1. Diagnosis

2. Barium studies
demonstrate the primary lesion and reveal a synchronous cancer elsewhere in the colon  

3. Annular constricting or napkin-ring carcinoma of colon
Figure A, A gross surgical specimen of annular constricting or napkin-ring carcinoma of the colon. B, Full-column barium enema demonstrating the annular constricting lesions.

4. Annular constricting or napkin-ring carcinoma of colon
Figure A, A gross surgical specimen of annular constricting or napkin-ring carcinoma of the colon. B, Full-column barium enema demonstrating the annular constricting lesions.

5. Colonoscopy
most accurate and complete examination of the large bowel.
The purpose of a complete colon and rectal evaluation for patients with large-bowel cancer is to rule out synchronous carcinomas and polyps.
Serum level of CEA
important in the evaluation of patients with colorectal cancer.

6. Chest x-ray - pulmonary metastasis.
CT of the abdomen - extent of invasion of the primary tumor and to search for intraabdominal metastatic disease.

7. Staging depth of tumor, penetration into the bowel wall
presence of both regional lymph node involvement
distant metastases

8. Staging of colorectal cancer
Table Staging of colorectal cancer according to the American Joint Committee for Cancer using the Tumor, Node, and Metastasis (TNM) classification. This system was developed to provide more uniform staging of colorectal cancer. Tis-tumor in situ. (From American Joint Committee for Cancer Staging and End Result Reporting [14]; with permission.)
References:
[14]. In Manual for Staging Cancer, edn 3 Philadelphia: JB Lippincott; 1988

9. Treatment

10. Optimum Treatment Strategy
Surgery is the only hope for CURE
Adjuvant chemotherapy for Colon CA
> Stage III disease
High risk Stage II disease
Obstruction / Perforation
High grade histology
Adjuvant chemo-radiotherapy for Rectal CA
> Stage II disease
Either pre-operative or post-operative

11. Total resection of tumor - optimal treatment when a malignant lesion is detected in the large bowel..
The detection of metastases should not preclude surgery in patients with tumor-related symptoms such as gastrointestinal bleeding or obstruction, but it often prompts the use of a less radical operative procedure.
Laparotomy- the entire peritoneal cavity should be examined, with thorough inspection of the liver, pelvis, and hemidiaphragm and careful palpation of the full length of the large bowel.

12. Radiation therapy
reduces the 20–25% probability of regional recurrences following complete surgical resection of stage II or III tumors, especially if they have penetrated through the serosa.
either pre- or postoperatively, reduces the likelihood of pelvic recurrences but does not appear to prolong survival.

13. Chemotherapy 5-FU – backbone of treatment
Concomitant administration of folinic acid (leucovorin) improves the efficacy of 5-FU in patients with advanced colorectal cancer, presumably by enhancing the binding of 5-FU to its target enzyme, thymidylate synthase.

14. Irinotecan - prolongs survival when compared to supportive care in patients whose disease has progressed on 5-FU.

15. FOLFIRI regimen
Irinotecan mg/m2 as a 90-min infusion day 1
LV mg/m2 as a 2-h infusion during irinotecan
5-FU bolus mg/m2 and 46-h continuous infusion of 2.4–3 g/m2 every 2 weeks.
FOLFOX regimen
2-h infusion of LV (400 mg/m2 per day)
5-FU bolus -(400 mg/m2 per day) and 22-h infusion (1200 mg/m2) every 2 weeks,
Oxaliplatin, 85 mg/m2 as a 2-h infusion on day 1.
FOLFIRI and FOLFOX are equal in efficacy.