MBBS V Surgery – Colorectal CA (tutorial)
Colorectal cancer
Colonic polyp
70-80% adenoma-carcinoma sequence
Developed into carcinoma after 10-15 years
Accumulation of gene mutation
o Proto-oncogene
o Tumour suppressor gene
Types aware of pathology after polypectomy
o Neo-plastic polyp (% of villous component: higher risk feature)
Tubular adenoma 5% (most common)
Tubo-villous adenoma 20-25%
Villous adenoma 35-40% (higher risk of malignant transformation)
o Non-neoplastic
Inflammatory
Hyperplastic
Harmatomatous
Sequence: Malignant colonic polyp
o Indication of malignancy (require pathology report)
1. Size >1.5cm
2. Histological type (more villous component: higher transformation)
3. Degree of dysplasia (high grade: faster malignant transformation)
4. Confined within muscularis mucosae Tis/submucosal T1
Tis = No risk of lymph node spread if in muscularis mucosae
T1 = Breached submucosa
o Classification: Haggitt’s classification (site of cancer cell component)
0: carcinoma confined to mucosa
1: head of polyp
2: neck of polyp
3: stalk of polyp
4: submucosa involvement
Colonic polyp treatment (endoscopy: end view vs side view = ERCP)
o i. Endoscopic resection: haustra fold know colonoscopy
Polypectomy
Working channel: snare + hemostasis
Pathological report
Retain polyp: depends on size of polyp
o Suction channel
o Working channel: polyp retriever with tripod
ESD (endoscopic submucosal dissection, en-bloc)
Indication: very large polyp
Inject hyaluronic acid to raise the polyp
Special knife to cut away mucosa and dissect across sub-
mucosal plane
o ii. Formal surgical resection: colectomy
Endoscopic vs surgical resection
Endoscopy: no GA, ensure adequate margin
Laparoscopic resection: GA, achieve negative margin, requires
vessel ligation + lymph nodes resection may revise staging
and management (e.g. adjuvant chemo)
MBBS V Surgery – Colorectal CA (tutorial)
Indication for colectomy - absence of any of the following features:
1. Poorly differentiated
2. Vascular or lymphatic
3. Invasion beyond submucosa
4. Positive resection margin
Surveillance after colonic polyp removal
o Normal colonoscopy: 10 years
o Normal colonoscopy (if 1st relative has CRC): 5 years
o <20 hyperplastic polyps <10mm: 10 years
o Hyperplastic polyps >10mm: 3-5 years
o 1-2 Low risk adenomas (tubulo-adenoma): 7-10 years
o 3-4 low risk adenomas or 1 high risk adenoma: 3 years
o >10 adenoma: 1 year
o Sessile polyposis: 1 year
High risk adenoma:
o Villous/tubulovillous adenoma
o High grade dysplastia
o Adenoma >10mm
Epidemiology and etiology
Sporadic: 80%
Familial: strong fam hx
o More than 2 first degree relatives irrespective of age of onset
Hereditary: gene mutation
o Familial adenomatous polyposis
Features
Autosomal dominant, mutation of APC gene (5q)
<1% of CA colon (not common)
100% penetrance at age <30 years prophylactic colectomy
Dx: >100 polyps
Mx
Endoscopy yearly since 12 years old
Prophylactic colectomy (until diagnosis of CA colon)
o Hereditary non-polyposis colorectal CA (more common)
Features
Autosomal dominant, MMR mismatch repair gene
Commonest inherited colonic cancer: 5-10% of CA colon 80%
risk for development of CA (not 100% penetrance, not
prophylactic mx)
Less polyps than FAP
Right side colon tumour
Dx at age 45 y/o
Lower stage, better survival
Higher occurrence - synchronous/metachronous tumour (20%)
o Synchronous: <6 months, metachronous >6 months
Lynch syndrome
Lynch syndrome 1:
o Only early onset CA colon
Lynch syndrome 2: other cancers
MBBS V Surgery – Colorectal CA (tutorial)
o CA colon, endometrial CA, stomach CA, HBP
system, ureter CA, small bowel, renal pelvis
Amsterdam diagnostic criteria
3 family members with colorectal CA or other HNPCC extra-
colonic cancer
At least 2 generations affected
At least 1 individual before 50 y/o
1 affected case is first degree relative f other two
Excluded FAP
Bethesda criteria
Diagnosis: genetic study (young CA colon study) = MSH2, MHL1
Hereditary gastrointestinal cancer registry
o Any
Clinical presentation of CRC
Right side CRC (less symptoms)
o Iron deficiency anemia
o Right lower quadrant mass
o Stool FOB positive
o More liquid stool: less likely bowel symptoms
Left side CRC
o PR bleeding
o Blood mix with stool
o Tenesmus
o Mucus with stool
o Change in bowel habit
o Palpable abdominal or rectal mass
o More solid stool: bowel symptoms more prominent
Constitutional S/S
o Significant weight loss
