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1. SEMINAR COLORECTAL
CANCER
Supervisor:
Ms. Nur Afdzillah Abdul Rahman
Presenter:
1. Fahmi Mazlan A166734
2. Anusha Munusamy A163299
3. Yuen Nursinta A163307

2. INTRODUCTION
Anatomy & Clinical features

3. ANATOMY & CLINICAL FEATURES
Occult bleeding
Anemic symptoms/
history of blood
transfusion
(d/t chronic bleeding)
Unexplained IDA in men
>50y/o and
post-menopausal
woman
Melena
Altered bowel habits (size,
consistency, frequency, amount)
- Constipation –> loose stool –>
spurious diarrhea
Hematochezia
Colicky abdominal pain (bowel
obstruction)
RECTAL
Hematochezia
Mucus in stool
Pain/ pruritus over perianal area
Tenesmus
Fecal incontinence
Complications:
1. Intestinal obstruction/ peritonitis
2. Fistula (pneumaturia/ fecaluria)
3. Metastasis - lung/ liver/ bone/ brain
RIGHT
LEFT

4. CASE PRESENTATION

5. En. K, 53 years old, Malay gentleman with underlying HPT, dyslipidemia, DM and
obesity presented with altered bowel habit for 4 months
Altered bowel habit
- Previously pass stool once per day with bristol 3-4
- Since 4 months ago, having loose stool (bristol 6), alternating with constipation
- 3-4 episodes per day, amount = 1 small cup (about 200ml)
- Occasionally mix with fresh blood (2-3 episodes per week)
- Half small cup
- No blackish stool/ hematemesis
- No staining over toilet bowl/ tissue/ undergarment
- No anemic symptoms
- No previous blood transfusion
- No mucus in the stool
- Associated with tenesmus
- Occasional feeling of bloatedness
- No fecal incontinence
- No pneumaturia/ fecaluria

6. No abdominal pain
No fever
No history of chronic constipation
No joint pain/ eye pain/ oral ulcers suggestive extra-intestinal sx in IBD
No symptoms of metastasis to liver (RUQ pain/ yellow discoloration of skin)/ lung
(hemoptysis/ SOB)/ bone (back pain)/ brain (headache/ confusion)
No symptoms of intestinal obstruction such as vomitting/ obstipation
No LOA
Has LOW 5kg in 10 months (not significant)

7. Risk factor :
- Consume high amount of red meat - almost daily
- Low fibre diet
- First degree family history of breast cancer (younger sister dx at age of 40)
- Chronic smoker for 20 pack years, starting from 20 years ago started to smoke
1-2 cigarettes only per day
- Obesity class I (BMI 30)
- T2DM

8. Past medical history
Hypertension
- 20 years
- On Amlodipine 10mg OD and Perindopril 4mg OD
- SMBP : 120-125/ 80-90
Dyslipidaemia
- 20 years
- On Simvastatin 40mg OD
T2DM
- 7 years
- On Metformin 1000mg BD & Glicazide 4mg OD
- SMBG: fasting : 7-8 / 2HPP : 9
- No osmotic sx/ no TOD symptoms (chest pain/ unilateral side weakness/ frothy urine/ claudication/
glove-sock numbness/ BOV)

9. Past surgical history
- Nil
Medications and allergies
- Does not consume other
medications/ supplements
- No known drug/ food allergies
Family history
- Father passed away at age of 65 due to
MVA
- Mother currently 75 years old has
underlying HPT/DM/CKD/dyslipidaemia
- 8 siblings (3rd child)
- Others is well and healthy
Social
- Married and blessed with 4 children (all
well and healthy)
- Work as online businessman
- Does not consume alcohol
- Financially stable - medical fees
covered by GL

10. General examination
- Conscious and alert
- Comfortable lying down supine
- Not cachexic looking
Periphery:
- No clubbing
- No stigmata of CLD
- No koilonychia (IDA)
- No bruises/ scratch marks noted over arms
- Pulse rate is 90 bpm, regular rhythm and good volume
- Not pale
- Not jaundice
- Good oral hydration and hygiene

