• Morbidity
• Mortality rate
• 5 year survival in Malignancy

52. Prognosis
• The Average 5-year relative survival rate is
64.6%
• TNM stage–dependent 5-year survival rate
for rectal carcinomas is as follows:
– Stage I - 90%
– Stage II - 60-85%
– Stage III - 27-60%
– Stage IV - 5-7%

53. Investigations
•

54. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology
– Germline Testing and Molecular Analysis
• Diagnostic Laparotomy.

55. Investigations in Malignancy
• For diagnosing
• For Staging
• For Screening

56. Investigations in Malignancy
• For diagnosing
– Biopsy
• For Staging
– USG Abd. EUS
– CT Chest and Abdomen
– MRI local staging
– Endoscopy- Sigmoidoscopy
– Nuclear scan- PET CT
• For Screening

57. Investigations in Malignancy
• For Screening
– Colonoscopy. ...
– Computed tomography (CT or CAT)
colonography. ...
– Sigmoidoscopy. ...
– Fecal occult blood test (FOBT) and fecal
immunochemical test (FIT). ...
– Double contrast barium enema (DCBE). ...
– Stool DNA tests.

58. Investigations
• Laboratory Studies
– Carcinoembryonic antigen (CEA) test
– Cancer antigen (CA) 19-9 assay

59. Diagnostic Studies

60. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

61. Diagnostic Studies
Imaging Studies
• X-Ray
• USG Abd. EUS
• CT Chest and Abdomen
• Angiography
• MRI local staging
• Endoscopy- Sigmoidoscopy
• Nuclear scan- PET CT

62. Differential Diagnosis

63. Differential Diagnosis
• Hemorrhoids
• Solitary Rectal ulcer.
• Inflammatory stricture
• amoebic granuloma
• Endometriomas
• Benign adenomas

64. Operative Therapy

65. Operative Therapy
• TME- Total Mesorectal Excision.
• APR Abdominal perineal resection
• Low anterior resection, coloanal
anastomosis
• Transanal excision
• Transanal total mesorectal excision
(taTME)
• Transanal endoscopic microsurgery-TEMS
• Endoluminal stenting
• Pelvic exenteration

66. Adjuvant medical management

67. Adjuvant medical management
• Adjuvant radiation therapy
• Intraoperative radiation therapy
• Endocavity radiotherapy
• Adjuvant chemotherapy
• Adjuvant chemoradiation therapy
• Radioembolization

68. Prevention

69. Prevention
• Aspirin
• Fibre
• Alcohol
• Tobacco smoking
• Calcium
• Vitamins and antioxidants
– Selenium, carotenoids, and vitamins A, C, and
E
• Fresh Fruits and vegetables
• Fish
• Early detection -screening

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