Change in bowel habits … 60 year old male Complains of progressive constipation for the past 6 months

Change in bowel habits … 60 year old male Complains of progressive constipation for the past 6 months 10 kg unintentional weight loss Occasional rectal bleeding

No pain No pain Not vomiting Not vomiting

No pain No pain Not vomiting Not vomiting Past medical history- unremarkable Never had colonoscopy Family history- Grandfather and uncle with colon cancer

Physical exam: Good nutritional status Good nutritional status Abdomen- unremarkable, no mass Abdomen- unremarkable, no mass Rectal- No mass, guiac + stool Rectal- No mass, guiac + stool

Physical exam: Good nutritional status Good nutritional status Abdomen- unremarkable, no mass Abdomen- unremarkable, no mass Rectal- No mass, guiac + stool Rectal- No mass, guiac + stool Colonoscopy: Colonoscopy: Sigmoid colon

Physical exam: Good nutritional status Good nutritional status Abdomen- unremarkable, no mass Abdomen- unremarkable, no mass Rectal- No mass, guiac + stool Rectal- No mass, guiac + stool Colonoscopy: non obstructing mass at the sigmoid colon

Physical exam: Good nutritional status Good nutritional status Abdomen- unremarkable, no mass Abdomen- unremarkable, no mass Rectal- No mass, guiac + stool Rectal- No mass, guiac + stool Colonoscopy: non obstructing mass at the sigmoid colon Pathology- adenocarcinoma

Colorectal Cancer Oded Zmora Department of Surgery B Sheba Medical Center Tel Hashomer

Colorectal Cancer Adenocarcinoma of the large bowel, originating at the bowel mucosa 2 nd in cancer incidence in the Western world 2 nd in cancer incidence in the Western world Significant cause of morbidity, expenses, and death Significant cause of morbidity, expenses, and death

Predisposing Factors: Age: Age: Uncommon before the age of 40 years Uncommon before the age of 40 years Risk gradually increase with age Risk gradually increase with age When at young age – may be associated with known genetic predisposing factors When at young age – may be associated with known genetic predisposing factors

Predisposing Factors: Colonic polyp: Colonic polyp: Polyp is a benign growth of the mucosa Polyp is a benign growth of the mucosa The adenoma – carcinoma sequence The adenoma – carcinoma sequence

Predisposing Factors: Family history: Family history: Known genetic disorders Known genetic disorders FAP FAP Autosomal dominant dis Presents with hundreds of adenomatous polyps Almost all develop cancer Extra-colonic manifestations: Duodenal carcinoma, Gastric adenomas, desmoid tumors, osteomas Prophylactic restorative proctocolectomy

Predisposing Factors: Family history: Family history: Known genetic disorders Known genetic disorders FAP FAP

Predisposing Factors: Family history: Family history: Known genetic disorders Known genetic disorders HNPCC- hereditary non polyposis colorectal cancer (=Lynch syndrome) HNPCC- hereditary non polyposis colorectal cancer (=Lynch syndrome) The presence of multiple colorectal cancer within a family

Predisposing Factors: Family history: Family history: Known genetic disorders Known genetic disorders HNPCC- hereditary non polyposis colorectal cancer (=Lynch syndrome) HNPCC- hereditary non polyposis colorectal cancer (=Lynch syndrome) The presence of multiple colorectal cancer within a family Known genetic mutations in repair genes Early onset of cancer More Rt sided Associated with other malignancies

Predisposing Factors: Family history: Family history: No known genetic disorders No known genetic disorders 2-3 fold increased risk 2-3 fold increased risk

Predisposing Factors: IBD IBD Ulcerative colitis > Crohn ’ s Ulcerative colitis > Crohn ’ s Dysplasia in UC patient – consider prophylactic restorative proctocolectomy

Predisposing Factors: Undetermined factors Undetermined factors ? Diet ? Diet ? Smoking ? Smoking ? Other environmental factors ? Other environmental factors

Clinical Presentation May be asymptomatic for years May be asymptomatic for years Screening – controversial Screening – controversial May treat pre-malignant conditions May treat pre-malignant conditions May detect early cancer May detect early cancer Cost effectiveness - ? Cost effectiveness - ? Ability to extend lifespan should be demonstrated Ability to extend lifespan should be demonstrated

Clinical Presentation Rt colon: Rt colon: Anemia, occult blood in stool Anemia, occult blood in stool Small bowel obstruction Small bowel obstruction Perforation – less common Perforation – less common

Clinical Presentation Lt colon: Lt colon: Change in bowel habits Change in bowel habits Anemia- occult or gross blood Anemia- occult or gross blood Large bowel obstruction Large bowel obstruction Perforation – less common Perforation – less common

Clinical Presentation Rectum: Rectum: BRBPR* BRBPR* Change in bowel habits Change in bowel habits Tenesmus / incomplete evacuation Tenesmus / incomplete evacuation Obstruction – mainly upper rectum Obstruction – mainly upper rectum * Every rectal bleeding requires investigation even in the face of known anal pathology