11. Abdominal examination
Inspection
- Abdomen is not distended
- No scars
- No dilated veins/ visible peristalsis
Palpation
- Soft and non tender
- No palpable mass
- No hepatosplenomegaly
- No ballotable kidney
- No shifting dullness
- No inguinal lymphadenopathy
Auscultation
- Bowel sound is present and normal
- No renal/ aortic bruit
Systemic review : unremarkable

12. Differential diagnosis

13. Differential diagnosis Points for Points against
Colorectal carcinoma -painless PR bleed
-altered bowel habits
-tenesmus
-no constitutional symptoms
Diverticular disease -PR bleed
-altered bowel habits
-no constitutional symptoms
-no abdominal pain
Inflammatory bowel disease -PR bleed -- No extraintestinal
manifestation (e.g. uveitis,
acute arthritis, aphthous
ulceration)
-no abdominal pain
- no weight loss
Haemorrhoids -painless PR bleed -no mucus in stool
-blood is mixed with stool
-no lump/swelling noted
during wiping

14. INVESTIGATIONS
+ Screening & Staging

15. Investigations
Diagnostic investigation - Colonoscopy
● Direct visualization for the location and size of lesion
● Biopsy for histological investigation
● Detection of synchronous lesions
Staging investigation
● CT-TAP
● MRI Pelvis- rectal cancer
Assessment of complication/fitness for surgery
● FBC
● Liver function test
● CRP
Preoperative investigations
● Carcinoembryogenic antigen (CEA)-tumour marker
● Chest X-ray
● Coagulation Profile
● Renal Profile
● Group Cross Match (GXM)

18. Screening

19. All individuals with family history suggestive of a hereditary colorectal cancer syndrome
should be referred to a clinical genetics service for genetic risk assessment, where accessible.

20. Results

21. Blood investigations
Hb (13 - 15) g/dL 14
WCC (4 - 10) x 109
/L 7.77
Plt (150 - 410) x 109
/L 393
MCH (27 - 32) pg 27.5
MCV (83 - 101) fl 84.2
Full blood count (pre-op)
Liver function test (pre-op)
Albumin (34 - 48) g/L 36
Total protein (64 - 83) g/L 65
Total bilirubin (3.4 - 20.5)
umol/L
6.8
ALT (0 -55) U/L 13
ALP (40 - 150) U/L 81
Na+
(136 - 145) mmol/L 138
K+
(3.5 - 5.1) mmol/L 4.1
Urea (2.5 - 6.7) mmol/L 2.8
Creatinine
(50.4 - 98.1) umol/L
84
PT (11.7-14.9) seconds 12
INR 0.89
APTT (29.5-43.6) seconds 37.1
(0 - 5) ng/mL 40
Renal Profile
Coagulation profile
CEA

22. Colonoscopy (17/2/22)
1. Retrosigmoid polypoid tumour
2. 15cm-20cm from AV
3. Occupy 50% of the lumen
Impression : rectosigmoid tumour
HPE: Adenocarcinoma, well to moderately
differentiated, arising on a tubulo-villous
adenoma with high grade dysplasia.
CT TAP (8/3/2022)
1. Short segment irregular circumferential bowel wall
thickening seen at rectosigmoid region measuring
approximately 3cm in thickness, 6.2cm in length and
17.5cm from anal verge.
2. Liver is homogeneously enhanced with no focal liver
lesion.
3. No obvious lung nodules
4. Mildly enlarged right paratracheal lymph node with fatty
hilum measuring 1.1cm

23. Management & Complication

24. Surgical management
❖ The mainstay of treatment for colorectal carcinoma is surgical
resection, which offers the best curative outcome.
❖ Chemotherapy and radiotherapy are used to downstage, as adjuvant
therapy and for palliative purposes. The treatments for colon and rectal
carcinoma are outlined in Algorithm C and Algorithm D.

