Post on 13-Jan-2016
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Change in bowel Change in bowel habits…habits…
60 year old male60 year old maleComplains of progressive Complains of progressive constipation for the past 6 monthsconstipation for the past 6 months
Change in bowel Change in bowel habits…habits…
60 year old male60 year old maleComplains of progressive Complains of progressive constipation for the past 6 monthsconstipation for the past 6 months
10 kg unintentional weight loss10 kg unintentional weight loss
Occasional rectal bleedingOccasional rectal bleeding
No painNo pain Not vomitingNot vomiting
No painNo pain Not vomitingNot vomiting
Past medical history- unremarkablePast medical history- unremarkable
Never had colonoscopyNever had colonoscopy
Family history- Grandfather and uncle Family history- Grandfather and uncle with colon cancerwith colon cancer
Physical exam: Physical exam: Good nutritional statusGood nutritional status Abdomen- unremarkable, no massAbdomen- unremarkable, no mass Rectal- No mass, guiac + stoolRectal- No mass, guiac + stool
Physical exam: Physical exam: Good nutritional statusGood nutritional status Abdomen- unremarkable, no massAbdomen- unremarkable, no mass Rectal- No mass, guiac + stoolRectal- No mass, guiac + stool
Colonoscopy:Colonoscopy:
Sigmoid colon
Physical exam: Physical exam: Good nutritional statusGood nutritional status Abdomen- unremarkable, no massAbdomen- unremarkable, no mass Rectal- No mass, guiac + stoolRectal- No mass, guiac + stool
Colonoscopy: non obstructing mass at Colonoscopy: non obstructing mass at the sigmoid colonthe sigmoid colon
Pathology- adenocarcinomaPathology- adenocarcinoma
Colorectal Colorectal CancerCancerOded ZmoraOded Zmora
Department of Surgery B
Sheba Medical Center
Tel Hashomer
Colorectal CancerColorectal Cancer
Adenocarcinoma of the large bowel, Adenocarcinoma of the large bowel,
originating at the bowel mucosaoriginating at the bowel mucosa
22ndnd in cancer incidence in the Western in cancer incidence in the Western
worldworld
Significant cause of morbidity, expenses, Significant cause of morbidity, expenses,
and deathand death
Predisposing FactorsPredisposing Factors::
Age:Age:
Uncommon before the age of 40 yearsUncommon before the age of 40 years
Risk gradually increase with ageRisk gradually increase with age
When at young age – may be associated When at young age – may be associated
with known genetic predisposing factorswith known genetic predisposing factors
Predisposing FactorsPredisposing Factors::
Colonic polyp:Colonic polyp: Polyp is a benign growth of the mucosa Polyp is a benign growth of the mucosa The adenoma – carcinoma sequenceThe adenoma – carcinoma sequence
Predisposing FactorsPredisposing Factors::
Family history:Family history: Known genetic disordersKnown genetic disorders
FAPFAP
Autosomal dominant disAutosomal dominant dis
Presents with hundreds of adenomatous polypsPresents with hundreds of adenomatous polyps
Almost all develop cancerAlmost all develop cancer
Extra-colonic manifestations: Duodenal Extra-colonic manifestations: Duodenal carcinoma,carcinoma,
Gastric adenomas, desmoid tumors, osteomasGastric adenomas, desmoid tumors, osteomas
Prophylactic restorative proctocolectomyProphylactic restorative proctocolectomy
Predisposing FactorsPredisposing Factors::
Family history:Family history: Known genetic disordersKnown genetic disorders
FAPFAP
Predisposing FactorsPredisposing Factors::
Family history:Family history: Known genetic disordersKnown genetic disorders
HNPCC- hereditary non polyposis colorectal HNPCC- hereditary non polyposis colorectal cancer (=Lynch syndrome)cancer (=Lynch syndrome)
The presence of multiple colorectal cancer within a The presence of multiple colorectal cancer within a familyfamily
Predisposing FactorsPredisposing Factors::
