Good

1. MANAGEMENT OF
COLORECTAL CANCER
Moderator- Prof. Berhanu Kotisso
(consultant General and Colorectal Surgeon)
presenter- Mahlet Befrdu.(GSRIII)
Sept 13/2023 G.C
2/22/2024 1

2. Outlines
• Overview
• Incidence
• Risk factors
• Pathogenesis
• Management of colonic ca
• Rectal ca
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3. Overview
• Colorectal cancer is cancer of the colon or rectum
• It is the third most common cancer diagnosed in the U.S
• Treatment depends on the stage of the cancer
• Main treatments include surgery, chemotherapy, radiation
therapy, and targeted therapy
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4. Incidence
• Colorectal carcinoma is the third most common malignancy, and the
second leading cause of carcinoma death
• The American Cancer Society estimated that roughly 105,000
Americans would be diagnosed with colon cancer and 43,000 with
rectal cancer, and that 53,200 deaths would be attributed to these
cancers in the year 2020
• The incidence and mortality has declined in recent years most likely
due to increased screening
• The overall lifetime risk of developing colorectal cancer is 4.7% in men
and 4.4% in women
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5. • In the United States, over the past several decades the survival rate
has improved for each stage
• The current 5-year relative survival for people with
• stage I colon cancer is about 92%,
• stage IIA 87%,
• stage IIB 63%,
• stage IIIA 89%, stage IIIB 72%,
• stage IIIC 53%, and
• stage IV 11%
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6. • Limited data suggests the incidence of colorectal cancer in
Ethiopia is relatively low compared to other African countries,
but still a growing problem
• Ethiopia is estimated to have an age-standardized incidence
rate for colorectal cancer of around 6 cases per 100,000
population per year
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11. Risk Factors
• Increasing age
• Gender
• Family history of colorectal cancer
• Personal history of colorectal polyps or inflammatory bowel
disease
• Lifestyle factors like smoking, heavy alcohol use, obesity, red
and processed meat consumption
• Low fiber diet
• Pelvic radiation
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13. Site
• The distribution of carcinoma in the various segments of the large
bowel has been the subject of several detailed clinical studies
• Studies have shown that over the past 50 years there has been a
gradual shift in the location of carcinomas from the rectum and left
colon toward the right colon
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14. Geographic Distribution
• There is a wide variation of the incidence of colorectal carcinoma in
different countries
• In general, countries of the Western world have the highest incidence
of colorectal carcinoma, and these include Scotland, Luxembourg,
Czechoslovakia, New Zealand, Denmark, and Hungary
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15. Etiology and Pathogenesis
• A number of factors have been considered important in its causation, and
certain clinical conditions are considered precursors of carcinoma
• Polyp–Cancer Sequence
• Inflammatory Bowel Disease
• Genetics
• Dietary Factors
• Alcohol Ingestion and smoking
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16. • Ureteric Implantation
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17. Polyp–Cancer Sequence
Inflammatory Bowel Disease
Genetics
Dietary Factors
Alcohol Ingestion and smoking
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19. Modes of Spread
• Direct continuity
• Transperitoneal spread,
• Lymphatic spread,
• Hematogenous spread, and implantation
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20. Site of Spread
• For every 100 patients with intestinal carcinoma, approximately on half will
be cured by operation and 5 will die from lymphatic spread, 10 from local
recurrence, and 35 from blood-borne metastases
• The organs most frequently involved are the
• Liver (77%),
• Lungs (15%),
• Bones (5%), and
• Brain (5%)
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22. • Staging
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25. • The International Union Against Cancer, the American Joint
Committee on Cancer, a National Cancer Institute consensus panel,
and the College of American Pathologists have all recommended
evaluation of at least 12 nodes to ensure adequate sampling

26. • The rate of growth of an individual carcinoma is almost certainly the
most important prognostic discriminant
• Colorectal carcinomas are relatively slow-growing neoplasms, and
metastases occur relatively late

27. Clinical Features and Symptoms
• Patients with carcinoma of the large intestine may present in one of
three characteristic ways:
• insidious onset of chronic symptoms,
• acute intestinal obstruction,
• or perforation with peritonitis.