25. Pre operative management
❖ Prophylactic antibiotics (IV Ceftriazone + Metronidazole)
- To cover both aerobes & anaerobes, reduce risk of wound infection &
sepsis
❖ Venous thromboembolism prophylaxis (risk of thromboembolism)
- Anti-embolic stockings (TED stockings)
- Heparin
❖ Bowel preparation
- Should be performed in rectal carcinoma surgery
- May be performed in colon carcinoma surgery

27. Principles of surgery for colonic CA
1. Remove the cancer completely with clear margins
2. Resect adjacent draining lymph nodes
3. Avoid excessive disruption or spillage of tumour cells
4. Reconstruct the bowel, if possible, in order to achieve intestinal continuity and normal or near normal
bowel function post-operatively.
- Main segmental vessels are ligated & divided (i.e. high tie at the IMA for oncological clearance)
- En-bloc resection of tumour with adequate margins. A margin of 5 cm proximally and distally is
adequate. While segmental resection is sufficient for primary tumour removal, a wider resection is
often required to achieve sufficient lymphadenectomy. Adequate clearance of the draining lymphatics
involves excision of the vascular arcades supplying the segment of involved colon back to their origin
(from the SMA or IMA) as lymphatics follow the arteries generally.

29. Right hemicolectomy Tumour site
Caecum/Ascending colon
Structures involved
(excision of structures + division
of blood vessels)
Excision of caecum + ascending
colon
-ileocolic artery
-right colic artery
-right branch of the middle colic
artery
15-20cm + proximal ⅓ transverse
colon
Extended right hemicolectomy Hepatic flexure/transverse
colon near hepatic flexure
Excision of caecum,ascending
colon and proximal transverse
colon
-ileocolic artery
-right colic artery
-middle colic artery(at its origin)
- distal ⅓ transverse colon

30. Left segmental colectomy Transverse colon near splenic
flexure
Excision of distal transverse colon
and proximal descending colon
-left branch of middle colic artery
-left colic artery
Left hemicolectomy Descending colon Excision of descending colon
-left colic artery
-left branch of middle colic artery
-inferior mesenteric vessel

33. Local excision Small tumours
Low anterior resection and Hartmann’s procedure -lesions located in the upper ⅔ of the rectum
-defunctioning stoma decreases clinical anastomotic
leak rate and re-operation rate
Abdominoperineal resection with permanent
colostomy
-rectal tumour sited in the distal ⅓ of the rectum
within 5 cm of anal verge
-involves removal of the anus,rectum and part of the
sigmoid colon with associated regional lymph nodes

34. Stoma
- Artificial opening of a luminal organ into the external environment
- A defunctioning loop ileostomy (or loop colostomy) is usually created during low AR as the manipulation of
the colon deep within the pelvic cavity causes increased risk of an anastomotic leak & also poorer blood
supply to anastomosis (immediate anastomosis is not possible)
- A defunctioning stoma does not protect against anastomotic leak, but mitigates against disastrous
complications of faecal peritonitis should a leak occur
- Closed in 2-6/12 after check with gastrografin reveals no leak (contrast agent during X-ray imaging)

35. Stoma
Ileostomy Colostomy
Location Right iliac fossa Left iliac fossa
Calibre Small Large
Flushed/Spouted Spout- to prevent ileal content
(corrosive) contact to skin
Flushed to the skin
Content Watery greenish ileal output Firm brown faecal output

36. Operative complications
Immediate <24h - Anastomotic leak
- Damage to other organs (ureters,
small bowel, large bowel)
- Bleeding
Early <30d - Wound infection
- Bleeding
- Abscess
- Anastomotic leak -> fecal peritonitis
- Early stoma complications
Late >30d - Diarrhoea
- Impotence
- Adhesions -> IO
- Anastomotic stricture
- Late stoma complications

37. Chemotherapy and radiotherapy
Colon CA
1. Stage 1 & 2
-surgery
2. Stage 2 with high risk features
-adjuvant chemo
3. Stage 3
-fluorouracil (5-FU)/ leucovorin with
oxaliplatin (FOLFOX)
Rectal CA
1. Short course preoperative
radiotherapy is a treatment option
for rectal carcinoma
2. Neoadjuvant chemoradiotherapy
should be offered to T3-T4 / node
positive rectal carcinoma
3. Long course concurrent
chemoradiotherapy may be given
pre or post operatively

38. Follow-up and surveillance
❖ History, physical examination and CEA every 3 to 6 months for 5 years
❖ Surveillance colonoscopy at first year and every 3 to 5 years
❖ CT scan of thorax,abdomen and pelvis is performed annually for 3 years
❖ Encouraged to maintain an ideal body weight,participate in regular physical
activity and consume a well balanced diet

39. Thank you