COLORECTAL CANCER FAISALGHANISIDDIQUI MBBS; FCPS; PGDIP-BIOETHICS; MCPS-HPE

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1 COLORECTAL CANCER FAISALGHANISIDDIQUI MBBS; FCPS; PGDIP-BIOETHICS; MCPS-HPE PROFESSOR OF SURGERY & DIRECTOR, PROFESSIONAL DEVELOPMENT CENTRE J I N N A H S I N D H M E D I C A L U N I V E R S I T Y faisal.siddiqui@jsmu.edu.pk

2 COLORECTAL CANCER: PREAMBLE EPIDEMIOLOGY AETIOLOGY CLINICAL FEATURES SPREAD & STAGING INVESTIGATIONS TREATMENT

3 COLORECTAL CANCER EPIDEMIOLOGY AETIOLOGY CLINICAL FEATURES SPREAD & STAGING INVESTIGATIONS TREATMENT

4 ADENOCARCINOMA OF COLON EPIDEMIOLOGY Most common malignancy of the gastrointestinal tract Third most common cancer overall Effects both genders equally; slight male predominance for rectal cancer Incidence increases with age Higher incidence in industrialized countries

5 EPIDEMIOLOGY Countries with high risk Australia New Zealand Western Europe Canada The United States Countries with low risk India/Pakistan China Africa South America

6 Distribution of colorectal carcinoma with common occurrence in rectum and sigmoid

7 COLORECTAL CANCER EPIDEMIOLOGY AETIOLOGY CLINICAL FEATURES SPREAD & STAGING INVESTIGATIONS TREATMENT

8 ADENOMA-CANCER SEQUENCE Colorectal cancer arises from adenomatous polyps AETIOLOGY after a series of genetic mutations influenced by environmental factors

9 AETIOLOGY BENIGN POLYPS OF COLON Inflammatory Metaplastic Hamartomatous Adenomatous Histological appearance of an adenomatous polyp

10 AETIOLOGY

11 AETIOLOGY FACTORS CAUSING COLORECTAL CANCER Genetic mutations Environmental factors

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13 ENVIRONMENTAL FACTORS AETIOLOGY Age Male gender Westernized diet Diet high in fat and red meat Low fiber diet Smoking / Alcohol Dietary deficiency of calcium and Vitamin D Long-standing Ulcerative / Crohn s colitis Cholecystectomy

14 FACTORS THAT PROTECT AGAINST COLORECTAL CANCER AETIOLOGY Asprin NSAID Broccoli Vitamin D and calcium supplements Exercise

15 COLORECTAL CANCER EPIDEMIOLOGY AETIOLOGY CLINICAL FEATURES SPREAD & STAGING INVESTIGATIONS TREATMENT

16 CLINICAL FEATURES Weight loss, anorexia Left colon Change in bowel habit / rectal bleeding Right colon Anaemia Lump Rectum Tenesmus Emergency Obstruction Bleeding and shock Perforation

17 CLINICAL FEATURES On examination Anaemia Hepatomegaly Ascites Abdominal mass

18 COLORECTAL CANCER EPIDEMIOLOGY AETIOLOGY CLINICAL FEATURES SPREAD & STAGING INVESTIGATIONS TREATMENT

19 SPREAD & STAGING SPREAD OF COLORECTAL TUMOURS Direct Lymphatic Hematogenous Transcoelomic

20 SPREAD & STAGING A DUKE S STAGING Spread into, but not beyond muscularis properia B Spread through full thickness of bowel wall C Involvement of lymph nodes D Distant metastases

21 COLORECTAL CANCER EPIDEMIOLOGY AETIOLOGY CLINICAL FEATURES SPREAD & STAGING INVESTIGATIONS TREATMENT

22 INVESTIGATIONS FOR SCREENING FOR DIAGNOSIS FOR STAGING

23 INVESTIGATIONS INVESTIGATIONS FOR SCREENING FOB test using guaiac-impregnated paper Faecal immunological test for human hemoglobin (FIT) Flexible sigmoidoscopy

24 INVESTIGATIONS INVESTIGATIONS FOR DIAGNOSIS Double contrast Barium enema Colonoscopy

25 INVESTIGATIONS Barium enema showing a malignant apple core appearance in the sigmoid colon due to stenosing colorectal cancer

26 INVESTIGATIONS

27 INVESTIGATIONS

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29 INVESTIGATIONS INVESTIGATIONS FOR STAGING Provides information on prognosis Helps formulate surgical strategy Indicates need for adjuvant radiotherapy (rectal cancer) and adjuvant postoperative chemotherapy

30 INVESTIGATIONS INVESTIGATIONS FOR STAGING CT chest, abdomen and pelvis Pelvis MRI Endoanal ultrasound

31 COLORECTAL CANCER EPIDEMIOLOGY AETIOLOGY CLINICAL FEATURES SPREAD & STAGING INVESTIGATIONS TREATMENT

32 CURATIVE TREATMENT -INDICATIONS TREATMENT Localized disease Lymph node metastases No distant metastases

33 CURATIVE TREATMENT -INCLUDES TREATMENT Resection of the primary tumour Excision of the colonic mesentery Ligation of the arterial supply at its origin Excision of all regional lymph nodes

34 CURATIVE TREATMENT -MODALITIES Right hemicolectomy Carcinoma of caecum or ascending colon TREATMENT Extended right hemicolectomy Carcinoma of hepatic flexure or transverse colon Left hemicolectomy Descending colon and sigmoid cancers Anterior resection / abdominoperineal resection with permanent colostomy High or low rectum respectively

35 TREATMENT Surgical resection for colorectal cancer arising at various locations within the large bowel

36 TREATMENT

37 TREATMENT

38 ADJUVANT THERAPY TREATMENT Radiotherapy Neoadjuvant (operable but tethered tumours) -5 days regimen Radical (fixed, inoperable tumours) -3 month regimen Chemotherapy 5-Flourouracil postoperatively in Duke C colorectal cancer

39 SUMMARY Colorectal cancer is third commonest cancer Risk factors include increasing age, preexisting adenomatous polyps, westernized diet, and Crohn s/ulcerative colitis Genetic mutations cause colorectal cancer Symptoms depend upon the site Diagnosis involves radiology, endoscopies, and CT scan Surgery is the mainstay of treatment