28. • Depending on the location in the bowel, one or another of the
following symptoms may predominate
• Bleeding is probably the most common symptom of large bowel
malignancy
• may be occult, as is often the case in right-sided lesions,
• or overt, being either bright red, dark purple, or even black, depending on the
location in the bowel

29. • The second most common presenting symptom is probably a change
in bowel habits, either constipation or diarrhea
• Lesions in the proximal colon may not result in a change in bowel
symptoms until they are very far advanced
• Lesions in the distal colon are more likely to manifest in symptoms
since the stool is more formed in consistency and the bowel lumen is
narrower
• A progressive narrowing of the caliber of the stool may be reported in
the case of a compromised lumen

30. • Pain may occur with almost equal frequency as the preceding
symptom
• Abdominal pain may be vague and poorly localized, or it may result
from a partially obstructing lesion of the colon
• Rectal pain does not occur with carcinoma unless there is sacral nerve
root or sciatic nerve involvement
• tenesmus may occur with rectal carcinoma
• Back pain is a late sign of penetration of retroperitoneal structures

31. • Other symptoms include
• mucus discharge
• weight loss
• Nonspecific symptoms of general impairment of health
• loss of strength, anemia, and sporadic fever
• carcinoma of the cecum may present with the signs and symptoms of acute
appendicitis
• Iron deficiency anemia

32. • In the report of the Commission on Cancer, in which 16,527 patients were diagnosed with
carcinoma of the colon, the presenting symptoms in order of frequency were
• abdominal pain (40.5%),
• change in bowel habits (33.2%),
• rectal bleeding (28.5%),
• occult bleeding (34.3%),
• malaise (16%),
• bowel obstruction (14.9%),
• pelvic pain (3.4%),
• emergency presentation (6.6%), and jaundice (1%)

33. General and Abdominal Examinations
• Any obvious excess weight loss may indicate advanced disease
• Pallor
• The assessment may help in evaluating the patient’s fitness for
operation
• mass may be present and may indicate the primary malignancy or
possible metastatic disease

34. • The liver may be enlarged
• Ascites
• Abdominal distention
• Inguinal and left supraclavicular lymphadenopathy
• Peritonitis

35. • Digital Rectal Examination will not identify the presence of a colon carcinoma, it
should reveal the presence of a rectal lesion
• Sometimes a sigmoid carcinoma that hangs down into the cul-de-sac may be
palpable
• Extraintestinal Manifestations
• acanthosis nigricans,
• dermatomyositis,
• pemphigoid

36. • Synchronous Carcinomas are not uncommon, and in recent reviews
the incidence was found to range from 2 to 8% in colon carcinoma
patients
• Colonoscopy performed preoperatively in patients undergoing
elective resection is the optimal method for assessing the unresected
colon for synchronous lesions

37. Complications
• Obstruction
• Depending on the macroscopic features and location of the
malignancy, interference with the passage of intestinal contents may
occur
• Carcinoma is the most common cause of large bowel obstruction,
contributing to 60% of cases in the elderly
• Incidences ranged from 7 to 29%

38. • Complete obstruction of the colon from carcinoma is often entirely
insidious in its onset
• Nausea and vomiting with progressive symptoms of obstipation
• patients may present with sudden, severe, colicky abdominal pain
that persists, and investigation may reveal a complete obstruction

39. • On examination, the patient’s general condition usually is found to be
good, because dehydration and electrolyte depletion are often late
phenomena
• abdomen reveals that it is distended and tympanitic but not tender
Hyperactive peristalsis may be present

40. • Sigmoidoscopy
• Plain X-ray
• nonspecific type of colitis may develop proximal to an obstructing
carcinoma of the colon

41. Perforation
• The incidence of perforation associated with carcinoma of the colon is
in the 6 to 12%
• peritonitis,
• abscess formation,
• adherence to a neighboring structure, or
• fistulous communication into a viscus

