Colorectal Cancer

By Dr. Sumayya Latif

 Epidemiology
• Colorectal caner is the 3rd most frequently
diagnosed & 2nd leading cause of cancer
deaths in the US men and women
• Median age group- 7th decade but can occur
any time in adulthood.
• Incidence rates increase dramatically between
ages 40 and 50 years and each subsequent
decade thereafter.
• Cecum 14%
• Ascending colon 10 %
• Transverse colon 12 %
• Descending colon 7 %
• Sigmoid colon 25 %
• Rectosigmoid junct 0.9 %
• Rectum 23 %
 Clinical Anatomy
• 12-15 cm from anal verge.
• Diameter
4 cm (upper part)
Dilated (lower part)
• Posterior part of the lesser pelvis and in front of
lower three pieces of sacrum and the coccyx
• Begins at the rectosigmoid junction, at level of S3
vertebra.
• Ends at the anorectal junction, 2-3 cm in front of
and a little below the coccyx
 Parts of Rectum

The Lower Rectum

• 5 cm from the anal verge.
The Mid Rectum
• 5 to 10 cm from the anal verge.
The Upper Rectum
• 10 to 15 cm from the anal verge.
 Peritoneal Relations
 Superior 1/3rd
▫ Covered by peritoneum on the anterior and lateral
surfaces
 Middle 1/3rd
▫ Covered by peritoneum on the anterior surface
 Inferior 1/3rd
▫ Devoid of peritoneum
▫ Close proximity to adjacent structure including
bony pelvis.
 Lymphatic drainage
Upper and middle rectum
▫ Perirectal lymph nodes, located directly on the
muscle layer of the rectum
▫ Inferior mesenteric lymph nodes, via the nodes
along the superior rectal vessels
Lower rectum
▫ Sacral group of lymph nodes or Internal iliac lymph
nodes
Below the dentate line
▫ Inguinal nodes and external iliac chain
Lymphatics
 Risk factors

• Age: more than 50 years

• Gender: male
• Lifestyle :
– high fat and low fiber diet

– Smoking and alcohol intake

– Processed meat intake, refined grains, starches & sugars

– Low folate consumption

• Family history of malignancy or personal history of polyps

• Familial adenomatous polyposis (FAP)
• Hereditary non-polyposis colorectal cancer (HNPCC)
• IBD particularly ulcerative colitis
 Clinical Presentations
• Symptoms
▫ Asymptomatic
▫ Change in bowel habit (diarrhoea, constipation, narrow stool,
incomplete evacuation, tenesmus).
▫ Blood PR
▫ Abdominal discomfort (pain, fullness, cramps, bloating,
vomiting)
▫ Weight loss, tiredness
• Acute Presentations
▫ Intestinal obstruction
▫ Perforation
▫ Massive bleeding
Signs
▫ Pallor
▫ Abdominal mass
▫ PR mass
▫ Jaundice
▫ Nodular liver
▫ Ascites

Rectal metastasis travel along portal drainage to liver via

superior rectal vein as well as systemic drainage to lung via
middle & inferior rectal veins
 Pathological features
WHO Classification
• Adenocarcinoma in situ
• Adenocarcinoma
• Mucinous (colloid) adenocarcinoma (>50% mucinous)
• Signet ring cell carcinoma (>50% signet ring cells)
• Squamous cell (epidermoid) carcinoma
• Adenosquamous carcinoma
• Small-cell (oat cell) carcinoma
• Medullary carcinoma
• Undifferentiated Carcinoma
 Dukes classification
• Dukes A: Invasion into but not through the
bowel wall.
• Dukes B: Invasion through the bowel wall but
not involving lymph nodes.
• Dukes C: Involvement of lymph nodes
• Dukes D: Widespread metastases
Modified astler coller classification
Stage A : Limited to mucosa.
Stage B1 : Extending into muscularis propria but not
penetrating through it; N: -ve
Stage B2 : Penetrating through muscularis propria; N: -ve
Stage C1 : Extending into muscularis propria but not
penetrating through it. N: +ve
Stage C2 : Penetrating through muscularis propria. N: +ve
Stage D: Distant metastatic spread
TNM Staging
Staging
I- T1,T2

II: T3,T4a, T4b

III: N +ve

IV: M +ve
 Screening
• American cancer society has recommended to
begin screening at age 50 in average risk
patient by either:
Annual fecal occult blood tests or flexible
sigmoidoscopy every 5 years
Double contrast Barium enema every 5 years
Colonoscopy every 10 years
• Intensive Surveillance is recommended for
patients at high risk
 Workup
• History & Physical examination
Digital rectal examination, inguinal L.N.s
• Proctoscopy
• Sigmoidocolonoscopy
• Pathological confirmation of adenocarcinoma by colonoscopy or
CT guided biopsy
• Blood CP, LFTs, RFTs, S.CEA
• CT SCAN abdomen and pelvis e contrast
• EUS
• CXR
• MRI
• PET : useful in evaluating patient with oligometastatic disease
who may be candidate for resection of metastatic disease with
curative intent
 Prognostic factors
Good prognostic factors Poor prognostic factors
 Old age  Obstruction
 Gender(F>M)  Perforation
 Asymptomatic pts  Ulcerative lesion
 Adjacent structures
 Polypoidal lesions
involvement
 Positive margins
 LVSI
 Signet cell carcinoma
 High CEA
 Tethered and fixed cancer
Thank you