this is a case report done by a medical intern about colorectal Ca, ppt was done via input and compilation from other ppt

1. Jaime Vinc Angelo D. Landero
PGI

2.  LL
 57/male
 Carcar City
 Roman Catholic
 1st admission at VSMMC

3.  Inability to pass stool

4.  1 yr PTC, passing of small lumpy brown
colored stools, with excess straining of >10
episodes per day.
 7 months prior, consult with private
physician; Abdominal Obstruction, advised
for further workup, no compliance

5.  5 months, vague abdominal fullness, with
persistence of symptom.
 4 months, (+) easy fatigability, with above
symptoms, (-) black tarry stools/ blood upon
defecation
 3 months, noted abdominal distention with
concurrent weight loss, sought consult

6.  UTZ whole Abdomen:
> Complex mass at lower abdomen

7.  Whole Abdominal CT:
 Lobulated soft tissue attenuating mass,
rectosigmoid colon, producing luminal
narrowing and colonic obstruction, A primary
malignant neoplasm is considered
 6.9 x 7.6 x 4cm approx. 7.6cm from anal
verge

8.  1 week prior, still with persistence of
symptoms, with abdominal tenderness, and
inability to pass out stools,
 3 days prior, can only pass out flatus and
watery stools

9.  On admission, patient came in with distended
abdomen, with dyspnea, and inability to pass
out stool.

10.  (-) BA/DM
 (+) PTB (2010,2017) fully treated
 (+) HPN – carvedilol
 No other medical or surgical history

11.  (+) HPN and Liver malignancy on paternal
side

12.  Non Alcoholic
 Non Smoker
 Used to work in a leather foot wear factory
 (+) exposure to leather thinner, adhesives

13.  SKIN: no lesion, abrasions noted
 HEENT: no gross deformity, icteric sclerae,
pale conjunctivae, moist oral mucosa, no
cervical lymphadenopathy
 Chest: symmetric chest expansion, Clear
breath sounds

14.  Cardiac: adynamic precordium, PMI 5th ICS
LAAL, normal rate and regular rhythm, no
murmur
 Abdomen: distended, (-) tenderness,
Hypoactive bowel sounds

15.  DRE: Not done
 Urogenital: grossly normal, (-) KPS
 Extremities: Grossly normal, 5/5 in all four
limbs
 Neurologic: intact. GCS 15

16. Differentials Rule In Rule out
ADULT HD Chronic Constiaptiom
Sudden/ abrupt stool
stoppage
Enlarging Abdominal
Girth
Imaging showing
intramural mass
No Biopsy done prior
rare
Ulcerative Colitis Abdominal cramping
Failure to pass out
stool
diarrhea
Occurs mostly <30yrs
old
Diagnosed thru
colonoscopy with
biopsy
Intestinal PTB + PTB
Enlarging Abdomen
Weightloss
Vague/ crampy
abdominal Pain
Imaging showing
Intramural Mass
No AFB done

17.  Complete Mechanical Bowel Obstruction
secondary to Colonic Mass probably
Malignant

18.  NPO
 IVF: PLR at 400cc for the 1st hour
 Then 240cc/hr for 5 hours
 Insert NGT and FBC
 For CVP Insertion – 4 mm H2O
> 600cc for the 1st hour then 360cc for the
next 5 hours

19. >Labs:
 CBC
 BT
 Electrolytes
 Protime
 Creatinine
 ABG
 CXR PA
 Abd Flat Plate Upright
 12 leads ECG

20. Protime 14.8 sec 95. 4%
INR 1.25
Na 137.4
K 4.04
Cl 98.8
Ca 1.05
O +
WBC
17.49
RBC
3.90
HGB
103
HCT
.31
APC 550
N 95%
L 3%
Creatinine 1.37
Albumin 2.10

24.  > Proctoscopy; Biopsy, Exploratory
Laparotomy, Diverting Colostomy
Intraoperative findings
Mass ~ 10cm from anal
verge
Post Op diagnosis:
CMBO sec to Rectosigmoid
Ca
Clinical stage IIIC(T3N2M0)

25.  S: asleep
 O: arousable, intubated
VS: BP 100/70 PR 88
A: CMBO sec to rectosigmoid Ca
P: Piptaz 4.5g IVTT q8
Ranitidine 50
Tramadol 50
PCM 900 RTC
Ascrobic acid 500 IVTT q6

