Colorectal Cancer

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Colorectal Cancer

• Assessment Management
• Orla Dunlea
• Surgical Resident

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The Facts

• It is common
• 80 Australians die each week from colon cancer
• 1/12 of us will be diagnosed with it in our
  lifetime
• It is preventable
• 90 is treatable if detected early enough
• Currently lt40 is detected in the early stages

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Who develops colon cancer?

• MF
• Peak incidence at 65 years
• Family history
• Ulcerative colitis x 8-10 years
• History of polyps
• Fibre intake? (Proposed by Burkitt Irish)
• Aspirin reduces risk

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Polyps

• Morphological term protrudes from the bowel
  wall into the lumen
• Pedunculated
• Sessile

• Villous
• Most malignant potential
• Frond-like
• Mucus-secreting which may be presenting complaint
  or low K

• Tubulovillous
• Most common type
• Pedunculated
• Tubular
• Least malignant potential
• Polyps found in FAP

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Polyps on colonoscopy
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Colon cancer on colonoscopy
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How does it present?

• Right sided
• Anaemia
• RIF mass
• Dont tend to cause obstruction (unless the
  ileocaecal valve is involved) as diameter is
  greater than left stool is more liquid

• Left sided
• Change in bowel habit
• PR bleeding
• Tenesmus (lower rectal lesion)
• Pericolic abscess erodes through the bowel
  wall, LIF pain, tender swinging pyrexia
• Large bowel obstruction acute presentation

• Presentation with mets
• Obstructive jaundice nodes compressing porta
  hepaticus
• Ureteric or duodenal obstruction
  retroperitoneal lymph nodes
• Weight loss, anorexia, hepatomegaly due to liver
  mets

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On Examination

• Signs of anaemia
• Weight loss
• Abdo exam
• Normal
• Palpable mass
• Hepatomegaly due to mets
• Ascites
• PR exam
• Mass
• Local extension into pouch of douglas
• Amount of fixation to local structures
• FOB

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Investigations

• Bloods
• CEA
• HB
• LFTs
• Barium enema

• Colonoscopy
• Visualise tumour
• Biopsy tumour
• Look for other tumours/polyps
• /- stenting if palliative

• If histology confirmed
• Imaging
• U/S for liver Mets
• CT thorax/abdo/pelvis with contrast for staging
• MRI /endoanal U/S for rectal CA (if MRI
  incompatible)

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Scope
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Liver metastasis
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Barium enema
Apple core lesion
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Candidate for surgery?

• Stage of cancer is it operable?
• QOL life expectancy prior to surgery
• Does the patient want surgery?
• Suitable for anaesthetic- anaesthetic review
• Co-morbidities IHD, DM, COPD etc
• Are risks of complications too high?
• Nutrition and ability to heal

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Pre-operative work up

• Routine bloods FBC, UEs, LFTs, Coag
• Group cross match
• CEA for baseline
• CXR
• Consent
• /-bowel prep
• NPO
• Catheter
• IVABs
• TEDS

• (Radiotherapy)
• (Chemotherapy)
• (Stoma education)
• (Stoma positioning)
• (PFTs)
• (Echo/cardiac mibi/ coronary angio)

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Surgery
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Right hemi-colectomy
Caecal R colon tumours
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Extended right hemi-colectomy

• Proximal or mid-transverse colon tumours

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Left hemicolectomy
Splenic flexure and left colon tumours
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Sigmoid colectomy
Sigmoid tumours
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Abdomino-perineal resection

• Low rectal tumours, FAP
• Permanent stoma

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Resection with stoma

• Hartmans procedure with formation of a stoma
• If present acutely
• If anastomotic healing doubtful
• 50 will be reversed

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Colectomy

• HNPCC
• FAP
• Multiple tumours

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Laparoscopic resection
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Post-operative complications

• Early
• Bleeding
• Infection
• Perforation
• Local structure damage ureters, bladder,
  spleen, duodenum
• Anastomotic leak or breakdown
• Wound infection
• Wound dehiscence
• Sepsis multiorgan failure
• Stoma problems
• TPN
• Late
• Diarrhoea due to short bowel syndrome
• Impotence pelvic parasympathetic nerve damage
• Small bowel obstruction
• Adhesions
• 2nd radiotherapy

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Staging Dukes Classification

• Dukes A
• Bowel wall only
• No nodes
• No mets
• 75 5 year survival

• Dukes B
• Through muscularis propria
• No nodes
• No mets
• 55 5 year survival

• Dukes C
• C1
• Node positive but only around tumour not distal
• 40 5 year survival
• C2
• Node positive up to proximal resection margin
• 20 5 year survival

• Dukes D
• Distant metastasis

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TNM staging

• T Tumour
• T1 Invasion into submucosa (connective tissue
  glands)
• T2 Invasion into muscularis propria (muscles
  layers)
• T3 Invasion into subserosa
• T4 Invasion to local organ or structures /-
  visceral peritoneum
• N Nodes
• N0 - No lymph node invasion
• N1 spread to 1-3 regional lymph nodes
• N2 - gt4 regional lymph nodes
• M Metastasis
• M0 No mets
• M1 Distant mets

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Metastasis

• Lymphatic spread to mesenteric then para-aortic
  nodes
• In the blood to the liver
• Unusually to bone, lung or brain

Absence or presence of liver mets most important
factor in determining prognosis!!!
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Chemotherapy

