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

Change in bowel Change in bowel habits…habits…

60 year old male60 year old maleComplains of progressive Complains of progressive constipation for the past 6 monthsconstipation for the past 6 months

Change in bowel Change in bowel habits…habits…

60 year old male60 year old maleComplains of progressive Complains of progressive constipation for the past 6 monthsconstipation for the past 6 months

10 kg unintentional weight loss10 kg unintentional weight loss

Occasional rectal bleedingOccasional rectal bleeding

No painNo pain Not vomitingNot vomiting

No painNo pain Not vomitingNot vomiting

Past medical history- unremarkablePast medical history- unremarkable

Never had colonoscopyNever had colonoscopy

Family history- Grandfather and uncle Family history- Grandfather and uncle with colon cancerwith colon cancer

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


Colonoscopy:Colonoscopy:

Sigmoid colon


Colonoscopy: non obstructing mass at Colonoscopy: non obstructing mass at the sigmoid colonthe sigmoid colon

Pathology- adenocarcinomaPathology- adenocarcinoma

Colorectal Colorectal CancerCancerOded ZmoraOded Zmora

Department of Surgery B

Sheba Medical Center

Tel Hashomer

Colorectal CancerColorectal Cancer

Adenocarcinoma of the large bowel, Adenocarcinoma of the large bowel,

originating at the bowel mucosaoriginating at the bowel mucosa

22ndnd in cancer incidence in the Western in cancer incidence in the Western

worldworld

Significant cause of morbidity, expenses, Significant cause of morbidity, expenses,

and deathand death

Predisposing FactorsPredisposing Factors::

Age:Age:

Uncommon before the age of 40 yearsUncommon before the age of 40 years

Risk gradually increase with ageRisk gradually increase with age

When at young age – may be associated When at young age – may be associated

with known genetic predisposing factorswith known genetic 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 sequenceThe adenoma – carcinoma sequence


Family history:Family history: Known genetic disordersKnown genetic disorders

FAPFAP

Autosomal dominant disAutosomal dominant dis

Presents with hundreds of adenomatous polypsPresents with hundreds of adenomatous polyps

Almost all develop cancerAlmost all develop cancer

Extra-colonic manifestations: Duodenal Extra-colonic manifestations: Duodenal carcinoma,carcinoma,

Gastric adenomas, desmoid tumors, osteomasGastric adenomas, desmoid tumors, osteomas

Prophylactic restorative proctocolectomyProphylactic restorative proctocolectomy



FAPFAP



HNPCC- hereditary non polyposis colorectal HNPCC- hereditary non polyposis colorectal cancer (=Lynch syndrome)cancer (=Lynch syndrome)

The presence of multiple colorectal cancer within a The presence of multiple colorectal cancer within a familyfamily



HNPCC- hereditary non polyposis colorectal HNPCC- hereditary non polyposis colorectal cancer (=Lynch syndrome)cancer (=Lynch syndrome)

The presence of multiple colorectal cancer The presence of multiple colorectal cancer within a familywithin a family

Known genetic mutations in repair genesKnown genetic mutations in repair genes

Early onset of cancerEarly onset of cancer

More Rt sidedMore Rt sided

Associated with other malignanciesAssociated with other malignancies


Family history:Family history: No known genetic disordersNo known genetic disorders

2-3 fold increased risk2-3 fold increased risk


IBDIBD Ulcerative colitis > Crohn’sUlcerative colitis > Crohn’s

Dysplasia in UC patient – consider Dysplasia in UC patient – consider prophylactic restorative proctocolectomyprophylactic restorative proctocolectomy


Undetermined factorsUndetermined factors

? Diet? Diet

? Smoking? Smoking

? Other environmental factors? Other environmental factors

Clinical PresentationClinical Presentation

May be asymptomatic for yearsMay be asymptomatic for years

Screening – controversialScreening – controversial

May treat pre-malignant conditionsMay treat pre-malignant conditions

May detect early cancerMay detect early cancer

Cost effectiveness - ?Cost effectiveness - ?

Ability to extend lifespan should be Ability to extend lifespan should be

demonstrateddemonstrated


Rt colon:Rt colon:

Anemia, occult blood in stoolAnemia, occult blood in stool

Small bowel obstructionSmall bowel obstruction

Perforation – less commonPerforation – less common


Lt colon:Lt colon:

Change in bowel habitsChange in bowel habits

Anemia- occult or gross bloodAnemia- occult or gross blood

Large bowel obstructionLarge bowel obstruction

Perforation – less commonPerforation – less common


Rectum:Rectum: BRBPR*BRBPR* Change in bowel habitsChange in bowel habits Tenesmus / incomplete evacuationTenesmus / incomplete evacuation Obstruction – mainly upper rectumObstruction – mainly upper rectum

* * Every rectal bleeding requires Every rectal bleeding requires investigation even in the face of knowninvestigation even in the face of known anal pathologyanal pathology

