COLORECTAL CARCINOMA

Presentor: Dr. Lakshmi Niranjan G

Moderator: [Link].V
ANATOMY OF COLON

The large intestine starts at the ileocecal junction and

extends to the anus.
It is about 5-6 ft (125-150 cm) long and can be divided into
● Cecum with the appendix,
● Ascending colon,
● Transverse colon,
● Descending colon,
● Sigmoid colon
● Rectum.
 BLOOD SUPPLY
The arterial blood supply to the colon comes from the
superior mesenteric artery (SMA) and the inferior mesenteric
artery (IMA), which communicate in a watershed area in the
splenic flexure.

Iliocolic, right colic, and middle colic arteries which are

branches of superior mesenteric artery supply the colon from
caecum to splenic flexure.

• Left colic, sigmoid, superior rectal arteries which are

branches of inferior mesenteric artery supply the descending
and sigmoid colon
VENOUS
DRAINAGE
Venous drainage occurs into superior
mesenteric vein (which joins the
splenic vein to form the portal vein)
and inferior mesenteric vein (drains
into the splenic vein).
 LYMPHATIC
DRIANAGE
Nodes are epicolic (located in
the colonic wall), paracolic
(located along the inner
margin), intermediate (located
near mesenteric vessels),
principal (located near main
mesenteric vessels)
NERVE SUPPLY

The nerve supply to the large intestine is derived from the splanchnic nerves via
sympathetic plexuses surrounding the superior and inferior mesenteric
arteries.
COLORECTAL CARCINOMA

● Colorectal cancer (CRC) is a formidable health problem worldwide.

● It is the third most common cancer in men and the second most
common in women
● Almost 60% of cases are encountered in developed countries.
● CRC is the fourth most common cause of death due to cancer.
● In India, the annual incidence rates (AARs) for colon cancer in men
are 4.4, respectively. The AAR for colon cancer in women is 3.9per
100000.
ETIOLOGY
● PRE-CANCEROUS

ADENOMAS

POLYPOSIS SYNDROMES

INFLAMMATORY BOWEL DISEASES

● HEREDITARY NON-POLYPOSIS COLORECTAL CANCER (HNPCC)

● DIET
● RADIATION OF PROSTATE CANCER
● ALCOHOL AND CIGARETTE SMOKING
● PREVIOUS SURGIERIES; cholecystectomy, ileal resection, ureterosigmoidostomy
● SPORADIC- 85-90%
PRE-CANCEROUS CONDITIONS:
Conventional Adenomas:85% of colorectal adenocarcinoma arise from conventional
adenomas. It may take 5-15years. The risks include sessile adenomas > 2cm with villous
pathology.

ADENOMA-CARCINOMA SEQUENCE

This is a multistep model that describes the carcinogenesis as an accumulation of genetic

events, uninhibited cell growth, proliferation and clonal development. It involves several
mutations and deletions.

APC gene (adenoma-polyposis coli)- a tumour suppressor gene. Its mutation is the initial
step of carcinogenesis. Present in 60-80% of sporadic colorectal cancer.
 ADENOMA-CARCINOMA SEQUENCE

MCC gene (mutated in colon cancer)

K-ras (an oncogene). Present in 30-50% of

colorectal cancer

DCC (deleted in colonic cancer)- a tumour

suppressor gene. Loss of DCC is important from
progression of benign polyp to malignant
conditions.

P53. a tumour suppressor, present in 75% of

colorectal cancer.
PATHOLOGY
MACROSCOPICALLY : There are 4 types
Proliferative type is a bulky fungating tumour which project into the lumen of
the gut. As it grow it may become necrotic and ulcerates. They are usually
tumours of the right side.
Ulcerative type: ulcers has raised, irregular, everted edges and a sloughing
floor. It grows in the transverse axis of the bowel. Commonly on the right side
Annular (stenosing); common on the left side. It is circumferential 52cm.
Present with intestinal obstruction.
Tubular or infiltrative; when annular spread longitudinally to involve segment
5cm and above.
HISTOLOGICAL TYPES

● Adenocarcinoma-90%.
● Mucinous adenocarcinoma-5-10%.
● Signet ring cell carcinoma.
● Small cell/oat cell carcinoma-rare-extremely poor
prognosis.
● Squamous cell carcinoma.
● Undifferentiated carcinoma.
SPREAD
[Link] spread

[Link] lymphatic vessels.

