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Colorectal Cancer: - Dr. Suneet Khurana
Colorectal Cancer: - Dr. Suneet Khurana
Colorectal Cancer: - Dr. Suneet Khurana
* Harrisons
Familial Factors – Risks for CRC
Syndrome Distrubution Histology Malignant Other
potential Lesions
Familial Large Intestine Adenoma Common none
Adenomatous
Polyposis
Gardner Large and Adenoma Common Multiple
Syndrome Small Intestine Malignancies
Turcot Large Intestine Adenoma Common Brain Tumors
Syndrome
Nonpolyposis Large Intestine Adenoma Common Endometrial
Syndrome and Ovarian
Tumors
Peutz Jeghers Small, Large Hamartoma Rare Multiple
Syndrome Intestine, Malignancies
Stomach
Juvenile Large and Hamartoma Rare Congenital
Polyposis Small Intestine Anomalies
Genetic Changes in CRC
GENETIC CHANGES MECHANISM - the
Activation of proto- mutational activation
oncogenes (K-ras) of an oncogene
Loss of tumour-
followed by and
suppressor gene coupled with the loss
activity (APC, DCC) of genes that
normally suppress
Abnormalities in
tumorigenesis
DNA repair genes
(hMSH2, hMLH1),
especially HNPCC
syndromes
Colorectal Polyps
Pathophysiology
Prevention
Often asymptomatic
Hematochezia / melena, abdominal pain, change
in bowel habits
Weakness, anemia, weight loss, palpable mass,
obstruction
Spread
Direct extension, lymphatic, hematogenous (liver
most common, lung, rarely bone and brain)
Peritoneal seeding: ovary, Blumer’s shelf (pelvic
cul-de-sac)
Intraluminal
Clinical Presentation
Right Colon Left Colon Rectum
Frequency 25% 35% 30%
Pathology Exophytic lesions Annular invasive Ulcerating lesions
with occult lesions
bleeding
Symptoms Weight loss, Constipation, Obstruction,
weakness, rarely alternating bowel tenesmus,
obstruction patterns, bleeding
abdominal pain,
decreased stool
caliber, rectal
bleeding
Signs Fe-Deficiency Bright Red Blood Palpable mass on
Anemia Per Rectum, Large rectal exam.
Bowel Bright Red Blood
Obstruction Per Rectum
TNM Classification
Primary Tumor Regional Lymph Distant Metastasis
Nodes
T0 No Primary Tumor N0 No Regional LN M0 No Metastasis
Tis CA in situ N1 Metastasis in 1-3 M1 Distant Metastasis
pericolic nodes
T1 Invasion into N2 Metastasis into 4 or
submucosa more pericolic nodes
T2 Invasion into N3 Metastasis into any
muscularis propria nodes along the course
of named vascular trunks
T3 Invasion into serosa
T4 Invasion into adjacent
structures
Stages of Colorectal Cancer
Prognosis
Stage 5 Year Survival (%)
T1 N0 M0 >90
T2 N0 M0 85
T3 N0 M0 70 - 80
Tx N1 M0 35 - 65
Tx Nx M1 5
Treatment
SURGERY (indicated in potentially curable or symptomatic cases - not always in stage IV)
Curative: wide resection of lesion (5 cm margins) with nodes and mesentery
Palliative: if distant spread, then local control for hemorrhage or obstruction
80% of recurrences occur within 2 years of resection
Improved survival if metastasis consists of solitary hepatic mass that is resected
Colectomy:
- most patients get primary anastomosis (e.g. hemicolectomy, low anterior resection (LAR)-
- if cancer is below levators in rectum, patient may require an abdominal perineal resection
(APR) with a permanent end colostomy, especially if lesion involves the sphincter complex
- complications: anastomotic leak or stricture, recurrent disease, pelvic abscess,
enterocutaneous fistula