26.  ABG
 CBC
 CXR PA
 Electrolytes
 For delayed intubation
 To start TPN
 severe stress; 40kgx30kcal=1200x1.6
= 1920kcal/day

28. pH 7.30
PCO2 58.5
pO2 34
BEecf 2.4
HCO3 7.302
TCO2 30.9
sO2 59.3
Na 131.
8
K 4.39
Cl 101.
2
Ca 1.04
WBC 21.6
HGB 88
HCT .26
APC 471
N 56
B 41

30.  S: Complains of pain upon swallowing
 O: Stable VS, Extubated, Bipedal edema gr 3
 CVP: mean of 10
130/80 pr 92 JP drain 723cc serosanguinous
Colostomy drained 95ml
A: status qou

31.  P: cont. TPN
 Terminate peripheral line
 Cont. meds
 Rpt ABG
 Refer to rehab and IM

32. pH 7.39
PCO2 47.2
pO2 62
Beecf 3.5
HCO3 28.9
TCO2 30.4
SO2 92

33.  S: can tolerate short soft feeding
 O: stable VS
130/90-150/90
Face mask at 6LPM
CVP~ 13
JP Drain ~ 6/75, 20/50, 12/105, 14/95

34.  A: status Qou
 P: Amlodipine 10mg/tab OD
Atorvastatin 80mg/tab
Cont. meds

35. pH 7.47
PCO2
pO2
40.5
119
Beecf 6.4
HCO3 30.2
TCO2 31.4
sO2 98.9
5/13/18
pH 7.45
PCO2
pO2
37.9
73.9
Beecf 4.3
HCO3 28.2
TCO2 29.2
sO2 96
5/14/18
WBC 12.46
HGB 93
HCT .28
APC 442
Na 133.4
K 3.43
CL 100.4
Ca 1.10
Na 135.6
K 3.37
Cl 100.3
Ca 1.07
5/15/18

37. INTRODUCTION
•2nd commonest cancer in men and ranks 3rd in frequency
in women in the western countries
• 2nd m/c cause of cancer mortality (after Ca Lung)
• Globally 800,000 new CRCs occur each year, accounting
for 10% of all incident cancers with 450,000 deaths/year
• About 75-80% present with localized disease
• Incidence : 35.8/100,000 (USA)
• Developing countries < 10/100,000
• India: incidence - 7/1,00,000
• Median age of diagnosis- 62 yrs
• Unfavorable prognosis if age <40 yrs
SOURCE: RRCR 2007

38. CLINICAL ANATOMY
• Large intestine- Colon and Rectum
• Intraperitoneal- Caecum, Transverse colon
• Retroperitoneal- Ascending colon, Descending colon,
both flexures, initial part and end of Sigmoid
• Significance
– May have compromised sx margins
– Tumor spread from these regions may involve retroperitoneal soft
tissue, kidneys, ureters and pancreas
• Cancer <12 cm anal verge – rectal cancer
• Cancer >12 cm anal verge – colon cancer

39. Ascending Colon 4%
Transverse Colon 8%
Descending Colon 14%
Sigmoid Colon 35.7%
Rectum 39%

41.  Age
◦ More than 90% of colorectal cancer is found
people ages 50 and over.
 Family history (in a mother, father,
brother, sister, or child):
◦ Colorectal cancer
◦ Adenomatous polyps or “adenomas”

42. Personal history of:
◦ Colorectal cancer
◦ Adenomatous polyps or
“adenomas”
 An adenoma is a growth that can
turn into cancer
◦ Ovarian or endometrial
cancer before age 50
◦ Inflammatory bowel disease
 Ulcerative colitis and Crohn colitis
Source: NCI
Source: American Cancer Society

43. CLINICAL RISK FACTORS
• Age > 40yrs
• Male sex
• Genetic syndromes- PJS/FAP/Gardener’s/Turcot /Oldfield’s
• F/H- Lynch-I : Familial CRC syndrome
Lynch-II : Hereditary adenocarcinomatosis synd.
• Other
– Prior h/o CRC /Malignant colorectalpolyps
– Inflammatory bowel disease
– High BMI / Low physical activity
– Red meat / processed food/ ? Low fiber diet
– Excessive alcohol consumption/ low folate intake
– Prolonged cigarette smoking
– Pelvic irradiation

44.  Early stages of colorectal cancer may have
NO signs or symptoms.
 If signs and symptoms are present, they
may include:
◦ Bleeding from the rectum or blood in the stool
◦ Marked change in bowel habits
◦ Abdominal mass
◦ Abdominal cramps or pain
◦ Iron deficiency anemia that is not due to other
conditions
Source: American Cancer Society

46.  People ages 50 and over
 People under 50 with:
◦ Personal or family risk factors
Source: American Cancer Society
Colorectal Cancer Screening
Saves Lives!