3. via the blood stream

4. Transperitoneal seedling
DIRECT SPREAD

Direct infiltration, in the bowel it spread transversely to encircle it

Spread in longitudinal axis is limited.
Microscopically it does not spread beyond 5cm.
It spread through all layer to involve the adjacent structures. Invasion
may lead to formation of internal fistulae
 LYMPHATIC SPREAD
Growth through lymphatics spreads to paracolic nodes,
intermediate and principal group of lymph nodes.
Groups of lymph nodes draining colon
N1: Nodes immediately adjacent to bowel wall.
N2: Nodes along ileocolic/right colic/middle colic/left
colic/sigmoid arteries
NI: Nodes near the origin of SMA and IMA.
Nodal spread in carcinoma colon is sequential from N1 N2 N3
However, and in about 30% of cases nodal involvement can skip
a tier of glands
BLOOD SPREAD
33-40% of carcinoma colon spreads to liver via portal veins.

Secondaries may be either solitary or multiple, present as liver with hard,

umbilicated nodules.

It spread to the lungs (22%), adrenals(11%), kidneys, bones (10%) and the brain.

TRANSPERITONEAL SEEDLING
When tumour has spread to the peritoneal surface, they drop as seedlings.
Ascites may result.
CLINICAL PRESENTATION
● Occurs usually after 50 years. Usually in the 6th and 7th decades.
Familial type can present in younger age group.
● common in females.
● Presentation maybe insidious (75%) or urgent as in intestinal
obstruction (18%) or perforation (7%)
● The commonest and important symptom is change in bowel habits and
abdominal pain.
● Change in bowel habits maybe constipation, diarrhea or alternating
constipation and diarrhea. Passage of blood or mucus in the faeces,
abdominal pain, distension and dyspepsia are other presenting
symptoms.
CLINICAL PRESENTATION
● The patient often notices a lump in the abdomen especially in carcinoma
of the caecum
● Right sided growth commonly presents with anaemia, asthenia and
anorexia. Palpable mass in the right iliac fossa, which is not moving with
respiration, mobile, non-tender, hard, well-localized with Impaired
resonant note
● Left sided growth presents with colicky pain, altered bowel habits
(alternating constipation and diarrhea), palpable lump, distension of
abdomen due to sub acute/chronic obstruction. Later may present like
complete colonic obstruction. Tenesmus, with passage of blood and
mucus, with alternate constipation and diarrhea is common .
CLINICAL PRESENTATION

Sigmoid colon and rectum: most important symptoms is rectal

bleeding. The blood is bright red and either mixed with faeces
and mucus or passed alone.
Tenesmus; frequent urge to defecate
Spurious diarrhea
INVESTIGATIONS
● Colonoscopy and biopsy confirms the diagnosis.
● Transrectal USS; depth of invasion, lymphnode
● Abdominal USS; To see secondaries in liver, peritoneum, lymph
node status, rectovesical secondaries. Presence of
hydronephrosis.
● Double contrast Barium enema: Shows irregular filling defect
and 'apple core' deformity (in left sided carcinoma). It also helps
in finding colonic polyps (Air-contrast barium enema).
INVESTIGATIONS
CEA (Carcinoembryonic antigen): cell surface glycoprotein, a tumour marker. CEA is
primarily associated with colorectal cancers, however non specific.

Uses in colorectal cancers are:

● Preoperative levels >7.5 ng/ml signifies poor prognosis.

● If postoperative level does not fall, it indicates either incomplete resection, or
occult metastasis elsewhere. Increase CEA during follow-up indicates
recurrence or secondaries.
● A slow rise indicates loco regional disease.
● 51-53/80
● A rapid rise signifies metastasis.
STAGING
MODIFIED DUKE'S

A. Growth limited to colonic wall

B. Growth extending into extracolonic tissues but no lymph node spread

● B1: Invading muscularis mucosa

● B2: Invading into or through the serosa

C. Lymph node secondaries

D. Distant spread
STAGES OF COLON CANCER
MANAGEMENT OF COLON CANCER
● Operable disease: Primary surgery with or without adjuvant
chemotherapy
● Locally advanced disease, primary curative resection unlikely:
Consider preoperative chemotherapy
● Isolated metastatic disease: Consider resection of primary disease
followed by metastasectomy with or without neoadjuvant and/or
adjuvant chemotherapy
● Widespread metastatic disease: Palliative chemotherapy, supportive
●
care
Principles of Surgery
● For colon cancer: The affected part of the colon and at least
a 5-cm
● segment on either side together with the draining lymph
nodes along the feeding vessels should be resected
● Laparoscopy-
Assisted Laparoscopic resection may be considered by
experienced laparoscopic surgeons for uncomplicated early
disease.
Principles of Surgery
● Hand-sewn and stapler anastomotic techniques afford
equivalent surgical outcomes. (Level 2A)
● Primary anastomosis may be deferred for long-standing
obstruction leading to bowel oedema, poor nutritional status,
peritonitis, and co-morbidities.
● Re-resection (salvage surgery) for recurrent disease has a
role in improving long-term survival.(Level 2B)
Adjuvant Therapy for Colon Cancer
In most patients with colon cancer preoperative chemotherapy is not required;
however, a recent research study (FOXTROT) has shown that it is safe and
further work on case selection has been recommended.

