16/12/2012 Mr. Ravi-Kumar Stafford General Hospital1 ABC of CRC (Colo-Rectal Carcinoma) Mr Ravi-Kumar Consultant Surgeon Coloproctology, Laparoscopy & General

11/12/2012 Mr. Ravi-Kumar Stafford General Hospital2

 Incidence  Aetiology  Pathogenesis  Heritable cancers/ FH  Clinical presentation  Role of screening  Treatment options  Recent advances 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital3

 Colorectal cancer is second commonest cancer causing death in the UK  20,000 new cases per year in UK - 40% rectal and 60% colonic  Some cases are hereditary (5%)  Most related to environmental factors - dietary red meat, animal fat & lack of fibre  Role of alcohol, smoking, obesity and lack of exercise  Role of micro-nutrients 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital4

 Most cancers believed to arise within pre-existing adenomas  Risk of cancer greatest in villous adenoma  Of all adenomas - 70% tubular, 10% villous and 20% tubulo- villous  Series of mutations results in epithelial changes from normality, through dysplasia to invasion 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital5

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 1% due to Familial Adenomatous Polyposis coli (FAP)  4% due to Hereditary Non-Polyposis Colon Cancer (HNPCC)  Definition- at least 3 relatives affected (one of whom is a first degree relative of the other two)  At least one under the age of 50  Potential HNPCC- relatives of people with CRC under 45 or multiple cases 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital9

 Not a germ-line mutation  Still a cluster of cases in various generation  Not enough to fall under HNPCC or FAP  Risk to be stratified and screened accordingly 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital10

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 Age- disease of old age  Peak age incidence  More & more younger patients are being diagnosed with CRC (still makes only 5% of all cases)  Strong FH – younger age presentation  IBD – increased incidence esp. With extensive UC 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital12

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 Bleeding PR- o Mixed in with the stools o Dark red in colour o Even one episode of bleeding may be significant in the elderly o Rarely massive lower GI bleed 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital14

 Increased stool frequency  Diarrhoea alternating with constipation  Tenesmus  Abdominal pain  Incontinence 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital15

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 Abdominal pain  Diarrhoea alternating with constipation  40% of all cancers present as a surgical emergency with either obstruction or perforation 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital17

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 Anaemia –iron deficiency  Mass- RIF  Increasing in incidence of right sided tumours  FH 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital19

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 May present with fistulation into nearby viscera- colovaginal, colovescical, coloenteral fistulae  Poor appetite  Weight loss 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital21

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 FAST TRACK – FAXED REFERRAL  Bleeding PR lasting over 6/52 in anyone over the age of 60  Loose stools lasting over 6/52 in anyone over 60  Both symptoms in anyone even under 60 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital23

 FAST TRACK – FAXED REFERRAL  Mass in the RIF  Mass in the rectum  Unexplained iron deficiency anaemia 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital24

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 To diagnose  Colonoscopy – Gold standard  To Stage  Contrast CT- Thorax, abdomen and Pelvis  MRI Pelvis in addition to stage rectal cancer 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital26

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 Developed by Cuthbert Duke in 1932 for colorectal cancers  Dukes staging of colorectal cancer 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital30

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 TX Primary tumor cannot be assessed  T0 No evidence of primary tumor  Tis Carcinoma in situ: intraepithelial or invasion of lamina propria  T1 Tumor invades submucosa  T2 Tumor invades muscularis propria  T3 Tumor invades through the muscularis propria into pericolorectal tissues  T4a Tumor penetrates to the surface of the visceral peritoneum  T4b Tumor directly invades or is adherent to other organs or structures 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital32

 N0 No regional lymph node metastasis.  N1 Metastases in 1–3 regional lymph nodes.  N2 Four or more regional lymph nodes.  NX Regional lymph nodes cannot be assessed. 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital33

 M0 No distant metastasis.  M1 Distant metastasis.  M1a Metastasis confined to 1organ or site (e.g., liver, lung, ovary, non-regional node).  M1b Metastases in >1 organ/site or the peritoneum. 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital34

 Little improvement over the last 30 years in general  How can we improve the prognosis?  Considerable improvement achieved recently in rectal cancer treatment  Role of screening 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital35

 TME- better surgical technique  Better staging- MRI, EUS, CT  Selective use of pre-operative Radio/chemotherapy  MDT 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital36

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 Right Hemicolectomy  Ext. Right Hemicolectomy  Transverse Colectomy  Left Hemicolectomy  Sigmoid colectomy  Subtotal colectomy 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital39

 - is a very useful site for senior trainees and consultants  Free to register and thousands of video clips can be viewed for free 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital40

 Laparoscopic vs. open  Fast Track / enhanced post-op recovery 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital41

 Pre-op- Counseling, Carbohydrate load  Per-op – Less opiates, epidurals, Goal directed fluid therapy, Transverse incision  Post-op- Analgesic ladder, Less tubes, IVI for less than 24 hours, early feeding and promote mobility 12/15/2015 Mr. Ravi-Kumar Stafford General Hospital42

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