DiagnosisDiagnosis

History-History-

Change in bowel habitsChange in bowel habits

Rectal bleedingRectal bleeding

Wight lossWight loss

Reduced appetiteReduced appetite

Abdominal painAbdominal pain

DiagnosisDiagnosis

Physical exam:Physical exam:

General appearanceGeneral appearance

Abdominal massAbdominal mass

Abdominal distentionAbdominal distention

Abdominal tendernessAbdominal tenderness

Digital rectal exam- mass, blood, occult Digital rectal exam- mass, blood, occult

bloodblood

DiagnosisDiagnosis

Lab:Lab:

Hg levelsHg levels

CEA levelsCEA levels

LFT’sLFT’s

DiagnosisDiagnosis

Imaging studies:Imaging studies: Barium enemaBarium enema

DiagnosisDiagnosis Endoscopy:Endoscopy:

AnoscopyAnoscopy RectoscopyRectoscopy Short colonoscopyShort colonoscopy Full colonoscopy – the gold standardFull colonoscopy – the gold standard

DiagnosisDiagnosis

Imaging studies:Imaging studies: CTCT Virtual colonoscopyVirtual colonoscopy Plain abdominal x-ray – in obstructionPlain abdominal x-ray – in obstruction

Metastatic workupMetastatic workup

CXRCXR

Liver USLiver US

CTCT

PETPET

StagingStaging

Duke’s stagingDuke’s staging

AA limited to the bowel walllimited to the bowel wall

BB Through the entire bowel wallThrough the entire bowel wall

CC Mesenteric lymph nodesMesenteric lymph nodes

DD MetastaticMetastatic

StagingStaging TNM stagingTNM staging

T0T0 Carcinoma in SituCarcinoma in Situ T1T1 Invasive cancer, confined to the mucosaInvasive cancer, confined to the mucosa T2T2 Through the muscularis propriaThrough the muscularis propria T3T3 Through the bowel wallThrough the bowel wall

N0N0 Nodes negativeNodes negative N1 N1 Nodes positiveNodes positive

M0M0 No metastasisNo metastasis M1M1 Metastatic diseaseMetastatic disease

Treatment – colon cancerTreatment – colon cancer

Surgical resectionSurgical resection

Resected segment depends on the site of cancerResected segment depends on the site of cancer

Mobilization of the segmentMobilization of the segment

En-block resection with its lymphatic drainageEn-block resection with its lymphatic drainage

Anastomosis of the proximal and distal bowel Anastomosis of the proximal and distal bowel

endsends


Surgical resection- Rt colectomySurgical resection- Rt colectomy








Surgical resection- Lt colectomySurgical resection- Lt colectomy


Surgical resection- SigmoidectomySurgical resection- Sigmoidectomy

Treatment – Upper Treatment – Upper rectumrectum

Same principles as colon cancerSame principles as colon cancer Surgery- Anterior resectionSurgery- Anterior resection

TreatmentTreatment

Adjuvant therapy:Adjuvant therapy:

Recommended for nodes positive Recommended for nodes positive

diseasedisease

First line: 5-FU based chemotherapyFirst line: 5-FU based chemotherapy

Mid and low Rectal Cancer- Mid and low Rectal Cancer- ConsiderationsConsiderations

The anal sphincter may be at riskThe anal sphincter may be at risk

The tumor may be accessible The tumor may be accessible through the anusthrough the anus

Radiation therapy is possibleRadiation therapy is possible

T staging determines treatment path

DiagnosisDiagnosis

In rectal cancer staging:In rectal cancer staging: Rectal USRectal US CTCT MRIMRI

Treatment – mid and lower Treatment – mid and lower rectumrectum

Pre-operative staging – Rectal US, CT, Pre-operative staging – Rectal US, CT, MRIMRI

T1- may be treated with transanal T1- may be treated with transanal excision unless unfavorable excision unless unfavorable characteristicscharacteristics


T3 ± T2 / N1 – Addition of radiation T3 ± T2 / N1 – Addition of radiation

therapy ± chemosensitizationtherapy ± chemosensitization

Pre operative or post operativePre operative or post operative

““European” low dose or “American” high European” low dose or “American” high

dosedose


Radical surgery – Resection of the entire Radical surgery – Resection of the entire

rectumrectum

Abdomino- perineal resection for the very low Abdomino- perineal resection for the very low

tumorstumors

If 2 cm of clean distal margin is impossibleIf 2 cm of clean distal margin is impossible

a permanent colostomya permanent colostomy


Radical surgery – Restorative Radical surgery – Restorative proctectomy:proctectomy: Very low anterior resectionVery low anterior resection Colo-anal anastomosisColo-anal anastomosis Colonic J pouch if possibleColonic J pouch if possible


PrognosisPrognosis

It’s better to be young and rich It’s better to be young and rich rather then old with colon cancerrather then old with colon cancer

Duke’s ADuke’s A 80%80% Duke’s BDuke’s B 60%60% Duke’s CDuke’s C 30%30% Duke’s DDuke’s D 5%5%

Documents

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