Adjuvant chemotherapy improves survival after surgery in patients with

node-positive colon cancer (stage III/Dukes C). Fluoropyrimidine regimes are
often used, with the addition of oxaliplatin in patients who are otherwise fit and
have high-risk stage III disease.

Patients with stage II disease on show less benefit in overall survival with
adjuvant chemotherapy, thus it is reserved for those with high-risk stage II
disease.
CHEMOTHERAPY
- Chemotherapy can be given in neoadjuvant setting
● short course for 5-6 days followed by surgery.
● Long course down staging for weeks; wait for 6 weeks before
surgery
REGIMEN’s
FOLFOX: 5-FU, Oxiplatinum, Folinic Acid.
FOLFIRI :5 Fu, Folinic acid, Irinotecan
CAPEOX : Capecitabine, Oxiplatinum
METASTATIC DISEASE
Hepatic and pulmonary metastases can be resected and series have
demonstrated 5-year survival of around 40% in resectable disease

CT, MRI and positron emission tomography (PET) scanning are all used to
identify colorectal metastases and assess patients' suitability for further
resection

Many centres offer adjuvant chemotherapy as standard and neoadjuvant

therapy also in those with high- risk disease.

In patients with widespread disease, palliative chemotherapy is offered along-

side symptomatic treatment and support by a palliative care team.
RECTAL CARCINOMA
ANATOMY OF RECTUM

● The rectum begins at rectosigmoid

junction and ends at the level of the
anus.
● Length-15-20cm
● Diameter- upper part 4 cm, lower part
dilated as ampulla
● Curved in both sagittal and coronal
planes
Fascial relationships of rectum

A thin layer of investing fascia (fascia propria)

coats the mesorectum and represents a distinct
layer from the presacral fascia against which it lies
The presacral fascia covers the anterior sacrum
and coccyx.
The rectosacral fascia, or Waldeyer fascia, is a
thick condensation of endopelvic fascia
connecting the presacral fascia to the fascia
propria at the level of S4 that extends to the
posterior-inferior rectum.
Denonvilliers fascia, located anterior to the
rectum, is a membranous layer that is an extension
of the inferior peritoneal reflection and extends to
the perineal body.
RECTAL CARCINOMA
Globally, colorectal cancer is the second most common malignancy,
affecting more than 1 million people every year and resulting in around
715,000 deaths. It is the second most common cancer in women and the
third most common cancer in men

Risk factors include diet, obesity, smoking and lack of well- physical
exercise. Most colorectal cancers are due to old age, grade with around 60%
of cases affecting patients 70 years or older. The rectum is the most
frequently involved site, accounting for approximately one-third of the
cancers
CLINICAL FEATURES
● Bleeding: Bleeding is the earliest and most common
symptom. Typically, the bleeding is bright red in colour and
painless. It can be mixed with the motions or separate in the
toilet bowel.
● Tenesmus : The patient experiences a sensation of needing
to evacuate the rectum but is unable to pass a motion. This is
an important early symptom and is almost invariably present
in patients with tumours of the lower half of the rectum. The
patient may endeavour to empty the rectum several times a
day (spurious diarrhoea),
CLINICAL FEATURES
● Alteration in bowel habit:There is frequently a change in
bowel habit, with a tendency to more frequent defecation
and the passage of loose stool.
patients with a stenosing carcinoma at the rectosigmoid
junction may complain of increasing constipation.
● Pain:It is a late symptom, but pain of a colicky character may
accompany advanced tumours of the rectosigmoid
● Weight loss
INVESTIGATIONS

Abdominal examination: Occasionally, in patients with stenosing tumours at the

rectosigmoid junction, signs of subacute large bowel obstruction may be
present, with abdominal distension.

If large-volume liver metastases are present, an enlarged liver may be palpable

along with other signs, such as cachexia.

Occasionally, it may be possible to elicit ascites if there is widespread peritoneal

dissemination.
INVESTIGATIONS
Rectal examination: In many cases where the neoplasm is situated
within 7-8cm of the anal verge it can be felt on digital rectal
examination as an elevated, irregular and hard endoluminal mass.
When the centre ulcerates, a shallow depression will be felt with raised
and everted edges.

Rigid sigmoidoscopy
Rigid sigmoidoscopy can be performed in the outpatient clinic and is
useful to identify the neoplasm and possibly obtain biopsies
Colonoscopy
A colonoscopy is required in most patients to exclude a synchronous
tumour, be it an adenoma or carcinoma. If a proximal adenoma is found,
it can be conveniently snared and removed via the colonoscope.