47. Tests used to look for
colorectal cancer:
◦ Colonoscopy
◦ Flexible Sigmoidoscopy
◦ Fecal Occult Blood Test
(FOBT)
◦ Double contrast barium
enema
◦ Other Source: Oncolink

48. CARCINOGENESIS: Adenoma to Carcinoma
Pathway
APC
Loss/mutation
Ch. 5q
Normal
Epithelium
Early
Adenoma Cancer
Hyper-
proliferation
Intermediate
Adenoma
Late
Adenoma
K-ras
Mutation
Ch. 12p (50%)
DCC loss
Ch. 18q
DPC4
Ch. 4
p53
Loss
Ch. 17p
Loss of DNA
methylation

50. PATHOLOGY: WHO Classification
• I. Epithelial
– Benign
– Malignant
• Adeno ca >95%
• Mucinous adenoca 17%
• Signet ring cell ca 2-4%
• SCC
• Adenosquamous
• Undiff/ Unclassified
• II. Neuroendocrinal – carcinoid
• III. Nonepithelial
– Leiomyoma/ lipoma/hemangioma
– Leiomyosarcoma
• IV.Hematopoietic/
lymphoid(DLBCL)
V. Unclassified
VI. Secondaries
VII. Tumor like lesions
VIII. Epithelial atypia in Ulcerative
•
•
•
•
colitis

52. SPREAD
Local
Multidirectional growth progression
Intramural- bowel wall penetration
Invasion into adjacent organs/ structures
Perineural invasion ~10 cm from primary lesion
•Lymphomatous
• Tumor grade
• LVI
–Normal lymphatic flow along major arteries to three echelons of LN
• Pericolic/ Intermediate /Principal LN

53. • Hematogenous
– Liver- primary site – 40%
– Lung- 2nd m/c site
– 10-15% have e/o distant metastasis at diagnosis
• Peritoneal seeding/ implantation
– Intraluminal/ serosal sheding/ by surgical manipulation

54. CLINICAL PRESENTATION
• Related to tumor size/ type/ location
• Ascending colon- large, exophytic/ bulky
– Pain abdomen
– Bleed PR
– Unexplained anemia/ fatigability or weight loss
• Descending colon- infiltrating/annular/obstructive
– Altered bowel habits
– Decreased stool calibre
– Frequent gas pains, bloating, fullness ,cramps
– Mass P/A

55. DIAGNOSIS• Complete history
• Physical examination /DRE
• Routine investigations
• Confirmatory- Biopsy
• Staging workup
– CXR
– Barium enema
– Colonoscopy
– USG
– CECT abdomen- pelvis
– Virtual colonoscopy
– MRI
– PET
• Gold standard- Colonoscopy+
Biopsy
•Others
•CEA

56. BARIUM ENEMA– Complementary for colonoscopy
– Full column Ba enema misses 1/5th-1/4th of all colon ca and 2/5th of
all polypoidal lesions
– DOUBLE CONTRAST Ba enema detects almost all colonic
lesions~5mm
– C/I- Acute /severe IBD, suspected perforation, recent bowel surgery

57. • Can examine about half of the
colon
• Less incidence perforations
– 1-2/1000 Colonoscopy
– 1/10,000 Sigmoidoscopy
• Misses proximal lesions,
usually used in conjunction
with FOBT or BE
• Sensitivity-90% /Specificity-
99% (For areas examined by scope)

58. • Superior rectal A – fr. IMA; supplies
upper and middle rectum
• Middle rectal A- fr. Internal iliac A.
(supplies lower rectum)
• Inferior rectal A- fr. Internal pudendal A.
Venous drainage
▫ Superior rectal V- upper & middle third
rectum
▫ Middle rectal V- lower rectum and upper
anal canal
▫ Inferior rectal vein- lower anal canal
Innervations
• Sympathetic: L1-L3, Hypogastric
nerve
• ParaSympathetic: S2-S4

