• Colon Ca incidence: 105,500/US/yr

• Colon Ca mortality: 48,100/US/yr implies ~ 45% colon Ca case mortality

• Rectal Ca incidence: 42,000/US/yr

• Rectal Ca mortality: 8,500/Us/yr

implies ~ 21% rectal Ca case mortality

Epidemiology

33Characteristics in china

Young

Lower location

ulceration

Ethiology

• Dietary habits

• Precancous diseases

• Environment factors

• Heredity factors

• Other factors

Dietary habit

Heredity factors

• Adenomatous polyposis syndromes (APS)

• Hereditary “Non-polyposis” Colon Cancer

(HNPCC, Lynch syndrome)• Familial Adenomatous Polyp

osis (FAP)

Other factors

Anatomy

Arterial supply of the colon

• Ileocolic artery

• Right colic artery

• Meddle colic artery

• Left colic artery

• Sigmoid arteries

Venous drainage of the colon

• Superior mesenteric vein

• Inferior mesenteric vein

• Splenic vein

• Hepatic portal vein

Lymphatic drainage of the colon

• Epicolic nodes

• Paracolic nodes

• Intermediate nodes

• Central nodes

Ileocecal region

Arterial supply of the rectum

• Superior rectal artery

• Middle rectal artery

• Inferior rectal artery

Venous drainage of the rectum

• Internal hemorrhoidal plexus

• External hemorrhoidal plexus

Rectal region

Model of colorectal carcinogenesis （ 90% ）

Nomal epithelium Heperproliferative epithelium Adenoma Carcinoma

病理生理Pathology

Morphology

• Protrude type

• Infiltrate type

• Ulceration type

Pathology Cytology

• Carcinome

• Mucinous carcinomacarcinoide

• Undifferentiated carcinoma

• Squamous carcinoma

Route of metastasis

Route of metastasis

• Infiltration direct

• lymphatic metastasis

• Hematogenous dissemination

• Implantation metastasis

Liver Metastasis

Implantation metastasis

Classification of Pathology

• Dukes stages

Dukes A 、 B 、 C 、 D

• TNM stages

Ⅰ 、Ⅱ、Ⅲ、Ⅳ

DUKES Classification

Dukes Stages

• Stage A: limited to mucosa and submucosa 90%

• Stage B: extends into muscularis or serosa 60-75%

• Stage C: one positive node - 69% six or more positive nodes, 27%

• Stage D: mets. to liver, bone, lung 5%

COLORECTAL CANCER SURVIVAL (Dukes Stages, 5 y)

Stage Classification

• Stage 0 ＝ Tis, N0, M0

• Stage I ＝ T1, N0, M0 T2, N0, M0

• Stage II ＝ T3, N0, M0 T4, N0, M0

• Stage III ＝ Any T, N1, M0

• Any T, N2, M0

• Stage IV ＝ Any T, Any N, M1

Clinical findings

• Hematochezia (distinct from melena)

• Change in bowel habit: alternating constipation and diarrhea.

• Obstipation to clinical lower bowel obstruction.

Anemia

Weight loss Abdominal pain

FOBT

Mass

Fever

Anorexia

Location in right colon

Obstruction

Diarrhea

Location in left colon

Blood in feces

Constipation

Blood in stool

Change in normal bowel habits

Rectal examination

Cancer of rectum

Method of diagnosis

• Digital examination• Fecal occult blood• Endoscope anoscope Flexible sigmoidoscope• Electrical Colonoscope• Air-contrast barium enema• CEA • others －－ CT 、 MRI 、 PET

Single contrast

Double contrast

Air-contrast barium enema

Endoscopes

Endoscopes

Colonoscopy

Colonoscopy

Colonoscopy

Colonoscopy

Rectal polyp Rectal CA

CT Scan—Rectal tumor

Treatment

The main method is the operation

Operation of clolon

•  Right hemicolectomy

•  Transverse colon resection

•  Left hemicolectomy

• Sigmoide resection

Right hemicolectomy

Ileo-transversal anastomose• Cecum• Ascending colon• Hepatic flexure of colon• Terminal ileum 15cm• Greater omentum• Transverse colon• LN of right gastroepiploic artery

Transverse colectomy

Ascendo-descending colon anastomose

• Hepatic flexure of colon• Splenic flexure of colon• Transverse colon• Greater omentum• Mesocolon• LN of gastrocolic ligament

Radical correction of descending colon

Transversorectal anastomose• Splenic flexure of colon• Descending colo• Sigmoid colon• Parts of greater omentum• Mesocolon

Radical correction of sigmoid colon

Descendorectal anastomose• Parts of descending colon• Sigmoid colon • Superior extremity of rectum• Mesocolon of sigmoid

Operation of rectum

• Transanus Local resection• (APR)---Miles• (LAR)----Dixon• Parks• Reforming Bacon• Hartmann• Post-cavitas pelvis cleare• Entire cavitas pelvis cleare

Radical correction of rectum

• Dixon

location > 5cm dentate line

Incisal margin >3cm

Abdominal Perineal Resection(Miles)

• Indication

location <5cm

• Extent

Post-cavitas pelvis cleare

male female

Radical correction of rectum

• Parks

• Reforming Bacon

• Hartmann

Complication

• Hemorrhage anterosacrum

• Ureter injury

• Bladder injury

• Urine retention

• Sexual disturbance

• Stomal leak

Chemotherapy

• Methodsystemic chemotherapy

regional chemotherapy

• Medicin5-FU 、 CF

Systemic Chemotherapy

Regional hepatic chemotherapy

Chemoport

Radiotherapy

• External radiotherapy

• Internal radiotherapy

New adjuvant therapy

Sandwich

Chemotherapy + Radiotherapy

operation

Chemotherapy + Radiotherapy

Treatment indication

STAGE 0

• Local excision with clear margins

• Large lesion not amenable to local excision

STAGE 1

• Wide surgical resection and anastomosis

Treatment indication

STAGE 2

• Wide surgical resection and anastomosis

• Systemic or regional chemotherapy

• Radiation therapy

• Biologic therapy

Treatment indication

STAGE 3• Surgical resection and anastomosis• Pre/Postoperative chemotherapy 5-FU/leucovorin 6 M 5FU/levamisol 12M• Postoperative radiation therapy• Biological therapy Alone or combination

Treatment indication

STAGE 4

• Surgical resection/anastomosis or bypass

• Surgical resection of isolated metastases

• Chemotherapy

• Biologic therapy

• Radiation therapy

Postoperative follow up

• CEA

• Colonoscopy

• Ultrasonography

• Computer Tomography

• Trans-Rectal UltraSound

Polyps of colon

• Incidence in the general population is 1.6-12%• Incidence in people over 70 may be as high as 4

0%• Polyps are classified as neoplastic or nonneopla

stic• Most polyps are asymptomatic-requiring ten year

s to double their diameter• Polyps may grow large enough to cause sympto

ms

Adenomatous polyps

• Tubular adenoma 75% 5%

• Tubulovillous 15 % 22%

• Villous adenoma 10 % 40 %

TYPE PREVALENCE % MALIGNANT

Adenomatous polyps

• Tend to grow slowly and continuously

• They may be sessile, or pedunculated

Adenomatous polyps

Treatment• Removal of all polyps is recommended• Careful histologic assessment is mandatory for pro

per management• Resection either endoscopically or by open techniq

ues

Follow-up• Regular checkups are recommended since 40% wi

ll have reoccurrence (F/U 6m-1year)

Multiple Polyposis Syndromes

• Familial adenomatous polyposis

• Gardner’s syndrome

• Turcot’s syndrome

Familial adenomatous polyposis

Thank you