Colorectal Cancer

Colorectal Cancer
• Epidemiology
– Most common internal cancer in Western Societies
– Second most common cancer death after lung cancer
– Lifetime risk
• 1 in 10 for men
• 1 in 14 for women
– Generally affect patients > 50 years (>90% of cases)
 Colorectal Cancer

• Forms
– Hereditary
• Family history, younger age of onset, specific gene defects
• E.g. Familial adenomatous polyposis (FAP), hereditary
nonpolyposis colorectal cancer (HNPCC or Lynch syndrome)
– Sporadic
• Absence of family history, older population, isolated lesion
– Familial
• Family history, higher risk of index case is young (<50years) and the
relative is close (1st degree)

• Histopathology
– Generally adenocarcinoma
 Risk Stratification

• Risk factors
– Past history of colorectal cancer, pre-existing adenoma,
ulcerative colitis, radiation
– Family history – 1st degree relative < 55 yo and relatives with
identified genetic predisposition (e.g. FAP, HNPCC, Peutz-
Jegher’s syndrome) = more risk
– Diet – carcinogenic foods
• Risk category (for asymptomatic pts)
– Category 1 (2x risk) – 1o or 2o relative with colorectal cancer >55
yo
– Category 2 (3~6x) – 1o relative < 55yo or 2 of 1o or 2o relative at
any age
– Category 3 (1 in 2) – HNPCC, FAP, other mutations identified
 Screening
Group Screening Evidence
General Population FOBT every 2 years from age 50 to 75 1A
Category 1 FOBT yearly +/- 5 yearly sigmoidoscopy
from age 50

Category 2 FOBT yearly + colonoscopy 5 yearly IIIB

from age 50 or 10 years younger than
index case

Category 3 Variable  Consult Oncology, e.g. IIIB

- FAP – colonoscopy every 12 months
from 12-15 yo until age 35 then 3 yearly
- HNPCC – 1~2yearly colonoscopy from
age 50 or 5 years younger than index
case
 Clinical Presentation

• Depends on location of cancer

• Locations
– ⅔ in descending colon and rectum
– ½ in sigmoid colon and rectum (i.e. within reach of
flexible sigmoidoscope)
• Caecal and right sided cancer
– Iron deficiency anaemia (most common)
– Distal ileum obstruction (late)
– Palpable mass (late)
 Clinical Presentation
• Left sided and sigmoid carcinoma
– Change of bowel habit
• Alternating constipation + diarrhoea
• Tenesmus
• Thin stool
– PR bleeding, mucus
• Rectal carcinoma
– PR bleeding, mucus
– Change of bowel habits
– Anal, perineal, sacral pain
• Constitutional symptoms
– LOA, LOW, malaise
• Bowel obstruction
 Clinical Presentation

• Local invasion
– Bladder symptoms
– Female genital tract symptoms
• Metastasis
– Liver (hepatic pain, jaundice)
– Lung (cough)
– Bone (leucoerythroblastic anaemia)
– Regional lymph nodes
– Peritoneum (Sister Marie Joseph nodule)
– Others
 Examination

• Signs of primary cancer

– Abdominal tenderness and distension – large bowel obstruction
– Intra-abdominal mass
– Digital rectal examination – most are in the lowest 12cm and
reached by examining finger
– Rigid sigmoidoscope
• Signs of metastasis and complications
– Signs of anaemia
– Hepatomegaly (mets)
– Monophonic wheeze
– Bone pain
 Investigations

• Faecal occult blood

– Guaiac test (Hemoccult) – based on pseudoperoxidase activity
of haematin
• Sensitivity of 40-80%; Specificity of 98%
• Dietary restrictions – avoid red meat, melons, horse-radish,
vitamin C and NSAIDs for 3 days before test
– Immunochemical test (HemeSelect, Hemolex) – based on
antibodies to human haemoglobins
– Used for screening and NOT diagnosis
 Investigations
• Colonoscopy
– Can visualize lesions < 5mm
– Small polyps can be removed or at a later stage by
endoscopic mucosal resection
– Performed under sedation
– Consent: bleeding, infection, perforation (1 in 3000), missed
diagnosis, failed procedure, anaesthetic/medical risks
– Warn: bowel prep, abdominal bloating/discomfort afterwards,
no driving for 24 hours
 Investigations
• Double contrast barium enema
– Does not require sedation
– Avoids risk of perforation
– More limited in detecting small lesions
– All lesions need to be confirmed by colonoscopy and biopsy
– Performed with sigmoidoscopy
– Second line in patients who failed / cannot undergo
colonoscopy
 Other Imaging