Diagnosis History- History- Change in bowel habits Change in bowel habits Rectal bleeding Rectal bleeding Wight loss Wight loss Reduced appetite Reduced appetite Abdominal pain Abdominal pain

Diagnosis Physical exam: Physical exam: General appearance General appearance Abdominal mass Abdominal mass Abdominal distention Abdominal distention Abdominal tenderness Abdominal tenderness Digital rectal exam- mass, blood, occult blood Digital rectal exam- mass, blood, occult blood

Diagnosis Lab: Lab: Hg levels Hg levels CEA levels CEA levels LFT ’ s LFT ’ s

Diagnosis Imaging studies: Imaging studies: Barium enema Barium enema

Diagnosis Endoscopy: Endoscopy: Anoscopy Anoscopy Rectoscopy Rectoscopy Short colonoscopy Short colonoscopy Full colonoscopy – the gold standard Full colonoscopy – the gold standard

Diagnosis Imaging studies: Imaging studies: CT CT Virtual colonoscopy Virtual colonoscopy Plain abdominal x-ray – in obstruction Plain abdominal x-ray – in obstruction

Metastatic workup CXR CXR Liver US Liver US CT CT PET PET

Staging Duke ’ s staging Duke ’ s staging Alimited to the bowel wall Alimited to the bowel wall BThrough the entire bowel wall BThrough the entire bowel wall CMesenteric lymph nodes CMesenteric lymph nodes DMetastatic DMetastatic

Staging TNM staging TNM staging T0Carcinoma in Situ T0Carcinoma in Situ T1Invasive cancer, confined to the mucosa T1Invasive cancer, confined to the mucosa T2Through the muscularis propria T2Through the muscularis propria T3Through the bowel wall T3Through the bowel wall N0Nodes negative N0Nodes negative N1 Nodes positive N1 Nodes positive M0No metastasis M0No metastasis M1Metastatic disease M1Metastatic disease

Treatment – colon cancer Surgical resection Surgical resection Resected segment depends on the site of cancer Resected segment depends on the site of cancer Mobilization of the segment Mobilization of the segment En-block resection with its lymphatic drainage En-block resection with its lymphatic drainage Anastomosis of the proximal and distal bowel ends Anastomosis of the proximal and distal bowel ends

Treatment – colon cancer Surgical resection- Rt colectomy Surgical resection- Rt colectomy

Treatment – colon cancer Surgical resection- Rt colectomy Surgical resection- Rt colectomy

Treatment – colon cancer Surgical resection- Rt colectomy Surgical resection- Rt colectomy

Treatment – colon cancer Surgical resection- Rt colectomy Surgical resection- Rt colectomy

Treatment – colon cancer Surgical resection- Lt colectomy Surgical resection- Lt colectomy

Treatment – colon cancer Surgical resection- Sigmoidectomy Surgical resection- Sigmoidectomy

Treatment – Upper rectum Same principles as colon cancer Same principles as colon cancer Surgery- Anterior resection Surgery- Anterior resection

Treatment Adjuvant therapy: Adjuvant therapy: Recommended for nodes positive disease Recommended for nodes positive disease First line: 5-FU based chemotherapy First line: 5-FU based chemotherapy

Mid and low Rectal Cancer- Considerations The anal sphincter may be at risk The anal sphincter may be at risk The tumor may be accessible through the anus The tumor may be accessible through the anus Radiation therapy is possible Radiation therapy is possible T staging determines treatment path

Diagnosis In rectal cancer staging: In rectal cancer staging: Rectal US Rectal US CT CT MRI MRI

Treatment – mid and lower rectum Pre-operative staging – Rectal US, CT, MRI Pre-operative staging – Rectal US, CT, MRI T1- may be treated with transanal excision unless unfavorable characteristics T1- may be treated with transanal excision unless unfavorable characteristics

Treatment – mid and lower rectum T3 ± T2 / N1 – Addition of radiation therapy ± chemosensitization T3 ± T2 / N1 – Addition of radiation therapy ± chemosensitization Pre operative or post operative Pre operative or post operative “ European ” low dose or “ American ” high dose “ European ” low dose or “ American ” high dose

Treatment – mid and lower rectum Radical surgery – Resection of the entire rectum Radical surgery – Resection of the entire rectum Abdomino- perineal resection for the very low tumors Abdomino- perineal resection for the very low tumors If 2 cm of clean distal margin is impossible If 2 cm of clean distal margin is impossible a permanent colostomy a permanent colostomy

Treatment – mid and lower rectum Radical surgery – Restorative proctectomy: Radical surgery – Restorative proctectomy: Very low anterior resection Very low anterior resection Colo-anal anastomosis Colo-anal anastomosis Colonic J pouch if possible Colonic J pouch if possible

Treatment – mid and lower rectum

Prognosis It ’ s better to be young and rich rather then old with colon cancer It ’ s better to be young and rich rather then old with colon cancer Duke ’ s A80% Duke ’ s A80% Duke ’ s B60% Duke ’ s B60% Duke ’ s C30% Duke ’ s C30% Duke ’ s D5% Duke ’ s D5%