Malignant
colorectal
cancer
- Venkateswaran Arundathi Dipika
WHAT IS COLORECTAL CANCER?
• The cancer affecting caecum, colon and rectum. It is
most commonly an adenocarcinoma.
• PATHOGENESIS is by adenoma-carcinoma
sequence of genetic mutations influenced by
environment factors, where It begins with formation
of small fixed adenoma, and progresses into an
advanced larger adenoma and then finally a
carcinoma.
• EPIDEMIOLOGY-
- Colorectal cancer is the 3rd most common cancer
worldwide.
- Majority of the cases occur in people aged 50 and
above
- Incidence rates are highest in Europe, Australia and
new zealand. Mortality rates are highest in eastern
Europe.
- Disease occurs greater in men than in women.
ETIOLOGY
1. DIET: red meat, processed meat and saturated fats,
cholesterol increases bile concentration in intestinal
lumen which acts as carcinogen, diet with lack of fibers
and high fat.
2. Smoking & alcohol
3. GENETIC : mutation of APC gene , p53 gene mutation
(invasion marker), activation of k-ras (proto-oncogene),
loss of tumor suppressor gene (APC, DCC), abnormality
in DNA repair genes (hMSH2, hMLH1) and HNPCC
syndromes.
4. NON-HEREDITARY :
sporadic colon cancer
Familial colon cancer – common in Ashkenazi jews
TYPES
1. SYNCHRONOUS – multiple primary carcinomas in different parts of colon,
within 6 months of diagnosis of primary lesion
2. METACRONOUS – growths in different parts of colon in different periods after
6 months of diagnosis of primary lesion.
GROSS types :
- annular – common on left side, growth usually spreads around internal wall so It
usually presents with intestinal obstruction.
- Tubular – left side commonly
- Ulcerative- common on right side
- cauliflower/proliferative like –
fleshy bulky and polypoid.
RISK FACTORS
1. FAP- familial adenomatous polyposis
2. Hereditary non-polyposis colon cancer (HNPCC)
3. Long standing Ulcerative colitis/ Crohn's disease.
4. Alcohol & smoking
5. After cholecystectomy and ileal resection
6. Age above 50
7. Inflammatory bowel disease
8. Gardner syndrome
9. Turcot syndrome
10. Family history - 1st gen relatives of colonic cancer
patients have 2-4 times increased risk.
CLINICAL MANIFESTATION
● Common presentations
[Link] of appitite and weight
[Link]
[Link] discomfort
[Link] in abdomen
● Closed loop obstruction in
transverse colon - stricture type
growth with competent
ileocecal valve causes dilated
right sided colon, which is prone
to stercoral ulcer
● Manifestation based on side
affected.
RIGHT VS LEFT SIDE SYMPTOMS
RIGHT LEFT
i. Severe anemia (iron i. Altered bowel
deficiency) habits( alternating
ii. Pain in right iliac fossa constipation and diarrhea)
iii. Diarrhea ii. Colicky pain ( because
iv. Palpable Mass in RIF obstrcution)
v. Ocult blood in stool if iii. Lower left iliac fossa pain
ulceration present iv. Rectal bleeding
vi. Nausea vomiting v. Palpable lump
vii. Fainting vi. Distention of abdomen
viii. Dyspnea vii. Tenesmus
ix. Asthenia viii. Gross blood in stool
SPREAD
1. LOCAL SPREAD – limited to bowel
and spreads around intestinal wall.
Can invade bowel wall and spread
to other structures
2. LYMPHATIC SPREAD – to pericolic,
epicolic, intermediate lymph
nodes.
3. DIRECT– longitudinally or radially
to ureter/bladder cause
hydronephrosis, posterior abd.
