Aetiology Classification Clinical features Complications Investigation and screening TNM staging Treatment Followup

2. • Colorectal cancer is , in general , a disease of older
people with a peak incidence at 70s.
• A Large bowel malignancy in younger people
always raise a suspicion of an inherited cancer
syndrome (disorders such as polyposis)
HISTOLOGICAL TYPES (WHO) :
• Adencarcinoma – 90%
• Mucinous adenocarcinoma – 5-10%
• Signet ring cell carcinoma
• Small cell/Oat cell carcinoma – extremely poor prognosis
• Squamous cell carcinoma
• Undifferentiated Carcinoma

3. It is the most common type of Colon Cancer.
SITES :
Rectum(40%)
Sigmoid(20%)
Caecum(10%)
Transverse Colon(5%)
Ascending/Descending colon each(5%)
Flexures each(3%).
Remember:
• Most common site : Rectum
• Most common Colonic site : Sigmoid colon

4. RISK FACTORS:
• Red meat and Saturated fat
• Cholesterol – increases bile acid secretion (cocarcinogen)
• Alcohol and smoking
• Ureterosigmoidostomy – 100x risk
• Radiation
• Long standing IBD ( Ulcerative colitis > Crohns disease)
• Acromegaly
• Post-Cholecystectomy and ileal resection – increased bile salts
• Genetic conditions like adenoma colon,Familial adenomatous
polyposis,Gardner’s syndrome,Turcot’s syndrome.
• Heriditary non-polyposis colonic cancer.

5. PROCTECTIVE FACTORS :
• High fibre diet
• Calcium – combines with bile salt or direct action on mucoal cells
to reduce their proliferative potential.
• Dietary vitamins A,C,E & Zinc.
• Drugs like aspirin and NSAIDs.

6. • Adenoma-carcinoma sequence
• 80% - Loss of heterozygosity pathway – K-Ras mutation
• 20% - Replication error repair – DNA repair mechanism is lost.

7. • SYNCHRONOUS (5-10%)
refer to cases in which the second primary cancer
is diagnosed within 6 months of the primary cancer.
• METACHRONOUS (10-20%)
refer to cases in which the second primary cancer is diagnosed
more than 6 months after the diagnosis of the first primary cancer.

8. • Annular
• Tubular
• Ulcerative
• Proliferative
Left sided
Right sided

9. • Abdominal pain
• Altered bowel habits
• Hematochezia
• Anaemia
• Weakness
• Weight loss
USUAL PRESENTING SYMPTOMS :
• Loss of appetite and weight
• Anaemia
• Abdominal discomfort
• Mass per abdomen
NOTE:
• 20% cases present as acute intestinal obstruction.
• 20% cases of colon/colorectal cancer usually has stage 4
disease at time of presentation

10. • Right sided growths – Anaemia , RIF mass which is not
moving with respiration , mobile , non-tender , hard , well
localized with impaired resonant note , Like appendicitis ,
Intussusception.
• Left sided growths – Colicky pain , Altered bowel habits ,
palpable lump , abdominal distension due to obstruction
,Pericolic abscess , Tenesmus (intension to pass stool even
after the bowel is empty) , Diarrhoea with blood and mucus ,
Mass LIF.
APPLE CORE
DEFORMITY –
Lt sided Ca.
colon

11. URINARY SYMPTOMS (COLOVESICAL FISTULA):
• Fistula into bladder/vagina
• Hydronephrosis by ureter infiltration
LIVER SYMPTOMS (SECONDARIES) :
• Ascites
• Loss of weight & appetite
• Jaundice
• Palpable left supraclavicular LN – TROISIER’S SIGN.
OBSTRUCTION SYMPTOMS :
• Closed loop obstruction can occur in transverse colon cancer with
competent ileocaecal valve. Enormously dilated right sided colon
in prone for stercoral ulcer, perforation and faecal peritonitis.
FACT:
Faecal strength of Streptococcus bovis bacteria increases many
folds in patients with colonic cancer compared to normal
individuals.

