Colorectal cancer

Definition, diagnosis, staging , and treatment

Colon tumors remain one of the more common reasons for abdominal surgery.

Adenocarcinoma of the colon is still the most common histology requiring operative intervention.

Risk Factors

Asymptomatic until large in size.

Usually present with a tumor complication (eg, bowel obstruction, bleeding, perforation, or fistula formation) weight loss, anemia and weakness from chronic blood loss, flatulence, or episodes of colicky abdominal pain. Most are at stage IV at time of presentation, with distant metastasis

Presentation

Right Side of Colon:

Heme positive- brown stool Chronic anemia ( hypochromic, iron deficiency) in elderly. Liquid or semisolid stool large size before they cause an obstruction.

Presentation

Left Side of Colon ,sigmoid, rectum:

Obstruction symptoms ,Narrowing of stool caliber Bloody bowel movement. Endocarditis by Strep. Bovis and Clostridium Septicum . The more distal a lesion, the more likely the changes in bowel habits occur: rectal bleeding ,mucous discharge in or with the stool, sudden onset of constipation, alternating periods of diarrhea and constipation. Pelvic or anal pain :increasing size, perforation, or sphincter invasion of a rectal cancer.

Presentation

DDx:

Obstructive symptoms:
chronic diverticulitis benign polyps Crohn's disease Endometriosis postischemic stricture
Even if one of these benign diseases is found on clinical evaluation, the symptoms should not be attributed automatically to them before a malignant disease of the large intestine has been ruled out.

Fistula :

Bleeding per rectum :

complicated diverticulitis Crohn's disease tuberculosis.

hemorrhoids and other benign anorectal conditions diverticular disease arteriovenous malformations Endometriosis proctitis or colitis.

Presentation

Screening for colorectal cancer is clearly effective in reducing the overall mortality . Ideal disease for screening (precancerous phase is long).
Incidence in a slow decline over the past 1015 years(increased screening programs )

Screening

Nonhereditary Colon Cancer

SPORADIC COLON CANCER
Colon cancer arising in individuals without a family history

60% of all colorectal cancers

older than 50 years.

Etiology

Nonhereditary Colon Cancer

FAMILIAL COLON CANCER
2nd most common (2530%).
In affected families, develops too frequently to be considered a sporadic colon cancer, but the pattern is not consistent with the known inherited syndromes. APC germline mutation

Etiology

Hereditary Colon Cancer

FAMILIAL ADENOMATOUS POLYPOSIS
AD , with near-complete penetrance. Offspring of affected individuals thus have a 50% risk of inheriting FAP. 20% of patients with FAP are new mutations without a family history. Variants of the polyposis syndrome: Gardener's syndrome (ie, osteomas, desmoid tumors, thyroid neoplasms, and congenital hypertrophy of the retinal pigment epithelium) Turcot's syndrome (ie, brain tumors).

Etiology

Hereditary Colon Cancer FAMILIAL ADENOMATOUS POLYPOSIS

FAP and its variants accounts for less than 1% of all colon cancers. greater than 100 and often several thousands of adenomatous intestinal polyps that start to develop in the late teens and early twenties and turn into cancer by age 4045. Carcinoma arising in the antrum and duodenum after colectomy is the main cause of cancer-related deaths in FAP patients.

Etiology

Hereditary Colon Cancer

FAMILIAL ADENOMATOUS POLYPOSIS
Nonadenomatous fundic gastric polyps: (1030% of patients with FAP, no malignant potential). 10% develop desmoid tumors (fibromatous lesions consisting of large proliferation of myofibroblasts. do not necessarily carry features of a malignant lesion, low-grade sarcoma-like behavior, lethal in 10% , 3rd most frequent cause for mortality of FAP patients, mainly owing to the intraabdominal variants, which cause small bowel and ureteral obstructions) either intra-abdominally or on the abdominal wall, extremities, and trunk. 25% remain without an identified APC mutation (APC-negative) :
lower polyp number later age at diagnosis lower occurrence of extracolonic manifestations

This variant of FAP is known as attenuated familial adenomatous polyposis (AFAP).

