Colorectal Cancer

Prof. Igor Y. Galaychuk, MD

Chief, Department of Oncology & Radiology

Ternopil State Medical University

Anatomy of Colon

Risk Factors for Colorectal Cancer

• Average risk: Hamartomatous polyposis syndromes; Age 50 years and older; Peutz-Jeghers syndrome; Asymptomatic Juvenile polyposis

• Increased risk: Family history; Inflammatory bowel disease; Colorectal cancer; Chronic ulcerative colitis; Colorectal adenomas; Crohn disease, long-standing; Hereditary nonpolyposis colorectal cancer; Familial adenomatous polyposys (including Gardner and Turcot syndromes); Personal history; Breast, ovarian, or uterine cancers

Anatomic Areas of Large Intestine and

Correlating Colorectal Symptoms

• Right colon: Microcytic anemia; Occult blood in stool; Palpable mass in right lower quadrant

• Left colon: Hematochezia; Obstructive symptoms; Small-caliber (pencil-size) stools; Cramps; vague abdominal pain; Change in bowel habits

• Rectum: Rectal bleeding; Change in bowel habits; Pain; Change in stool caliber;

Tenesmus

THE LARGE INTESTINE

• Symptoms such as altered bowel habit, rectal bleeding, abdominal pain, weight loss and anemia may indicate serious colonic disease. Colonoscopy and barium studies are complementary and equally useful but their deployment depends to a large extent on the availability of colonoscopy services. Many clinicians use the barium enema as the first-line diagnostic investigation and either combine this with flexible fibreoptic sigmoidoscopy or reserve a full colonoscopy for those instances where a barium study is inconclusive or where a lesion shown radio-logically requires further direct examination and biopsy.

• Barium studies require full bowel preparation using one of a variety of cleansing techniques (fecal residue may mimic polyps or tumors). A double-contrast technique involves inflation of the colon using air or carbon dioxide, and peristaltic activity is temporarily abolished using a short-acting atropine-like pharmacological agent.

• Colonoscopv provides direct access to lesion- or suspicious areas of mucosa for biopsy: small polypoid lesions may be amenable to removal during the same diagnostic procedure. The examination may not be complete because in a significant proportion (10-30%) the caecum is not reached and there are also ‘blind’ spots at points of angulations of the colon. Advanced diverticular disease produces deformity and narrowing that is difficult to assess both in barium studies and during colonoscopy.

• Colonoscopy has a significantly higher risk of complications than barium enema, and the procedure is more time consuming.

Common disorders of the large intestine

• Carcinoma: Most are irregular strictures with ‘shouldering’. Destroyed mucosal pattern, proximal dilatation and obstruction. Invasion of adjoining tissues and organs. May appear as polyp, usually more than 2 cm with complex surface pattern. Long-standing ulcerative colitis and familial polyposis coli are predisposing conditions.

• Diverticular disease: Multiple diverticula particularly in sigmoid region, but may be widespread. Narrowing and deformity. Common, so may coexist with cancer. May bleed or perforate, or form fistulae, e.g. with bladder.

• Ulcerative colitis: Diffuse, uniform fine ulceration; loss of haustra, giving featureless tubular colon. Toxic megacolon and carcinoma are complications. May only involve distal colon or rectum in some cases.

• Crohn’s disease: Areas of narrowing, deep ulceration, strictures. Perianal disease is common. Prone to form fistulae. Coexists with small bowel disease often.

• Ischaemic colitis: Cause of profuse bleeding and acute abdominal pain. Narrowing of lumen, often affecting localised segment, with mucosal edema (‘thumb-printing’). Occasionally difficult to distinguish from Crohn’s disease

CRC: Diagnostic Workup Procedures

• Staging workup procedures:Colonoscopy and/or double-contrast barium enema (used to identify synchronous carcinomas and adenomas); Chest-radiograph; CT scan (in staging rectal cancer, it is helpful to evaluate local spread to adjacent organs, pelvic bones, or liver); MRI (for staging rectal cancer); Endoluminal ultrasonography (useful for finding local spread into rectal wall and occasionally for detecting perirectal nodes); Biopsy of lesion; Cystoscopy (for low sigmoid or rectal lesions); HIV testing (anal cancers are associated with acquired immunodeficiency disease syndrome)

CRC: Diagnostic Workup Procedures

• Laboratory studies:CBC with differential and platelet countLiver enzymes (SGOT, SGPT, alkaline dehydrogenase, and lactate dehydrogenase)ElectrolytesPT and PTTBUN and creatinineCEA