59. • Upper and middle rectum
▫ Pararectal lymph nodes,
musclelocated directly on the
layer of the rectum
▫ Inferior mesenteric lymph
nodes, via the nodes along the
superior rectal vessels
• Lower rectum
▫ Sacral group of lymph nodes or
Internal iliac lymph nodes
• Below the dentate line
▫ Inguinal nodes and external iliac
chain

60. COLONOSCOPY
• Essential procedure for the proper diagnosis/ t/t / and surveillance
of patients with nonfamilial colorectal polyps/ patients treated with
curative intent
• Detect the lesions and biopsy ± removal
• Rule out synchronous lesions/ anastomotic recurrence - aggressive
colonoscopy indicated in patients with a proven diagnosis
• Asymptomatic patients with well documented FOBT and
symptomatic patients should have a colonoscopy of entire colon
even with normal sigmoidoscopic findings and normal or equivocal
Ba enema
• Limitations- failure to reach / examine fully
– Splenic flexure (10%)
– Hepatic flexure (15%)
– Caecum (20%)

62. •TUMOR MARKER : CEA
–No role in diagnosis/ screening of ca colon
–Correlate with tumor burden and prognosis
–Monitoring tool for patients treated with curative intent
–Post op CEA level is more sensitive indicator of recurrence
–Normal :

66. • SURGERY- Primary
• RADIOTHERPY- Adjuvant
• CHEMOTHERAPY-Adjuvant and metastatic
• TARGETED / IMMUNOTHERAPY-Adjuvant and
metastatic

68. SURGERY
• SURGRYis the GOLD STANDARD and principle
therapy of primary and non metastatic ca colon
– Curative
– Palliative
– Accurate disease staging
– Guides adjuvant treatment
• Likelihood of cure is greater when disease is detected
at early stage

70. •Most important guide to prognosis is STAGE of the disease
i.e. depth of penetration and number of LNs involved
• ADVERSE C/F • ADVERSE PATHOLOGY
– Younger age < 40 yr – High grade
– Long symptomatology – Colloid/ Signet ring cell
– Obstruction/ perforation – LVI
– Ulcerative lesion – Perineural invasion
– BT – Aneuploidy
– ↑↑ CEA/ collagen
– Cell surface antigens CA-19.9
– Local immune response

71. Rational post therapy surveillance
programme
• CEA every 3 month x 1st 3 yrs, than 6 monthly
up to 5 yrs (CEA detects 80% recurrence) and
• Complete physical examination on each FU
• CECT abdomen pelvis yearly x 1st 3 yrs
• Colonoscopy every 3 to 5 yrs
• FDG-PET- rising CEA in two consecutive tests
in absence of imageable disease by CT

72. RISING CEA
COLONOSCOPY
FDG-PET
NORMAL
CXR CECT

73. The importance of EGFR in
metastatic colorectal cancer
 EGFR is involved in the progression of mCRC
 Patients with EGFR-expressing tumors have a
shorter survival
 EGFR is expressed in 75 – 89% of mCRC

74. Cetuximab (C225)
 Chimeric MCA to EGFR
 Binds with high affinity to transmembrane domain
of EGFR and blocks binding of natural ligands
(EGF, TGF)
 Inhibits EGFR function and downstream signal
transduction pathways, promoting apoptosis
 Synergistic inhibition with chemotherapy and
radiation
O‘Dwyer PJ, Benson AB III. Semin Oncol. 2002;29(suppl 14):10.

75. ACS colorectal cancer screening guidelines*
Fecal occult blood test (FOBT)† or fecal immunochemical test
(FIT) every year, or
Flexible sigmoidoscopy every 5 years, or
An FOBT† or FIT every year plus flexible sigmoidoscopy every
5 years (of these first three options, the combination of FOBT or
FIT every year plus flexible sigmoidoscopy every 5 years is
preferable), or
Double-contrast barium enema every 5 years, or
Colonoscopy every 10 years
• * Beginning at age 50, men and women who are at average risk for developing
colorectal cancer should have one of the five screening options listed. Those at
increased risk for colorectal cancer should undergo screening earlier and at more
frequent intervals.
• † For FOBT or FIT, the take-home multiple sample method should be used.
• Source: “Can colorectal polyps and cancer be found early?” American Cancer
Society (www.cancer.org); 2005 Accessed Sept 2008.

76. Stage Mean 5 yr survival
rate (%)
T1N0 97
T2N0 90
T3N0 78
T2N+ 74
T4N0 63
T3N+ 48
T4N+ 38