Family history:Family history: Known genetic disordersKnown genetic disorders
HNPCC- hereditary non polyposis colorectal HNPCC- hereditary non polyposis colorectal cancer (=Lynch syndrome)cancer (=Lynch syndrome)
The presence of multiple colorectal cancer The presence of multiple colorectal cancer within a familywithin a family
Known genetic mutations in repair genesKnown genetic mutations in repair genes
Early onset of cancerEarly onset of cancer
More Rt sidedMore Rt sided
Associated with other malignanciesAssociated with other malignancies
Predisposing FactorsPredisposing Factors::
Family history:Family history: No known genetic disordersNo known genetic disorders
2-3 fold increased risk2-3 fold increased risk
Predisposing FactorsPredisposing Factors::
IBDIBD Ulcerative colitis > Crohn’sUlcerative colitis > Crohn’s
Dysplasia in UC patient – consider Dysplasia in UC patient – consider prophylactic restorative proctocolectomyprophylactic restorative proctocolectomy
Predisposing FactorsPredisposing Factors::
Undetermined factorsUndetermined factors
? Diet? Diet
? Smoking? Smoking
? Other environmental factors? Other environmental factors
Clinical PresentationClinical Presentation
May be asymptomatic for yearsMay be asymptomatic for years
Screening – controversialScreening – controversial
May treat pre-malignant conditionsMay treat pre-malignant conditions
May detect early cancerMay detect early cancer
Cost effectiveness - ?Cost effectiveness - ?
Ability to extend lifespan should be Ability to extend lifespan should be
demonstrateddemonstrated
Clinical PresentationClinical Presentation
Rt colon:Rt colon:
Anemia, occult blood in stoolAnemia, occult blood in stool
Small bowel obstructionSmall bowel obstruction
Perforation – less commonPerforation – less common
Clinical PresentationClinical Presentation
Lt colon:Lt colon:
Change in bowel habitsChange in bowel habits
Anemia- occult or gross bloodAnemia- occult or gross blood
Large bowel obstructionLarge bowel obstruction
Perforation – less commonPerforation – less common
Clinical PresentationClinical Presentation
Rectum:Rectum: BRBPR*BRBPR* Change in bowel habitsChange in bowel habits Tenesmus / incomplete evacuationTenesmus / incomplete evacuation Obstruction – mainly upper rectumObstruction – mainly upper rectum
* * Every rectal bleeding requires Every rectal bleeding requires investigation even in the face of knowninvestigation even in the face of known anal pathologyanal pathology
DiagnosisDiagnosis
History-History-
Change in bowel habitsChange in bowel habits
Rectal bleedingRectal bleeding
Wight lossWight loss
Reduced appetiteReduced appetite
Abdominal painAbdominal pain
DiagnosisDiagnosis
Physical exam:Physical exam:
General appearanceGeneral appearance
Abdominal massAbdominal mass
Abdominal distentionAbdominal distention
Abdominal tendernessAbdominal tenderness
Digital rectal exam- mass, blood, occult Digital rectal exam- mass, blood, occult
bloodblood
DiagnosisDiagnosis
Lab:Lab:
Hg levelsHg levels
CEA levelsCEA levels
LFT’sLFT’s
DiagnosisDiagnosis
Imaging studies:Imaging studies: Barium enemaBarium enema
DiagnosisDiagnosis Endoscopy:Endoscopy:
AnoscopyAnoscopy RectoscopyRectoscopy Short colonoscopyShort colonoscopy Full colonoscopy – the gold standardFull colonoscopy – the gold standard
DiagnosisDiagnosis
Imaging studies:Imaging studies: CTCT Virtual colonoscopyVirtual colonoscopy Plain abdominal x-ray – in obstructionPlain abdominal x-ray – in obstruction
Metastatic workupMetastatic workup
CXRCXR
Liver USLiver US
CTCT
PETPET
StagingStaging
Duke’s stagingDuke’s staging
AA limited to the bowel walllimited to the bowel wall
BB Through the entire bowel wallThrough the entire bowel wall
CC Mesenteric lymph nodesMesenteric lymph nodes
DD MetastaticMetastatic
StagingStaging TNM stagingTNM staging