Muslces, colovaginal and
colovesical fistula. Anterior abd
wall and cause peritonitis
4. HEMATOGENOUS – to liver via
portal vein by inf and sup
mesenteric veins
DIAGNOSIS
1. Anamnesis
2. Lab tests – CBC , CEA (serum
carcnioembryonic antigen)
3. digital rectal exam
4. Fecal occult blood
5. LFT – Alkaline phosphatase
IMAGING TESTS
1. X ray with barium enema – apple
core deformity
2. Colonoscopy and biopsy -
confirmatory
3. CT abdomen and pelvis
4. Sigmoidoscopy
5. ultrasound
STAGING ● DUKES CRITERIA & TNM STAGING
TREATMENT
● Endoscopic mucosal/submucosal/
fullthickness resection
● Monoclonal antibodies –
panitumumab or cetuximab
● Immunotherapy
● Intraluminal laser
● Argon plasma coagulation and
radiotherapy for bleeding and
pain
● NSAIDS
● Aspirin
SURGICAL METHODS
1. Right hemicolectomy ( with ileo-transverse anastomosis)–
carcioma of ceacum or ascending colon
2. Extended right hemicolectomy- transverse colon and hepatic
flexure
3. Left hemicolectomy – desending colon and sigmoid colon, splenic
flexure
4. Left stenosing type of growth with intestinal obstruction –
colostomy
5. Laparascopic evaluation and resection.
6. Metal stenting – obstruction
7. Emergency surgery- incase of obstruction/ haemorrhage/
perforation
Right side lesion : right hemicolectomy with anastomosis
If there is perforation with contamintion a ileocolostomy is performed
Left sided lesion: hartmans with anastomosis or stoma is performed
- Transverse/ left sided stenosing obstruction causes closed loop
ADJUVANT THERAPY
● 30-40% of lymph node involvement due to which
there is high recurrency rate, recurrency is
usually within 3 years after diagnosis.
● Chemotherapy is given when there is lymph
nodes metastasis, t4 lesions, venous spread, CAE
level changes and poorly differentiated tumor.
● chemotherapy is generaly not required, but
recent studies show that adjuvant therapy
imporves prognosis in stage 3.
● 5-fluorouracil/folinic acid or fluoropyrimidine or
capecitabine in combination with oxaliplatin
● Epithelial growth factor receptor blockers
● Vascular endothelial growth factor blocker
NEW THERAPIES
● Antiangiogenesis therapy – given
along with chemo. Starves the
tumor by disrupting blood supply
(bevacizumab)
● Targeted therapy – therapy
targeted to cancer cells
(cetuximab)
FOLLOW UP
● Regular CEA analysis
● Abdomen ultrasound to
check liver metastasis
● Barium enema X ray
● Colonoscopy after 1 year
and then after every 3
years
COMPLICATIONS
● INTESTINAL OBSTRUCTION
● CLOSED LOOP OBSTRUCTION
● PERFORATION
● PERITONITIS
● VESICOCOLIC FISTULA
● INVASION OF URETER
● PERICOLIC ABSCESS
Screening
1. FIT (fecal immunochemical test)
2. Multitargeted stool DNA test
3. Fecal occult blood test
4. Flexible sigmoidoscopy
5. Colonoscopy
6. Air contrast barium enema
detects polyps >1cm
PREVENTION
Lifestyle changes need to be made and screeing at age 50 or
above in high-risk patients
a. High fiber diet
b. Decreased animal fat and red meat
c. Decrease smoking and alcohol
d. Increased exercise and decrease BMI
e. Calcium diet
f. Dietary vitamins A, C, E and zinc
PROGNOSIS
● Prognosis depends on tumor stage, lymph node metastasis,
complications and location of tumor.
● Left sided tumor has better prognosis.
● Prognosis is excellent in early stage of disease.
● Stage 1 has a 90% 5 year survival rate.
● Stage 2 has a 75% 5 year survival rate.
● Stage 3 has a 50% 5 year survival rate.
● Stage 4 has less than 5% 5 year survival rate.
THANK
YOU