42. • Patients with obstruction and a proximal perforation present as
desperately ill individuals with generalized peritonitis, dehydration,
and electrolyte depletion
• Immediate exploratory laparotomy is demanded
• Patients without obstruction but with perforation of the carcinoma
are also gravely ill and require immediate laparotomy after some
correction of dehydration and electrolyte depletion
• Patients without obstruction but with perforation of a carcinoma may
present with a localized peritonitis

43. • Bleeding
• Is a common symptom of colorectal carcinoma, but massive bleeding
is an uncommon presentation

44. Diagnosis
• occult blood testing and flexible fiberoptic sigmoidoscopy is the
minimum current recommendation
• Colonoscopy is ideal and preferable

45. Differential diagnosis
• Inflammatory bowel disease,
either of the nonspecific type
• ulcerative colitis
• or Crohn’s disease, amebiasis,
actinomycosis, or tuberculosis
• ischemic strictures
• Acute abdomen may be
confused
• Diverticulitis or appendicitis with
abscess
• Crohn’s disease, foreign body
perforation
• acute obstruction, volvulus,
diverticulitis
• Extrinsic pressure from a
metastatic carcinoma

46. Investigations
• Blood Markers
• Whole blood count
• Liver Function Tests
• Carcinoembryonic Antigen
• Normal concentrations of CEA are 2.5 to 5.0 ng/mL, depending on the assay
used
• 80% or more of patients with advanced colonic adenocarcinoma have
circulating CEA, the CEA assay should not be used as the sole diagnostic test
for suspected carcinoma
• CEA levels are not presently useful for distinguishing locally invasive polyps
from benign lesions
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47. • Preoperative serum CEA levels in diagnosed colorectal carcinoma are
elevated in 40 to 70% of patients
• Correlate inversely with the grade of the carcinoma and directly with
the pathologic stage
• The CEA is elevated in 95% of patients with well-differentiated
lesions, while it is elevated in as few as 30% of those with poorly
differentiated adenocarcinomas
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48. • The higher the preoperative CEA level, the greater the likelihood of a
postoperative recurrence
• An increase in the blood CEA concentration in a patient after
apparently successful surgical treatment for carcinoma has repeatedly
been shown to signal a recurrence of the carcinoma
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49. • Occult Blood Testing
• Endoscopy
• Sigmoidoscopy (flexible, rigid)
• Colonoscopy
• Radiology
• Barium Enema (In the past) an annular, or napkin ring, apple core”
• Intravenous Pyelography
• Ultrasonography
• Computed Tomography
• Magnetic Resonance Imaging
• Biopsy
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50. Management of colorectal cancer
Multidisciplinary team (MDT) approach
• Ideal for the management of patients with colorectal cancer
especially in locally advanced and recurrent CRC.
• Involvement of multiple subspecialists
• MDT team is involved in
• Staging process
• Pathologic evaluation
• Type of surgery needed and for neoadjuvant and adjuvant therapy