• CT colonoscopy
• Endorectal ultrasound
– Determine: depth, mesorectal lymph node involvements
– No bowel prep or sedation required
– Help choose between abdominoperineal resection or ultra-low
anterior resection
• CT and MRI – staging prior to treatment
• Blood tests
– Coagulation studies – for surgery
– Tumour marker CEA
• Useful for monitoring progress but not specific for diagnosis
 Management

• Pre-operative
– Bowel prep –
• Normally 1 day prior
• Partial obstruction – 2~3 days prior
• Complete obstruction – intra-operative lavage
– Antibiotics prophylaxis (up to 24 hours post-op)
• Ampicillin
• Metronidazole
• Gentamicin
– DVT/PE prophylaxis
Arterial supply
Resection
 Management

• Caecum or ascending colon

– Right hemicolectomy
– Vessels divided – ileocaecal and right colic
– Anastomosis between terminal ileum and transverse colon
• Transverse colon
– Close to hepatic flexure  right hemicolectomy
– Mid-transverse  extended right hemicolectomy (up to
descending) + omentum removed en-bloc with tumour
– Splenic flexure  subtotal colectomy (up to sigmoid)
• Descending colon
– Left hemicolectomy
– Vessels divided – inferior mesenteric, left colic, sigmoid
 Management

• Sigmoid colon
– High anterior resection
– Vessels ligated – inferior mesenteric, left colic and sigmoid
– Anastomoses of mid-descending colon to upper rectum
• Obstructing colon carcinoma
– Right and transverse colon – resection and primary anastomosis
– Left sided obstruction
• Hartmann’s procedure – proximal end colostomy (LIF) + oversewing
distal bowel + reversal in 4-6 months
• Primary anastamosis – subtotal colectomy (ileosigmoid or ileorectal
anastomosis)
• Intraoperative bowel prep with primary anastomosis (5% bowel
leak)
• Proximal diverting stoma then resection 2 weeks later
• Palliative stent
 Rectal Cancer

• Options
– Low anterior resection
– Transanal local excision
– Abdomino-perineal resection
– Palliative procedure
• Factors influencing choice
– Level of lesion – distance from dentate line, <5cm requires
abdomino-perineal resection to obtain adequate margin
• Note: only 3% of tumours spread beyond 2cm
– Grade – poorly differentiated  larger margin
– Patient factors – incotinence
– Mesorectal node status – resect if LN mets
 Rectal Cancer
• Anterior resection
– Upper and mid rectum cacinoma
– Sigmoid and rectum resected
– Vessels divided – inferior mesenteric and
left colic
– Mesorectum resected
– Coloanal anastomosis
– High – intraperitoneal anastamosis
(upper 1/3 of rectum)
– Low – extra-peritoneal anastomosis
– Post-op recovery
• Increased stool frequency
• 12-18 month to acquire normal bowel
function
• 1~4% anastamotic leak
 Rectal Cancer
• Abdominoperineal resection
– Larger T2 and T3 or poorly differentiated
tumour
– Rectum mobilised to pelvic floor through
abdominal incision
– Sigmoid end colostomy
– Separate perianal elliptical incision to
mobilise and deliver anus and distal
rectum
– Vessels ligated – inferior mesenteric
 Rectal Cancer

• Hartmann’s procedure
– Acute obstruction
– Palliative
• Transanal local exision
– Early stage
– Too low to allow restorative surgery
• En block resection – for locally advanced colorectal carcinoma (remove
adherent viscera and abdominal wall)
• Palliative procedures
– Diverting stoma
– Radiotherapy
– Chemotherapy
– Local therapy – laser, electrocoagulation, cryosurgery
– Nerve block
 Staging

• TNM Staging
– Stage 0 – Tis N0 M0 – i.e. small tumour within the lining of the colon or
rectum
– Stage 1 – T1 N0 M0 or T2 N0 M0 – i.e. tumour has invaded layers of the
colon without spread beyond wall
– Stage 2 – T3 N0 M0 or T4 N0 M0 – i.e. tumour has spread beyond wall and
into nearby tissue but no LNs
– Stage 3 – Any T with any N but M0 – i.e. spread to nearby LNs but not to
other organs
– Stage 4 – Any T with any N and M1 – i.e. spread to other organs (e.g. liver
and lungs)
• Duke’s staging
– Duke A – tumour confined to bowel wall
– Duke B – tumour invading through serosa
– Duke C – lymph node involvement
– Distant metastasis
 Prognosis

• 5 yr survivals
– T1 = >90%, T2 = >80%. T3 = >50%
– LN involvement = 30~40%
– Distant mets = <5%