Etiology

Hereditary Colon Cancer

HEREDITARY NONPOLYPOSIS COLON CANCERS Lynch I and II syndromes AD disease ,accounts for 35% of all colorectal cancers. Early onset , predominantly but not exclusively on the right side of the colon. Arise from colonic polyps, but a diffuse polyposis is not present

8085% lifetime risk of colorectal cancer and a 4050% risk of endometrial

Increased risk of developing extracolonic malignancies, such as cancer of the small bowel, stomach, hepatobiliary tract, urinary tract, ovary, and brain.
Lynch I: predominantly colorectal cancer at a young age. Lynchh II: both colorectal and extracolonic cancers.

Etiology

Hereditary Colon Cancer HAMARTOMATOUS POLYPOSIS SYNDROMES RARE

Several clinical syndromes manifest with a polyposis of hamartomatous polyps :
Juvenile polyposis Peutz-Jeghers Syndrome Cowden syndrome Bannayan-Riley-Ruvalcaba syndrome Cronkite-Canada syndrome

varying risks of intestinal and extraintestinal disease increased likelihood of developing intestinal cancer due to immature glandular elements in the hamartomatous polyp.

Etiology

Polyps Categorized along several dimensions, including Size

Character of their attachment to the bowel wall (eg, sessile or pedunculated) Cellular architecture (eg, adenomas, hyperplastic, hamartomas, inflammatory) and histologic appearance (eg, tubulous, tubulovillous, villous) Progression from benign to malignant behavior (eg, benign, dysplastic, cancer)

PATHOLOGY AND STAGING

Polyps Size:
larger mass have a greater volume of neoplastic cells, and hence a higher likelihood of harboring cancer.

PATHOLOGY AND STAGING

Polyps
ATTACHMENT TO BOWEL WALL Main clinical relevance is in the ease of endoscopic removal ( pedunculated). Does not accurately predict the presence versus absence of an invasive malignancy.

PATHOLOGY AND STAGING

Adenomatous Polyps
Any adenomatous polyp should be considered a premalignant lesion and be treated as such.

Invasive carcinoma is present in 5% of all adenomas, but the incidence correlates with the size and type of the adenoma( tubular, intermediate type, villous)
Haggitt classification:
four levels within the polyp describe the degree of cancer invasion into a pedunculated or sessile adenomatous polyp. forms the basis of the management of malignant polyp.

PATHOLOGY AND STAGING

level 0not invasive carcinoma

level 1invasion to the head of the pedunculated polyp level 2invasion to the neck of the pedunculated polyp level 3invasion to the stalk of the pedunculated polyp level 4invasion to the base of the pedunculated polyp. Sessile polyps: All lesions are level 4.

PATHOLOGY AND STAGING

Hamartomatous Polyps
Hyperplastic Polyps
small, sessile mucosal outgrowths, exaggerated crypt architecture. Distal distribution pattern ( rectum and sigmoid) patients older than 60 years at autopsy. well-formed glands and crypts lined by nonneoplastic epithelial cells. Because of their small size, they are generally clinically silent, but large or multiple hyperplastic polyps occasionally can be responsible for gastrointestinal symptoms. Historically, considered benign and not premalignant. The ability of hyperplastic polyps to develop defective mismatch repair genes and foci of microsatellite unstable cancers has been documented however.

PATHOLOGY AND STAGING

 The clinical significance of hyperplastic polyps and serrated adenomas is a topic of emerging importance in the field of colorectal cancer prevention. As with adenomatous polyps, individuals who have a predisposition to developing hyperplastic polyps may be at increased risk for developing colorectal cancer. World Health Organization (WHO) criteria :

(1) at least five histologically diagnosed hyperplastic polyps of which two are greater than 20 mm (2) any number of hyperplastic polyps occurring proximal to the sigmoid colon in someone who has a first-degree relative with hyperplastic polyposis (3) more than 30 hyperplastic polyps of any size that are distributed throughout the colon and rectum.