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52. Surgical treatment of colonic ca
• Preoperative Evaluation
• Bowel Preparation
• Curative Resection
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53. • When the abdomen has been opened, attention should be directed to
ruling out the presence of metastatic disease, with special attention
given to the liver and the pelvis
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54. Principles of Resection
• Removal of the primary lesion with adequate margin, including the
areas of lymphatic drainage
• En bloc resection of involved structures is firmly established
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61. • Complete mesocolic excision (CME) includes dissection in the
mesocolic plane with central vascular ligation, has been proposed as a
means of improving lymph node yield and subsequent outcomes
• The goal is to remove the entirety of the mesocolon along
embryologic tissue planes with transection of the critical vasculature
at the origin
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62. Invasion of Adjacent Viscera
• Carcinoma can becomes attached to the abdominal wall or the
adjacent viscera, such as the small bowel, urinary bladder, uterus,
stomach, spleen, ureter, or duodenum
• Combined or staged liver resection
• Lung metastasis
• Palliative resections
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63. Post operatively
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66. Rectal carcinoma
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68. Local Staging
• The two imaging modalities that are the most useful for local staging
of rectal adenocarcinoma are transrectal ultrasound (TRUS) and MRI
• CT of the pelvis can define tumor invasion into surrounding structures
for larger tumors, but does not adequately assess depth of invasion
for smaller tumors
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70. • Multidisciplinary Tumor Board
• All patients with rectal cancer should be discussed upon
prentation
• surgeons, radiologists, pathologists, medical oncologists, and
• radiation oncologists
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71. • Neoadjuvant Therapy
• Indications
• The use of neoadjuvant therapy has led to a significant reduction in local
recurrence rates for patients with resectable adenocarcinoma of the
rectum
• At present, the current standard of care for neoadjuvant therapy includes
• long-course chemoradiation (50.4Gy) delivered in 28 fractions with concurrent
• fluoropyrimidine-based radio-sensitizing chemotherapy and surgery after 6 to 8
weeks,
• or short-course preoperative radiotherapy delivered as 25 Gy in 5 fractions over 1
week, followed by surgery within a week of completion of therapy
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74. • Principles of Rectal Cancer Surgery
• Local Excision
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76. Low anterior resection
withTME
• Most important factor is the level
of the lesion, with safe distal
margin of resection 1-2cm.
• The only absolute
contraindication for a low
colorectal or coloanal
anastomosis are
• Invasion into the anal canal
• Invasion of the sphincter mechanism

77. • Total Mesorectal Excision
Dissection in the avascular “holy plane” between the visceral and
parietal layers of the endopelvic fascia ensuring en bloc removal of the
primary tumor and associated mesentery, lymphatics, vascular, and
perineural tumor deposits, as well as preserving autonomic nerve
and reducing bleeding
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82. • Distal Margin
• Distal intramural tumor spread is uncommon and is found beyond 1 cm from the
primary tumor in less than 10% of cases
• A 2-cm distal mural margin is usually adequate for distal rectal cancers when
combined with TME. A 1-cm distal mural margin is generally acceptable for
cancers located at or below the mesorectal margin recommended in the most
recent ASCRS practice parameters for rectal cancer
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83. • Abdominoperineal Excision
• Tumors that involve the distal mesorectal fascia, levator muscle, or
sphincter complex may require an APE to obtain a clear radial or distal
margin
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85. • Three types of APE can be defined based on patient and tumor
related factors
• intersphincteric APE,
• extralevator APE (ELAPE), and
• ischioanal APE
• For all three types, the abdominal portion is identical
• Pathologic macroscopic grading of the resected sphincter complex
(valid for ELAPE and ischioanal APE only) is performed in similar
manner graded as the mesorectum and is divided into three
categories: extralevator, sphincteric, and intrasphincteric/submucosal
planes
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87. • Reconstructive Techniques
• Defunctioning Stoma
• Pelvic Drainage
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88. Emergency
• Bleeding,
• radiation
• Obstruction,
• obstruction due to extraperitoneal rectal cancer, decompression with a
proximal diverting stoma should be considered and
• Perforation
• control the septic source, resection with or without anastomosis according to
oncologic Principles
• proximal to the tumor, an extended resection
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89. Postoperative care
• Diet
• Drainage
• Urinary catheter
complications
• Urinary complications(50%)
• Perineal wound infections(16%)
• Leaks from stoma
appliance(66%)
• Sexual dysfunction (67%)
• Stoma complications

90. • Postoperative Chemoradiation
• Patients with clinical stage I tumors who undergo up front surgery and are
upstaged to stage II or III,
• or patients who undergo upfront surgery for preoperative low-risk T3N0
tumors who have a positive CRM, incomplete TME, or residual disease after
surgery
• should be considered for postoperative chemoradiation to reduce the
risk of locoregional recurrence and distant metastasis.
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92. Surveillance
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93. References
• Gordon principles and practice of Surgery for the Colon Rectum and
Anus, 4th edition
• Schwartz’s principle of surgery, 11th edition
• Maingot’s Abdominal Operations, 13th edition
• NCCN Guideline Version 2023
• Sabiston Textbook of Surgery, 20th edition
• Uptodate.uptodate.com
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94. Thank you
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