1. Colorectal cancer is the second most common malignancy in females and third most common in males. It is also the fourth most common cause of cancer death. 2. Risk factors include red meat, obesity, smoking, alcohol, family history, and inflammatory bowel disease. Most cases are sporadic but some are hereditary. 3. Symptoms depend on the location of the cancer in the colon but may include blood in stool, changes in bowel habits, abdominal pain, weight loss, and anemia. 4. Treatment involves surgery, chemotherapy, radiation therapy, targeted therapy, and immunotherapy depending on the stage and characteristics of the cancer. The type of surgery performed also depends on the location and

1. Dr. Nabarun Biswas
(FCPS Surgery)
Registrar
Mymensingh Medical College
Hospital

2. • 2nd most common malignancy in female &
3rd most common in male
• 4th most common cause of cancer death
after lung, stomach & liver
• Most common malignancy in GIT
• Peak incidence above 70 years
• 7% less than 40 year
• Synchronous 7%
• Metachronous 3%

3. 1. Adenocarcinomas:
2. Carcinoid tumors:
3. Gastrointestinal stromal tumors
(GISTs):
4. Lymphomas:
5. Sarcomas:

4. Macroscopic:
1. Annular
2. Tubular.
3. Ulcerative.
4. Cauliflower
Microscopic
1. Adenocarcinoma
2. Squamous cell ca
3. Adeno squamous ca
4. Spindle cell carcinoma
5. Neuroendocrine cell ca

5.  Red meat and saturated fatty acids
 Obesity
 Sedentary lifestyle
 Old age
 Alcohol and Smoking
 FAP - defect in APC gene on chromosome
5q21
 HNPCC - MSH2 & MLH1 gene defect
 Family history – 2 or more first degree relatives
 Inflammatory bowel disease – Ulcerative Colitis
 Adenomatous polyp

6. CRC
Hereditary
5%
Genetic
mutation
FAP HNPCC PJS
Sporadic
95%
Adenoma
carcinoma
sequence
APC
K-ras
P 53

7. • Accounts for upto 75-95% of sporadic colo-rectal tumours and
typically arise form adenomatous polyp
•Mutation in wnt signaling pathway
1. APC mutation  activation of proto-oncogene (required
for normal cell renewal) over expression
2.Activation of oncogene k-ras  increase cell
proliferation.
3.Suppression of P 53 (for apoptosis)  immortal cell

8. Duke’s
Astler-Coller
TNM

9. A B C1 C2 D
MUCOSA
SUBMUCOSA
MUSCULARIS
PROPRIA
SEROSA
LYMPHNODE

10. N 0 N 1 N 2
T1 T2 T3 T4a T4b
MUCOSA
SUBMUCOSA
MUSCULARIS
PROPRIA
SEROSA/
Perirectal tissue
LYMPHNODE

11.  Stage I  100, 200 (T1 or 2 N0 M0)
 Stage II  300, 400 (T3 or 4 N0 M0)
 Stage III any T, any N, M0
 Stage IV any T, any N, M1

13. Caecum
 Anaemia
 Mass
 Dark stool
 Obstruction
 Dyspepsia
 Diarrhoea
 Appendicitis

14. Rt. colon
 Anaemia
 Mass
 Dark stool
 Diarrhoea
 Dyspepsia

15. Lt. colon
 Progressive
Constipation
 Obstruction
 Changes in the
bowel habit
 Colicky pain
 Blood in stool
 Mass

16. Sigmoid colon
 Early morning
diarrhea with
blood and/or
mucous
 Obstruction
 Altered bowel
habit
 Mass
 Colo-vesical fistula

17. Rectum
 Early
 Per rectal bleeding
 Tenesmus
 Spurious diarrhoea
 Bloody slime
 Early morning
diarrhoea
 Altered bowel habit
 Late
 Pain
 Weight loss

18.  Screening
 Faecal OBT
 Colonoscopy
 Diagnostic
 Colonoscopy
 Proctoscopy
 Biopsy
 Ba enema
 CT Colonoscopy
 Prognostic
 CEA
 CA – 19-9
 Staging
 USG
 CXR
 CT chest & Abdomen
 Pelvic MRI
 TRUS

19. 1. Preoperative workup
2. Operative procedure
3. Post operative
management
4. Surveillance program
1. Planning
2. Counseling &
consent
3. Tumour board
formation
4. Correction of
co-morbidities
5. Prophylaxis
6. Bowel
preparation

20.  Surgery
 Chemotherapy
 Radiotherapy
 Targeted therapy
 Immuno therapy
 Alternative treatment

21.  Surgery is the mainstay of treatment
 Radiation and/ or chemotherapy are given
before or after surgery
 The type of surgery depends on the site and
stage of the cancer
 Surgical treatment maybe curative (stage
I,II, III, or IV with resectable metastatic
disease) or palliative ( stage IVb)

24. 1. Local excision: TEMS / TAMIS
2. Radical surgery
I. AR with TME
a. High AR
b. Low AR
c. Ultra Low AR
II. APR
3. Surgery in advanced carcinoma

25.  Open
 Laparoscopic
 Robotic
 Trans anal

26.  For mid and lower rectal tumor
 For rectal adenomas and early rectal cancers
 Must below peritoneal reflection

27.  Indication:
 Well differentiated
 Grade 1 or 2
 Not mucinous
adenoma
 Lymphnode –ve
 Diameter < 3cm
 Tumor invades only
submucosa

28.  It is a sphincter saving operation
 Approach: open / laparoscopic / robotic
assistance
 Two terms: TME & CRM

30.  Neoadjuvant ,adjuvant or palliative setting
 Neoadjuvant is short course and long course
chemoradiation
 Long course RT 45-50 Gy for 6 weeks + 1st &
last week chemo  6 weeks interval  surgery
(down staging)
 Short course RT 25 Gy for 5 day + 1st & 2nd day
chemo  surgery within 7-10 days (sterilize
tumour) or, 12 weeks later (down staging)
 Adjuvant is EBRT or IORT/ contact RT

31. Short course
Long course

32.  As Neoadjuvant with RT or adjuvant to
reduce the risk of disseminated disease
 5 FU remain the 1st line therapy
 Oxaliplatin & Irinotcan is 2nd line

33.  Target specific type of cancer cells
 One type stops the growth of new blood vessel into
rectal tumour
 second type stops the cancer cells from receiving
signal to grow
 less likely to harm normal cells than chemotherapy
 eg, Bivacizumab

34.  Increases the activity of immune system
 Improves body’s ability to find and
destroy cancer cell
 Drugs are called checkpoint inhibitor
 eg: Ipilimumab

35.  Palliative resection
 Diversion / bipass
 Stenting
 Ablasion
 Palliative radiation