COLORECTAL
CARCINOMA
Bernard M. Jaffe, MD
Professor of Surgery
Emeritus
EPIDEMIOLOGY
• 1.4 Million People/Year, 700,000 Deaths
• 2nd Most Common Cancer in Women
(9.2%)
• 3rd Most Common Cancer in Men (10%)
• Overall, 3rd Most Common Malignancy
• More Common in Developed Nations
• 5% of Americans, Mean Age 61 Years
RISK FACTORS
• 75-95% No Genetic Risk Factors
• Risk Factors- Older Age, Male Gender
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High Intake of Fat, Red
Meat
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Alcohol (>1 Drink/Day)
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Obesity
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Smoking
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Insufficient Activity?
GENETICS
• <5% of Total Cases
• HNPCC (Lynch Syndrome) 3%
• FAP, Gardner’s Syndrome <1% of Total
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>90% Develop Carcinoma Without
Treatment
• 2 or More 1st Degree Relatives, 2-3 Fold
Increase in Carcinoma
POLYPS
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Almost All Adenomatous
Most Common Precursor
Types- Villous Adenoma (30%)
Tubulovillous
Tubular (<5%)
>5 Years to Become Malignant
Hamartomatous- Minimal Risk
INFLAMMATORY DISEASES
• Ulcerative Colitis
• 30% Develop Carcinoma
• >20 Years of Disease
• Predictable by Degree of Dysplasia
• Terrible Prognosis
• Crohn’s Disease
• Less Likely, But Increased Risk
SCREENING
• Can Reduce Likelihood by >60% Not 100%
• Fecal Occult Blood Testing q2years
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Positive Result→ Colonoscopy
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Mortality Decreased by >20%
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Cheap but Imperfect
• Air Contrast Barium Enema Not
Recommended
• Sigmoidoscopy Misses 43% of Lesions
SCREENING
• Colonoscopy
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Every 10 Years, Ages 50–75 Years
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Polyps Found/Removed, Every 3-5 Years
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High Risk Patient- Ages 40-75
• Virtual Colonoscopy (CT)- Imperfect
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Expensive
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Radiation Exposure
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Purely Diagnostic
SYMPTOMS
• Depends on Location in Bowel
• Right- Anemia, Weakness
• Left- Increased Constipation
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Blood in Stool
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Narrowed Stool Caliber
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Weight Loss
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Anorexia
HEMATOCHESIA- DIAGNOSIS
Young Patient
Older Patient
• Hemorrhoids
• Anal Fissure
• Inflammatory
Disease
• Hamartoma
• Rare Carcinoma
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Polyps
Carcinoma
Diverticulosis
A-V Malformation
Ischemia
Hemorrhoids
DIAGNOSIS
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Colonoscopy vs. Sigmoidoscopy Depends
on Site of Lesion
Biopsy
Imaging- CT Abdomen, Pelvis, ?Chest
MRI for Pelvic Lesions
PET Scan Rarely Needed
CEA NOT Diagnostic
OPERATIVE TREATMENT
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Almost All Laparoscopically
Cecum, Ascending, R Transverse
Right Hemicolectomy
Left Transverse
Left Hemicolectomy
Sigmoid, Proximal Rectum
Low Anterior Resection
GOALS OF OPERATION
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Lesion Resection With Adjacent Tissue
5cm Colon Margin (2cm Acceptable)
Vascular Anastamosis
Removal of Maximal Lymph Nodes (>12)
Possible Resection of Liver Metastases
Hysterectomy, Oophorectomy in Women
Check for Cholelithiasis
INVASION OF ADJACENT
STRUCTURES
• Vagina- Resection with Closure
• Uterus- Hysterectomy, Oophorectomy
• Ureter- Resection with Reimplantation,
Ureteroureterostomy
• Dome of Bladder- Resection with Closure
• Trigone of Bladder- Pelvic Exenteration
• Multiple Structures- Pelvic Exenteration
RECTAL CANCER
• Depends on Nodes and Depth of Invasion
• Determined by MRI, Transrectal Ultrasound
Superficial Lesion- Transanal Excision
• Deep Lesion or Positive Nodes•
Mesorectal Excision
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Sphincter Saved if 5cm from Verge
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Low Anastamoses Protected by Ileostomy
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Abdominoperineal Resection if Lower
DEPTH OF INVASION
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Important Determinant of Prognosis
Tis - In Situ (No Invasion)
T1 - Mucosa/Submucosa
T2- Muscularis Propria
T3 - Serosa
T4 - Adjacent Structures
NODAL METASTASES
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Critical Determinant of Prognosis
NX Can’t be Assessed
N0- No Positive Nodes
N1- 1-3 Positive Nodes
N2- >4 Positive Nodes
N3- Any Positive Nodes Along Major
Vascular Trunk
PROGNOSIS
Stage
•I
• II
• III
• IV
5 Year Survival
TNM
• 70-90%
T1-2, N0, M0
• 54-65%
T3-4, No, M0
Any T, N1-3, M0 • 39-6-%
Any T, Any N, M1 • 0-15%
ADJUVANT THERAPY
• Stages III and IV
• Possibly Stage 2- To Be Determined
• 5-FU/Capecitabine and
Leukovorin/Levamisole
• Increase Survival, Disease-Free Survival
• Newer Agents- Irimotecan, Oxiliplatin
• Radiation for Positive Margins on Solid
Tissues
USE OF CEA
• Not Reliable for Initial Screening
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BUT
• Elevation More Common With
Extensive Disease
• Should Return to 0 Post-Resection
• Post-Op Increase Means Tumor
Recurrence
INCREASED FOLLOW-UP CEA
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CT Scan/MRI of Abdomen, Pelvis
Chest
PET Scan
Colonoscopy
Laparotomy If No Lesion Identified
Mesentary/Adjacency Most Likely Site
Resection Yields 30% 5-Year Survival
LIVER METASTASES
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Presence Determines Prognosis
Mean 15-18 Month Survival
15% Stage IV Have Disease Limited to Liver
25% of Them Candidates for Resection
Resection IF Limited to One Lobe of Liver
OR
<5 Lesions, Each <3cm
Total Resection, 5-Year Survival 20-40%