T0T0 Carcinoma in SituCarcinoma in Situ T1T1 Invasive cancer, confined to the mucosaInvasive cancer, confined to the mucosa T2T2 Through the muscularis propriaThrough the muscularis propria T3T3 Through the bowel wallThrough the bowel wall
N0N0 Nodes negativeNodes negative N1 N1 Nodes positiveNodes positive
M0M0 No metastasisNo metastasis M1M1 Metastatic diseaseMetastatic disease
Treatment – colon cancerTreatment – colon cancer
Surgical resectionSurgical resection
Resected segment depends on the site of cancerResected segment depends on the site of cancer
Mobilization of the segmentMobilization of the segment
En-block resection with its lymphatic drainageEn-block resection with its lymphatic drainage
Anastomosis of the proximal and distal bowel Anastomosis of the proximal and distal bowel
endsends
Treatment – colon cancerTreatment – colon cancer
Surgical resection- Rt colectomySurgical resection- Rt colectomy
Treatment – colon cancerTreatment – colon cancer
Surgical resection- Rt colectomySurgical resection- Rt colectomy
Treatment – colon cancerTreatment – colon cancer
Surgical resection- Rt colectomySurgical resection- Rt colectomy
Treatment – colon cancerTreatment – colon cancer
Surgical resection- Rt colectomySurgical resection- Rt colectomy
Treatment – colon cancerTreatment – colon cancer
Surgical resection- Lt colectomySurgical resection- Lt colectomy
Treatment – colon cancerTreatment – colon cancer
Surgical resection- SigmoidectomySurgical resection- Sigmoidectomy
Treatment – Upper Treatment – Upper rectumrectum
Same principles as colon cancerSame principles as colon cancer Surgery- Anterior resectionSurgery- Anterior resection
TreatmentTreatment
Adjuvant therapy:Adjuvant therapy:
Recommended for nodes positive Recommended for nodes positive
diseasedisease
First line: 5-FU based chemotherapyFirst line: 5-FU based chemotherapy
Mid and low Rectal Cancer- Mid and low Rectal Cancer- ConsiderationsConsiderations
The anal sphincter may be at riskThe anal sphincter may be at risk
The tumor may be accessible The tumor may be accessible through the anusthrough the anus
Radiation therapy is possibleRadiation therapy is possible
T staging determines treatment path
DiagnosisDiagnosis
In rectal cancer staging:In rectal cancer staging: Rectal USRectal US CTCT MRIMRI
Treatment – mid and lower Treatment – mid and lower rectumrectum
Pre-operative staging – Rectal US, CT, Pre-operative staging – Rectal US, CT, MRIMRI
T1- may be treated with transanal T1- may be treated with transanal excision unless unfavorable excision unless unfavorable characteristicscharacteristics
Treatment – mid and lower Treatment – mid and lower rectumrectum
T3 ± T2 / N1 – Addition of radiation T3 ± T2 / N1 – Addition of radiation
therapy ± chemosensitizationtherapy ± chemosensitization
Pre operative or post operativePre operative or post operative
““European” low dose or “American” high European” low dose or “American” high
dosedose
Treatment – mid and lower Treatment – mid and lower rectumrectum
Radical surgery – Resection of the entire Radical surgery – Resection of the entire
rectumrectum
Abdomino- perineal resection for the very low Abdomino- perineal resection for the very low
tumorstumors
If 2 cm of clean distal margin is impossibleIf 2 cm of clean distal margin is impossible
a permanent colostomya permanent colostomy
Treatment – mid and lower Treatment – mid and lower rectumrectum
Radical surgery – Restorative Radical surgery – Restorative proctectomy:proctectomy: Very low anterior resectionVery low anterior resection Colo-anal anastomosisColo-anal anastomosis Colonic J pouch if possibleColonic J pouch if possible
Treatment – mid and lower Treatment – mid and lower rectumrectum
PrognosisPrognosis
It’s better to be young and rich It’s better to be young and rich rather then old with colon cancerrather then old with colon cancer
Duke’s ADuke’s A 80%80% Duke’s BDuke’s B 60%60% Duke’s CDuke’s C 30%30% Duke’s DDuke’s D 5%5%