TNM Clinical Classification

T - Primary tumor T0 No evidence of primary tumorTis Carcinoma in situT1 Tumor invades submucosaT2 Tumor invades muscularis propriaT3 Tumor invades through muscularis propria into subserosa or into non-

peritonealized pericolic or perirectal tissuesT4 Tumor directly invades other organs or structures and/or perforates

visceral peritoneum

N - Regional lymph nodesN0 No regional lymph node metastasesN1 Metastasis in 1-3 regional lymph node N2 Metastasis in 4 or more regional lymph node

M - Distant metastasisM0 No distant metastasisM1 Distant metastasis

Stage grouping

Stage 0 TisN0M0

Stage I T1-2 N0M0 Dukes A

Stage IIA T3N0M0 Dukes BStage IIB T4N0M0 (surv. 50-65%)

Stage III A T1-2N1M0 Dukes CStage III B T3-4N1M0 (15-40%)

Stage III C any T N2M0

Stage IV Any T Nx-2 M1 Dukes D(< 5%)

Colonoscopy: polyps

Endoscopic polypectomy

Colonoscopy: cancer

Stricture. A short circumferential narrowing is seen in the sigmoid colon (arrow) from a carcinoma.

Extrinsic compression. A narrowed length of sigmoid colon is seen caused by compression by an adjacent ovarian

Filling defects. Lumps of faeces have caused smooth filling defects surrounded by barium. However, in the sigmoid colon there is a large

filling defect with ill-defined edges (arrow). This is a carcinoma. A clean colon is essential for a

satisfactory barium enema.

Muscle hypertrophy and diverticula. Muscle hypertrophy gives the sigmoid colon a serrated appearance. Two small diverticula are arrowed

Ulcerative colitis. With long-standing disease the haustra are lost and the colon becomes narrowed and shortened coming to resemble a rigid tube.

Reflux into the ileum through an incompetent ileocaecal valve has occurred

A). Crohn's disease. The mucosal pattern has a 'cobblestone' appearance due to criss-crossing fine ulceration. B). Crohn's disease - strictures. A long stricture is present in the transverse colon (between curved arrows) and a shorter one in (hesigmoid colon (between small arrows). In this case the outline of the strictures are irregular, due to ulceration. C). These two abnormal segments with normal intervening bowel are an

example of skip lesions' - an important diagnostic feature of Crohn's

a

b c

Diverticular disease. Numerous diverticula are seen as out-pouchings

from the sigmoid colon

Diverticular disease. A stricture is present (arrow). Although there is recognizable diverticular disease at both ends of the stricture, it is impossible to exclude definitely a carcinoma

Scheme of the RHCE. Cancer of the Cecum

Right Hemicolectomy

Cancer of the Colon Liver Flexure: RHCE

Ileo-transverse colon anastomosis end-to-side

Cancer of Transverse Colon

Resection of Transverse Colon

Cancer of Descending Colon. LHCE

Left Hemicolectomy

Cancer of Sigmoid Colon. Resection

Colonic anastomosis end-to-end

Rectal Cancer: lymphatic ways

Patient’s position for surgery on rectum

Surgery of Rectal Cancer: Step 1

Surgery of Rectal Cancer: Step 2

Surgery of Rectal Cancer: Step 3

Scheme of abdomino-perineal resection of rectum (Quenu-Miles operation)

Colostomy

Anterior resection of rectum

Anterior resection of rectum

End-to-end stapled anastomosis

Scheme of abdomino-perianal resection with coloanal anastomosis

Coloanal anastomosis

Posttreatment Monitoring and Surveillance For

Colon Cancer Interim history and physical examination including DRE every 3

mo for 2 yr, then every 6 mo to 5 yr;CBC + chemistries every 3 mo for 2 yr, then every 6 mo to 5 yr;If CEA elevated at diagnosis or within 1 wk of colectomy, repeat

CEA every 6 mo for 2 yr, then annually for 5 yr;Chest radiograph every 12 mo to 5 yr of treatment if stage B2

or C, or every 6 mo to 5 yr of treatment if liver or abdominal metastases resected, or every 3 mo to 5 yr of treatment if lung metastases resected;

Abdominal CT every 6 mo to 5 yr, then annually for 3 yr if liver or abdominal metastases resected, or every 6 mo to 5 yr, then annually for 3 yr if rectal tumor resected;

Chest CT every 6 mo to 5 yr if lung metastases resected;Colonoscopy in 1 yr if negative for multiple synchronous polyps;

repeat in 1 yr if negative, then repeat every 3 yr.

Good-Bye Colorectal Cancer