If a synchronous carcinoma is present, the operative strategy is likely to

change.

If a full colonoscopy is not possible, for example where there is a

stenosing cancer, a CT colonography or barium enema can be
performed.
MANAGEMENT OF RECTAL CARCINOMA

Surgical excision of the tumour is the conventional treatment,

provided this can be achieved with clear oncological margins and
acceptable risk of morbidity and mortality.
The management needs to be discussed within a multidisciplinary
team (MDT) setting involving surgeons. radiologists, oncologists,
pathologists and specialty nurses.
PRINCIPLES OF SURGERY
● Radical excision of the rectum, together with the mesorectum and
associated lymph nodes, should be the aim in most cases.
● In the presence of widespread metastases, other means of palliation should
be considered, such as endoluminal stenting or external beam
radiotherapy, although there may still be a role for palliative resection.
● When a tumour appears to be locally advanced the use of neoadjuvant
radiotherapy or chemotherapy is usually considered
● Long-course chemoradiotherapy is given as five fractions of radiotherapy
combined with chemotherapy over a 6-week period. The aim is to
downstage the cancer and increase the chances of a complete resection
with clear oncological margins.
PRINCIPLES OF SURGERY
● Alternatively, preoperative 'short-course' (5 days) radiotherapy
can be used if the resection margins are not threatened but the
cancer is still at high risk for local recurrence (e.g perirectal
lymph node involvement).
● When radical excision is possible, the aim should be to restore
gastrointestinal continuity and continence by preserving the
anal sphincter whenever feasible.
● A sphincter-saving operation (anterior resection) is usually
possible for tumours whose lower margin is > 2 cm above the
anorectal junction.
ANTERIOR RESECTION
● The principles of anterior resection involve radical excision of the
cancer along with its complete mesorectal envelope, combined with
high proximal ligation of the inferior mesenteric lymphovascular
pedicle. Once the left colon and rectum have been mobilised, the
distal rectum is divided at least 1 cm (and preferably more) below
the distal cancer margin and the specimen removed.
● Rectosigmoid cancers and those in the upper third of the rectum
are removed by 'high anterior resection', in which the rectum and
mesorectum are taken to a margin of at least 3 cm distal to the
tumour and a colorectal anastomosis is performed.
TOTAL MESORECTAL EXCISION
For tumours in the middle and lower
thirds of the rectum, complete
removal of the rectum and
mesorectum is required, ie. TME
(Heald). Restoration of continuity is
usually performed using a stapling
technique, which might involve an
end-to-end, side-to-end or colopouch
cal construction in low cancers.
Hartmann's operation
This is an option in elderly and frail patients in whom there is
concern about poor anal sphincter function and
postoperative incontinence or the viability of an
anastomosis.
The rectal stump is stapled closed and the proximal colon
exteriorised as a permanent end-colostomy.
Abdominoperineal excision of the rectum
This operation is still required for some tumours of the lower third
of the rectum that are unsuitable for a sphincter-saving
The aim is to produce a complete resection of the rectum and
mesorectum along with cylindrical excision of the extralevator
component. This achieves wide excision at the level of the pelvic
floor, increasing complete resection rates and reducing local
perforation and the risk of local recurrence
An end colostomy is formed in the left iliac fossa
Endoluminal stenting

● An increasingly used alternative for patients with an obstructing

carcinoma is placement of an endoluminal stent, which can be
done endoscopically, often with fluoroscopic guidance,
● This can be used either as a palliative procedure or to relieve
obstruction and permit elective rather than emergency surgery
to be undertaken.
Palliative colostomy
● This is indicated only in cases giving rise to intestinal
obstruction, or where the rectal cancer is not resectable. It
can be performed by either an open or laparoscopic
approach.
● In some cases, a defunctioning colostomy is required in
advanced cancers to prevent obstruction during
downstaging chemoradiotherapy.
 Radiotherapy
● Radiotherapy is now commonly used and may be given
preoperatively (neoadjuvant) and less commonly postoperatively
(adjuvant).
● In the neoadjuvant setting, radiotherapy is used to either 'sterilise'
the operative field in cancers with suspected lymphovascular
involvement, or to downstage locally advanced cancers with
threatened circumferential resection margins.
● When radiotherapy is used to downstage a cancer, it is often
combined with chemotherapy (chemoradiotherapy) and given over
a period of 6 weeks with a 6-week recovery period before surgery.
Chemotherapy

● Chemotherapy is given either in combination with radio-

therapy (chemoradiotherapy) to downstage a cancer prior to
surgical resection or else in the postoperative setting to
reduce the risk of disseminated disease.
● 5-Fluorouracil (5-FU)-based regimens remain the first-line
therapy and are associated with a 10% improvement in
disease-free survival in patients with node-positive rectal
cancer