o Loss of appetite
Metastatic
o Supraclavicular LN
o Hepatomegaly
Emergency presentation
o Intestinal obstruction
o Bowel perforation
Site of perforation: cecum (esp. closed loop obstruction) (common)
Tumour perforated
MBBS V Surgery – Colorectal CA (tutorial)
Infected tumour
Risk factors
Modifiable
o Diet: low fiber, red processed meat/animal fat
o Smoking
o Alcohol consumption
o Obesity
Non-modifiable
o Long standing colitis: 8% in 20 years, 20% if 30 years
Inflammatory bowel disease: ulcerative colitis
Does not follow adenoma-carcinoma sequence
Low grade to high grade (much shorter sequence)
Requires endoscopy follow-up
o Personal hx of colonic polyp or CRC
o Significant family hx
o Hereditary cancer: HNPCC, FAP
Protective effect (debatable)
o Regular physical exercise
o Increase fiber
Prevention/screening for CRC
Average risk
o No hx or Fhx of CA colon or
o No 1st degree relative with CA colon or
o One 1st degree relative dx CA colon at age >60 years
o Px: Screening colonoscopy once at 50 years (gov: FOBT with FIT)
Moderate risk
o One 1st degree relative dx CA colon age <60
o Two 1st degree relative dx CA colon at any age
o Px: 5 yearly colonoscopy from age 40 / 10 years prior to dx of youngest relative
High risk
o Fam hx of FAP/HNPCC/other polyposis syndrome
o Px: Regular screening, every 1-2 years
Screening methods
Fecal occult blood (annual or biennial)
o Guaiac test based on pseudoperoxidase activity of hematin
16% reduction in mortality
Sensitivity 40%
3 samples collected (may not continuously bleed)
Dietary restriction: red meat, vitamin C (reducing agent – false-ve)
Qualitative test
Detect upper AND lower GI bleed
o Immunochemical test (FIT)
Antibodies to detect human hemoglobin
Quantitative test
If upper GI bleed: small bowel digestion will NOT detect intact Hb
If +ve = suggests lower GI bleed
Flexible sigmoidoscopy +/- double contrast Ba enema
MBBS V Surgery – Colorectal CA (tutorial)
o Advantage: Only food enema bowel prep and no sedation
o Disadvantage: not whole colon (need double Ba enema = need bowel prep)
o Every 5 years
o Accuracy of detecting colonic polyp >1cm = that of colonoscopy
o Need to be confirmed with colonoscopy and biopsy if +ve
o Need sphincter continence (not in very old patients: cannot hold air/contrast
for enema sub-optimal results)
o Appearance
Apple core: common GI malignancy
Pedunculated mass
Colonoscopy
o Diagnostic AND therapeutic (SNARE of polyp)
o Requires full bowel prep (PEG x3)
o Need sedation (IV diazemul/benzodiazepine, IV pethidine)
Antidote benzo: flumazenil
Antidote opioid: naloxone
o Risk:
Bleeding
Perforation (1/1000)
Delayed perforation – transmural necrosis after polypectomy –
intervened with clip of mucosal defect
Sedation overflow (respi depression) requires monitoring
CT colonoscopy
o Indication
Synchronous tumour
o Only diagnostic
o Full bowel preparation
Colonoscopy
Position: left lateral position
Confirm end site:
o See ileo-cecal valve
o Intubate terminal ileum (see terminal ileum = small bowel nodula mucosa)
Monitoring CEA (carcinoembryonic antigen)
Glycoprotein in cell membranes
Elevated:
o Chronic smoker
o CA lung, stomach, breast, ovary, prostate, bladder, kidney, H&N
Use
o Follow-up in CRC patients (NOT for screening) dx relapse
Non-smoker <4.7; Smoker <6.5 (depending on reference)
Investigations
Confirm dx
o Endoscopy + biopsy
o CT colonoscopy
Assess fitness for operation + complications of disease
o CBC
o LFT, RFT, CEA
MBBS V Surgery – Colorectal CA (tutorial)
Staging dx
o CT thorax, abdomen + pelvis with contrast
o PET (if CT is equivocal for any dissemination)
Duke’s staging (old staging method) (A: early, B: muscle, C: LN, D: distant)
A: lesion not penetrating submucosa
B1: lesion not through muscularis propria
B2: lesion through intestinal wall, no adjacent organ involvement
B3: lesion involve adjacent organ
C1: B1 + LN met
C2: B2 + LN met
C3: B3 + LN met
D: distant met
TNM staging
Stage II: no LN involvement
Stage III: LN involvement, requires adjuvant chemo, prognosis (relapse, survival)
Prognosis of 5 year survival
Stage I: 80-95%
Stage II: 55-80% (heterogeneous spectrum)
Stage III: 40% (requires adjuvant chemo)
Stage IV: 10%
Spread of tumour
Direct spread
o +/- fistulation (colo-vesico fistula risk of urosepsis)
Lymphatic
o Pericolic LN
o Regional LN
o Para-aortic LN (usually not removed)
Blood borne
MBBS V Surgery – Colorectal CA (tutorial)