12. DIRECT SPREAD :
• Bladder
• Obstruct ureter and cause hydronephrosis
• Peritonitis/Pericolic abscess/Faecal fistula
• Psoas muscle invasion
• Colovesical or colovaginal fistula.
LYMPHATIC SPREAD :
• Pericolic , epicolic , intermediate and principal group of lymph
nodes.
BLOOD SPREAD :
• 40% spreads to liver via portal vein which may be either
solitary or multiple , present with hard umbilicated nodules.

13. TUMOUR – T :
• Tx – Tumour cannot be assessed
• T0 – No evidence of tumour
• Tis – Carcinoma insitu – intraepithelial/invasion into
lamina propria.
• T1 – Invasion into submucosa
• T2 – Invasion into muscularis propria
• T3 – Invasion into pericolorectal tissues/fat
• T4
- T4a – Invasion into surface of visceral peritoneum
- T4b – Direct invasion or adherent to adjacent
structures/organs.
REGIONAL NODES – N :
• Nx – Lymph nodes cannot be assessed
• N0 – No nodal metastasis
• N1 – 1-3 nodes are involved
- N1a – 1 node involvement
- N1b – 2 to 3 nodes involvement
- N1c – serosa/mesentry

14. N2 – 4 or more LN involvement
- N2a – 4-6 LN involvement
-N2b – 7 or more LN involvement.
DISTATNT METASTASIS :
• M0 – No Metastasis
• M1 – Distant metastasis present
- M1a – spread confined to one organ or site
- M1b – spread to more than one organ or site
- M1c – spread to peritoneal surface alone or along with
other site or organ metastasis.

15. A - lntramucosal
B1 - Involvement up to muscularis propria
B2 - Spread through the wall into peritoneum
C1 - Involvement up to muscularis propria (B1) + involvement of lymph nodes
C2 - Spread through the wall into peritoneum(B2) + involvement of lymph nodes
D - Distant spread.
PROGNOSTIC CRITERIA : 5 year survival rate
• A – 90%
• B – 60-70%
• C – 30%
• D - <30%

16. • INTESTINAL OBSTRUCTION
• CLOSED LOOP OBSTRUCTON
• PERFORATION AND PERITONITIS
• PERICOLIC ABSCESS
• VESICOCOLIC FISTULA
• INVASION OF URETER

17. Due to high incidence and late presentation of colon cancer
Screening for colon cancer plays a vital role in management
of the disease.
VARIOUS SCREENING MODALITIES :
COLONOSCOPY
• Length of coloscope 110-140
• Rectum to Caecum can be screened
• Screening starts at 50yrs of age or (youngest relative
diagnosed – 10 years)
• Most accurate and most complete method.
• Can identify small polyps <1cm , control bleeding ,
polypectomy , stricture dilation.
• PROBLEM – Prior mechanical bowel preparation needed.
• Done once in 10 years.

18. SIGMOIDOSCOPY :
• Can see up to 60cms (only sigmoid)
• Done once in 5 years
FAECAL OCCULT BLOOD TESTING :
• Done every year
• Nonspecific test for peroxidase contained in Haemoglobin
• Simple with low specificity.
AIR CONTRAST BARIUM ENEMA :
• Detects polyps greater than 1cm
• Accurate in proximal colon than sigmoid colon , as you may
misinterpret a polyp for diverticulosis.
CT COLONOGRAPHY (VIRTUAL COLONOSCOPY)
• Non-Invasive.
• Extracolonic structures are better visualized.
• Good at detecting lesions >6mm in size.

19. • Blood investigations
• Barium enema
• Colonoscopy and biopsy
• Virtual colonoscopy
• Ultrasound
• CT Abdomen
• FNAC – If left supraclavicular lymph node is enlarged
• Liver Function test
• Carcinoembryonic antigen
CARCINOEMBRYONIC ANTIGEN:
• Tumour marker for colorectal cancer.
• Normal value <2.5ng/dl , levels >5ng/dl is significant.
USES :
1. Preoperative levels >7.5ng/dl signifies poor prognosis.
2. If postoperative levels doesn’t fall , it indicates incomplete
resection or occult metastasis elsewhere.
3. Slow rise indicates loco regional disease.
4. Rapid rise indicates metastasis.