• 5-Fluorouracil /- Leucovorin
• Following resection of stage 3, /- stage 2
• Metastatic disease
• Radiation may be used in rectal cancer to reduce
  the size of the lesion allow preservation of
  sphincter

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Follow up

• CEA levels
• Colonoscopy
• CT thorax/abdo/pelvis

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Familial colon cancer

• Hereditary non-polyposis colorectal cancer
  (HNPCC)
• Lynch syndrome 1 hereditary colon cancer
• Lynch syndrome 2 hereditary colon cancer
  increased risk of other GIT or reproductive
  tumours
• Familial adenomatous polyposis (FAP)
• Unknown mutations

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HNPCC

• DNA mismatch repair gene mutation (several
  different chromosome locations)
• Autosomal dominant 50 chance of offspring
  having mutation
• Polyps become malignant over 2-3 years (compared
  to 8-10 years for non hereditary colon cancer)
• 70-80 lifetime chance of getting colon cancer
• Lynch syndrome 2 increased risk of endometrial,
  ovarian, upper urinary tract stomach
• Treatment
• Colectomy with ileo-rectal anastomosis
• Colectomy permanent ileostomy

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Amsterdam criteria for HNPCC

• Used to identify people at risk of HNPCC
• gt3 more relatives with HNPCC-related cancer
• 2 successive generations
• At least 1 of the cancers diagnosed lt50 years
• FAP has been excluded

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Familial Adenomatous Polyposis (FAP)

• Rare
• 100 penetrance
• Autosomal dominant
• Deletion on chromosome 5 (adenomatous polyposis
  coli gene)
• Extra-intestinal features BORED
• Brain tumours
• Osteomas
• Retinal pigment hypertrophy
• Epidermal cysts
• Dentition abnormality
• Treatment
• Panproctocolectomy ileostomy

Good for screening as present in 95 people with
gene
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Screening

• National screening programme if gt50 years
• Home FOB test send off GP contacted if
  positive

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MCQs

• Polyps with the most potential to become
  malignant are tubulovillous polyps T or F

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Short cases

• Mr Murphy is a 69 year old man who has noticed
  passage of blood with stools over the last week
  please take a history. What investigations would
  you like to perform?

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Long cases

• Post-operative patient with a stoma
• Ostomy Surgically created opening connecting an
  internal organ to the surface of the body
• Stoma The opening of the ostomy
• Stoma important for exams
• Ileostomy
• Colostomy
• Ileal-conduit

EXTREMELY COMMON FOR LONG CASES!!!!!!
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Why form a stoma?

• Ileostomy
• To protect a distal at risk anastomosis
• Distal bowel rest for Crohns
• Permanent after panproctocolectomy

• Colostomy
• To protect a distal at risk anastomosis
• Perforation, infection or ischaemia means an
  anastomosis would not heal may be performed at
  later date
• Permanent after abdomino-perineal resection

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Examination of the stoma

1. Stoma itself
2. Stoma surroundings
3. Stoma bag

• 1. Stoma itself
• Where is it?
• How many lumens?
• Type of spout
• Does it look healthy?

• 2. Stoma surroundings
• Skin
• Scars
• Patient general health

• 3. Stoma bag
• What kind of bag?
• Whats in the bag?

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Stoma

• 1. Stoma itself
• Where is it?
• How many lumens?
• Type of spout
• Does it look healthy?

RIF ileostomy, left colostomy but beware
2 may be loop ileostomy (temporary)
Flush with skin colostomy, spouted ileostomy
(or prolapsing colostomy!)
Ischaemic? Prolapsing? Retracted? Stenosed?
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Stoma

• 2. Stoma surroundings
• Skin
• Scars
• Patient general health

Rash, necrosis, parastomal hernia
Previous surgeries, previous stoma sites
Young UC or Crohns, dehydrated looking high
stoma output, cachexic palliative stoma
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Stoma

• 3. Stoma bag
• What kind of bag?
• Whats in the bag?

Tap transparent post-op for output
measurements. Non-transparent no tap long-term
Greenish fluid ileostomy Brownish
colostomy Yellow ileal-conduit Any mucus or
blood?
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Stoma

• Choosing a site
• Stoma nurse
• Important for success of the stoma post-op
• Assess site when sitting, standing
• Avoid
• Previous scars/wound site
• Belt line
• Bony prominence
• Umbilicus
• Skin crease
• Obesity poses problems

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Complications of stoma

1. Stoma itself
2. Area surrounding stoma
3. Living with a stoma

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Complications of stoma

• 1. Stoma itself
• Ischaemia
• Retraction
• Prolapse
• Obstruction
• Stenosis

• 2. Area surrounding stoma
• Leakage
• Hernia
• Skin irritation (ileostomy)
• Fistula (Crohns)

• Living with a stoma
• Increased output/short gut syndrome
  (electrolytes, dehydration)
• Psychological/psychosexual especially if odour
  (charcoal filter helps)
• Kidney gall stones (if terminal ileum
  diseased/sacrificed)

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• From little things, big things grow

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Reading

• N Engl J Med. 2010 Jan 7362(1)85 author reply
  85.Screening for colorectal cancer. Mohammed F.
• Lancet. 2009 Mar 7373(9666)790-2.Rectal cancer
  optimum treatment leads to optimum results.
  Madoff RD.