o Hepatic (porto-venous circulation) (most common liver met)
o Pulmonary (systemic circulation)
Transcoelomic:
o Peritoneal (carcinomatosis)
o Ovaries (Krukenberg tumour)
Management
Surgical resection
o Location of tumour
Surgical resection of involved segment restoration of GI continuity
by anastomosis
Except in APR: very low CA rectum/sphincter involved CA anus
o Elective/emergency (obstructing tumour/perforation)
Cannot create pneumoperitoneum since in IO edema open
Fecal peritonitis/shock open
o Open/laparoscopic
o Patient’s condition
Adjuvant treatment by oncology
o Chemotherapy
High risk stage II:
Lymphovascular involvement
Poor differentiation
Emergency (perforation/obstruction)
Inadequate number of LN resected (>12 required)
Stage III
Stage IV
o Targeted therapy
Surgical approach
o Elective: resection + anastomosis (except low lying/sphincter rectum)
Low residue diet (smaller lumen: higher risk of IO)
Fluid diet day before OT
Bowel prep with PEG night before
Antibiotic: Cefuroxime, Metronidazole (Gram –ve, anaerobes)
Injection of dye during CLN for small tumour
Polypectomy: to stain serosa
o Emergency: usually IO and hopefully clear tumour
Right side colon: better blood supply
Resection + ileocolic anastomosis
o Usually ileocolic anastomosis has better healing
o One stage anastomosis
Left side: to relieve IO and cut both sides (poorer blood supply due
to one main artery, no bowel prep, hence usu. need stoma)
Resection + stoma (end/double barrel)
o End stoma: Hartmann
o Double barrel stoma: both ends of colon long enough
Resection + on table lavage + primary anastomosis +
covering stoma (if good conditions; on table lavage = Foley at
appendix use normal saline to clean the bowel)
Unfavourable patient conditions
o Dehydrated
o Bowel edema (from IO)
MBBS V Surgery – Colorectal CA (tutorial)
o Shock
o No bowel prep (different right and left side)
Inoperable (usually uncommon since imaging is available)
Indications
o Carcinomatosis
o Retroperitoneal mets/iliac met (invaded to life-
threatening structures)
Proximal diversion (for distal tumour) or ileocolic bypass
o Loop stoma: proximal diversion at transverse colon (CA
sigmoid/distal tumour)
o Ileo-colic bypass (right side tumour) (loop ileostomy
will be of too high output, no stoma = better QoL)
Colonic stenting
X-ray controlled: self-expandable metallic stent at IO site
Marker to be identified by X-ray
o Distal descending tumour from dilated bowel
o Indentation site = site of tumour (should be central)
o Slowly expand over time clinical assessment: any
flatus, abdominal distention decrease
Follow-up:
o If not disseminated can arrange elective op (after
edema subside due to IO) (no need to be GA twice, one
stage operation will be more feasible)
o If metastasis/frail palliative
Types of colectomy
o Right hemicoletomy: one stage (primary anastomosis)
o Left hemicolectomy: two stage (end colostomy + rectal stump)
o Transverse colectomy: three stage (rare)
o Hartman’s operation: emergency usually
o Subtotal colectomy
o Anterior resection +/- J pouch
Staged operations
o One stage: elective procedure (immediate restore GI continuity)
o Two stage: e.g. Hartman: resect tumour and stoma + reversion of stoma
o Three stage: Colostomy + stoma + reverse stoma
XR: risk of closed loop obstruction (competent ileo-cecal valve) = more URGENT
Dilated large bowel = large bowel obstruction
No small bowel dilatation
May present with bowel ischemia + perforation
No perforation
Vs incompetent ileo-cecal valve (diff S/S)
Usually present with vomiting, abd. distention
Emergency IO operation
MBBS V Surgery – Colorectal CA (tutorial)
Identify transition between distended bowel vs collapsed bowel: pathology
No ischemia
No perforation
No serosal tear
Decompress bowel by suction
Handle with care
Metastasis (usually perform PET scan to exclude multiple/disseminated disease)
Hepatic (portal venous circulation)
o Resection: hepatectomy
o Radiofrequency ablation (RFA)
o Chemotherapy
Pulmonary (systemic circulation)
o Resection: lobectomy
o Chemotherapy
Chemotherapy
5-Fluorouracil (5-FU)
Folinic acid
Oxaliplatin – FOLFOX
Irinotecan – FOLFIRI
Capecitabine – Xeloda (oral drug) – converted into 5-FU
Target therapy (for mets disease)
VEGF (vascular endothelial growth factor): Bevacizumab
EGFR (epidermal growth factor receptor): Cetuximab
Radi-collaboration project in HK
CT thorax, abdomen + pelvis to private for free
