2. More than 1 million people get colorectal cancer every year.
Colorectal cancer is the second most common cause of cancer
in women and the third most common in men.
It is the fourth most common cause of cancer death
after lung, stomach, and liver cancer.
It is more common in developed than developing countries.
Epidemiology of colorectal cancer
3. What Are the Risk Factors
for Colorectal Cancer?
Polyps (a noncancerous or precancerous growth associated with aging).
Age >50 (average risk).
Inflammatory bowel disease – chronic ulcerative colitis, Crohn’s disease.
Diet high in saturated fats, such as red meat.
Personal or family history of cancer colon.
HNPCC – Lynch syndrome I, II
Polyposis syndromes – FAP, Gardner’s syndrome, Turcot’s syndrome,
juvenile polyposis.
Obesity.
Smoking.
5. What Are the Symptoms
of Colorectal Cancer?
Symptoms could include:
A change in bowel movements (diarrhea, constipation, never feeling
“relieved”, narrower stools).
Blood in the stool (dark red).
Abdominal discomfort.
Loss of appetite.
Weight loss for no known reason.
Constant fatigue.
Nausea and vomiting.
Many people have no symptoms.
6. Staging is a way of describing a cancer, such as the depth of the tumor
and where it has spread.
Staging is the most important tool to determine patient’s prognosis
and the protocol of treatment.
The colon cancer staging can be made according to the TNM staging
system from the WHO organization, the UICC and the AJCC.
The Astler-Coller classification (1954) or the Dukes classification
(1932) are now less used.
Staging of Colorectal Cancer
7. Staging of Colorectal Cancer
Cancer
is in the
mucosa
Invasion of
muscularis
mucosa Beyond the
muscularis
mucosa
Spread to the
regional LN
8. What is the decision in the
following situations with
cancer colon ?
9. Polypectomy
Colonic Polyp with invasive cancer
Single specimen
Completely removed
Free margins
Fragmented spicemen
Involved margins
Unfavorable
histological features
Colectomy
Sessile Pedunculated
Follow up
Follow up Colectomy
Adjuvant therapy and surveillance according to pathological stage
10. Non metastatic cancer colon
Resectable
(non obstructing)
Locally
unresectable
Colectomy Colectomy Diversion
Adjuvant therapy and surveillance according to pathological stage
Resectable
(obstructing)
Resection
+
diversion
Stent Chemotherapy
Colectomy
11. Pathologicalstagedetermineadjuvanttherapyand surveillance
Tis, T1, N0, M0
T2, N0, M0
No Adjuvant therapy Surveillance by
Colonscopy in 1y
Advanced adenoma
Repeat in 1 y
No Advanced adenoma
Repeat in 3 y
T3, N0, M0
(no high risk features)
Advanced
No advanced
T3, N0, M0
(high risk for recurrence)
T4, N0, M0
Observe
Adjuvant therapy
(5FU/Leucovorin)
EX + CEA 3-6 m for 2y
6m for 5 years
PACT annually
PET CT not routinely recommended
Colonoscopy in
one year
T1-3, N1-2, M0
or T4, N1-2, M0
Adjuvant therapy
Adjuvant therapy
(5FU/Leucovorin)
Observe
12. Metastatic synchronous adenocarcinoma
Synchronous unresectable
metastasis of other sites
than liver, lung or
abdominal
Obstructing Resectable
ChemotherapyResection or diversion
or bypass or stenting
Synchronous
abdominal/Peritoneal
metastasis
Synchronous liver and
lung only
Chemotherapy
Non
Obstructing
UnresectableChemotherapy
13. Synchrouons or
staged colectomy
with liver or lung
resection
Resectable Unresectable
Neoadjuvant
synchrounous or
staged colectomy with
liver or lung resection
Observation or
shortened course
chemotherapy
Colectomy
chemotherapy
staged resection of
metastatic ds
Observation or
shortened course
chemotherapy
Conversion therapy
Colon resection only
ObstructionBleeding
Re-evaluate for conversion
Every 2 months
Remained unresectable
↓
Chemotherapy
Conversion
↓
Synchronized or staged resection of colon and metastatic cancer
↓
Chemotherapy
Adjuvant therapy
(Folfox is preferred)
Synchronous liver and lung only
14. DocumentedMetachronousmetastasisbyCt, MRI,anda biopsy
Resectable
Previous adj.
therapy< 12m
Conversion therapy
Unresectable
Active
chemotherapy
No previous
Adj. therapy
Confirm by
PET-CT
No pervious
chemotherapy
Pervious
chemotherapy
Neoadjuvant Resection
Resection Resection
Previous adj.
therapy> 12m
Active chemotherapy
Reevaluate for conversion
every 2 months
Conversion
Resection
Active chemotherapy
No Conversion
Neoadj. chemo
15. What is the decision in the
following situations with
rectal cancer ?
17. Free margins High risk features or T2
Observe
T1-2, N0, Mo T3-4 , N0, M0
or
T1-4, N1-2
Transanal excision
Adjuvant
therapy
Observe
Transabdominal resection
18. Clinical stage
Rectal cancerappropriate for resection
T1-2, N0
Mentioned
before
Tranabdominal resection If resection
contraindicated
Chemotherapy
Adjuvant therapy
T3, N0
or
any T, N1-2 or T4 or
locally unresctable
Neoadjuvant chemo / RT
20. Documentedmetachrounsmetastasis
Resectable Unresectable
Confirm by PET-CT
No pervious chemo Pervious chemo
Conversion
Resection
Active chemotherapy
Conversion therapy
Reevaluate every 2 m
No
conversion
Active chemotherapy
Resection
Adjvant
therapy
(folfox)
Neoadj.
chemotherapy
Resection
Neoadj.
chemotherapy
Resection
Resection
Active chemotherapy
22. General principles for rectal
Cancer resection
Local excision is the golden role in early stages (cT1 sm1/2).
Transanal endoscopic microsurgery (TEM) is the standard procedure, if local
excision is chosen.
Partial mesorectal excision is adequate for rectal cancer localized in the upper
third of the rectum (>10–15 cm from anal verge).
Abdomino perineal resection (APR) is the preferred surgical approach in case
of tumour involvement of the anorectal junction and anal sphincter or as
salvage of local failures after local excision.
Laparoscopic surgery might reveal equivalent results in terms of function and
relapse rate, compared with open surgery.
23. Take home message
Patients with colorectal cancer should be staged and treated in a centre of
experience.
Treatment strategy has to be decided by a multi-disciplinary team (MDT) before
treatment is started.
Multidisciplinary team of CRC should involve (Surgical Oncologist, Medical
Oncologist, Radiation Oncologist, Radiologist, Pathologist, Oncology Nurse
Specialist, Social Worker, Nutritionist, Patient Navigator, Pharmacist)
specialists.
Patients should be classified according to clinical stage TNM, involvement of
MRF, size, level and localization. Other factors, such as cN stage, and vascular
and nerve invasion are also relevant.