PATHOLOGY AND STAGING

Inflammatory Polyps
reactive regenerative processes occurring in or next to a damaged epithelium.

most commonly seen in IBD.

Histologically, a combination of distorted crypt architecture in conjunction with granulation tissue and inflammatory infiltrates.

Even though the underlying chronic IBD represents a high risk for colorectal cancer, the inflammatory polyps as such do not carry a malignant potential.
Biopsies in IBD should therefore also include the more flatappearing areas rather than the polyps only.

PATHOLOGY AND STAGING

POLYP TRANSFORMATION
Degree of dysplasia is categorized and reported in three grades. Common terms for polyps include
low-grade dysplasia intermediate-grade dysplasia high-grade dysplasia ( in situ [Tis] adenocarcinoma).

Once there are clear microscopic features of tumor invasion through the muscularis mucosa of the colorectum, an invasive cancer (T1 or greater) is present. This important demarcation is based on the finding that lymphatic vessels are almost never found superficial to the muscularis mucosa. The descriptive terms for invasive cancer include
well-differentiated (grade I) moderately differentiated(grade II) poorly differentiated (grade III) adenocarcinoma.

PATHOLOGY AND STAGING

MANAGEMENT OF COLORECTAL POLYPS

Colonoscopy: The majority of colonic polyps can be removed via colonoscopy.

a polyp may not be resectable due to size, attachment to bowel wall, or other reasons related to the anatomy of the patient or polyp. In these situations, a careful assessment of the risks of surgical resection versus observational management is warranted, as 1218% of these polyps harbor an invasive malignancy. Second, polypectomy may not be reasonable in the presence of innumerable polyps.

colonic cancers invasive to Haggitt's levels 1, 2, and 3 can be adequately treated with polypectomy (2-mm margin), whereas polyps with invasion into Haggitt's level 4 should be treated like a sessile lesion. Sessile Lesions:
If a sessile lesion cannot be snared in one intact piece with a microscopically clear margin of at least 2 mm, or if it demonstrates lymphovascular invasion or deep invasion into level Sm3 (lower third of submucosa) the patient should undergo a formal oncologic resection of the colon.
The approach for an adequately removed lesion with a lesser extent of invasion into the submucosa Sm1 (invasion only into upper third of submucosa), Sm2 (invasion only into upper two-thirds of submucosa)should be individualized based on the risk of a surgery versus the risk of lymph node metastases. It is advisable in any case to tattoo the area of a suspect polyp endoscopically with India Ink for later identification of the site.

PATHOLOGY AND STAGING

Malignant Tumors of the Colon

The vast majority of malignant colon neoplasms are cancers (carcinoma), that is, malignant neoplasms of epithelial origin. adenocarcinoma and its histologic variants are by far the predominant histopathology and account for 9095% of all colorectal malignancies

PATHOLOGY AND STAGING

ADENOCARCINOMA
Most frequent malignancy of the gastrointestinal tract, the fourth most frequently diagnosed malignancy, and the fourth most common cause of cancer-related mortality in the world.

Macroscopically, most colorectal cancers have either a polypoid or an ulcerative-infiltrating appearance, but combinations are frequent.
Adenocarcinoma has a less frequent variant of mucinous adenocarcinoma that includes signet ring cell carcinoma and accounts for approximately 10% of all colorectal cancers. Compared to nonmucinous colon cancers, mucinous carcinomas usually present at a more advanced stage and thus have an overall poorer prognosis.

PATHOLOGY AND STAGING

4555% of colorectal cancers are located in the rectum (1015%) or sigmoid colon (40%) 2535% in the cecum or ascending colon,

whereas the remaining are equally distributed through the rest of the colon.