20. SURGERY CHEMOTHERAPY RADIOTHERAPY IMMUNOTHERAPY
(MAIN MODE) (ONLY FOR RECTAL CANCERS)
BLOOD SUPPLY OF COLON:

21. CANCER SITE : Caecum
PARTS REMOVED : Terminal 6cm of
ileum , ileocecal junction , ascending
colon , hepatic flexure .
ARTERIES LIGATED : Ileocolic artery ,
Right colic artery , Right branch of
middle colic artery.
CANCER SITE : Ascending colon ,
hepatic flexure , transverse colon.
PARTS REMOVED : Terminal 6cm of
ileum , ileocecal junction , ascending
colon , hepatic flexure , transverse
colon.
ARTERIES LIGATED : Ileocolic , Right
colic artery , Whole middle colic
artery.
CANCER SITE : Splenic flexure
PARTS REMOVED : Terminal
6cm of ileum , ileocecal junction ,
ascending colon , hepatic flexure
, transverse colon , Splenic
flexure.
ARTERIES LIGATED : Ileocolic ,
Right colic artery , Whole middle
colic artery.

22. CANCER SITE : Descending colon
PARTS REMOVED : ½ of transverse colon ,
Descending colon.
ARTERIES LIGATED : Left Middle colic artery ,
high ligation of the inferior mesenteric artery
(IMA).
CANCER SITE : Sigmoid colon
PARTS REMOVED : Entire
sigmoid,rectum.
ARTERIES LIGATED : High ligation of
the inferior mesenteric artery (IMA).

23. TREATMENT OF LIVER SECONDARIES :
• Most common site of colorectal metastasis – Liver
• Metastatectomy improves the survival rate in
colorectal cancers.
Indications for liver metastatectomy :
• No.of metastasis not a criterion
• It should be resectable and after resection atleast
25% functional liver reserve(FLR) should be there.
OTHER SURGICAL METHODS:
• Turnball’s “No touch technique” – arteries ligated at
their origin to prevent to tumour spread due to
handling.
• Owen Wagensteen’s second look surgery – to resect
residual or recurrent tumours.
• Hand assisted laparoscopic surgery (HALS)
• Total abdominal colectomy – with ileorectal
anastomosis in HNPCC.

24. • FOLFOX – 5-fluorouracil , folinic acid , oxaliplatin.
• FOLFIRI – 5-fluorouracil , folinic acid , irinotecan
• CAPEOX – Capecitabine , oxaliplatin.
INDICATIONS :
• Positive nodes
• T4 Lesions
• Venous spread
• Signet cell type
• Poorly differentiated tumour/aneuploidy
• Changes in CEA level.

25. • Only for rectal cancers.
• For rectal cancer – combined chemoradiotherapy.
SHORT COURSE LONG COURSE
5 to 6 days of chemoradiation
Surgery
5 to 6 weeks of chemoradiation
Wait for 5 to 6 weeks
Surgery
INTRACAVITY RADIOTHERAPY:
• Also known as contact radiotherapy.
• This technique is called papillon technique.

26. Used only in metastatic or recurrent colorectal cancers.
• Bevacizumab – against VEGF
• Cetuximab – against EGFR
• Panitumumab – against EGFR
• Pembrolizumab , nivolumab – against PDLI
• Regular CEA analysis
• Ultrasound abdomen
• Barium enema X-ray
• Colonoscopy
• Rise in CEA is a definite indicator of recurrence or secondaries
In patients with raised CEA, radioisotope antibody study will
show the site of recurrence or secondaries
• Serum alkaline phosphatase

27. Depends on:
• Site-left sided tumours has got better prognosis as
they present early.
• Type--Colloid carcinoma has got poorer prognosis.
• Size of the tumour.
• Lymph nodes status: Number of lymph nodes
involved decides the prognosis.
• Liver secondaries has poor prognosis.
• Age of the patient.
• Associated diseases like HIV.
• Stage ofthe tumour.
• Presence of complications, perforation, peritonitis.