PATHOLOGY AND STAGING

local growth pattern:

circumferential and transmural invasion through the intestinal wall into the peritoneal cavity or surrounding organ structures. Tumor dissemination:
access to the lymphatic vessels into the locoregional lymph nodes. access to the blood stream as hematogenous metastasis to distant organs. The most common site of blood-borne spread is via the portal venous system to the liver other secondary locations include the lung or, less frequently kidneys, bone, etc. In addition, tumor dissemination can occur by transperitoneal seeding and result in peritoneal carcinomatosis. Following gravity, peritoneal seeds may accumulate in the pelvic cul-de-sac or paracolic gutters where they can grow to a considerable size (Blumer's shelf). About 20% of the patients have evidence of distant metastases (stage IV disease) at the time of presentation.

PATHOLOGY AND STAGING

Nonepithelial Tumors of the Colon

BENIGN NONEPITHELIAL TUMORS
Lipomas and Lipomatous Polyposis
submucosal lesions

develop in the fifth or sixth decade of life

more common in the large than in the small intestine. submucosal lump of adipose tissue that is covered with a normal colonic mucosa. Whereas solitary lipomas tend to occur more frequently on the right side of the colon in the vicinity of the ileocecal valve or the ascending colon, lipomatous polyposis may diffusely involve the entire small and large intestine. generally are asymptomatic but may be found incidentally on colonoscopy. The characteristic appearance is a smooth mass with normal overlying mucosa. The soft nature of the lipoma can be demonstrated by poking the tumor with an endoscopic instrument ("pillow test").

PATHOLOGY AND STAGING

Nonepithelial Tumors of the Colon

BENIGN NONEPITHELIAL TUMORS Lipomas and Lipomatous Polyposis
Occasionally, when lipomas become large enough to protrude into the lumen, they may cause symptoms such as gastrointestinal bleeding, diarrhea, intussusception, or bowel obstruction. Endoscopic removal of such a lipoma with a snare often is possible . Risk of hemorrhage - Surgery may be required if such a complication occurs. Alternatively, the mucosa overlying the lipoma may be opened endoscopically to allow the lipoma to spontaneously enucleate into the lumen

PATHOLOGY AND STAGING

POTENTIALLY MALIGNANT NONEPITHELIAL TUMORS OF THE COLON Carcinoid or Neuroendocrine Tumors

Modern nomenclature classifies carcinoids as neuroendocrine tumors, based on their neuroendocrine origin. subepithelial nests of epithelial-appearing cell elements.

may occur anywhere in the entire body.

A recent study on 11,427 patients from the SEER database found that the gastrointestinal tract is affected in 55%, with the most frequent locations being :
the the the the small intestine (44.7%) rectum (19.6%) appendix (16.7%) colon (10.6%)

Unlike most neoplasms, invasiveness of carcinoid tumors is not entirely based on histological criteria (eg, invasion of muscularis propria) but includes clinical aspects. In absence of other definite indicators for malignant behavior, carcinoids smaller than 1 cm are considered benign, lesions larger than 2 cm are likely malignant, and the gray zone in between remains undetermined or potentially malignant. Malignant carcinoids may spread locoregionally into the lymph nodes or directly to the liver.

PATHOLOGY AND STAGING

Patients with a gastrointestinal carcinoid tumor may be either completely asymptomatic or present with intestinal obstruction, bleeding, carcinoid syndrome, or carcinoid heart disease, that is, acquired and commonly right-sided valvular heart disease.
Vasoactive substances (eg, serotonin and 5-hydroxyindolacetic acid [5-HIAA]) are released from carcinoid tumors but for the most part are eliminated in a hepatic first-pass effect before reaching the systemic circulation. Carcinoid syndrome is therefore a bad prognostic sign because it does not typically develop until metastatic lesions in the liver directly release their products into the systemic circulation. Hindgut carcinoid tumors (those located in the distal transverse colon and beyond) classically do not cause carcinoid syndrome because they are less endocrinologically active. Diagnosis of a carcinoid may be suspected clinically but can be difficult to confirm histologically short of a surgical resection because the lesions are submucosal and not commonly in reach of an endoscopic biopsy. A preoperative workup for a carcinoid tumor should include a 24-hour urine collection of 5HIAA ( 5-hydroxyindolacetic acid) and a plasma chromogranin A. Both parameters can also be used for postoperative surveillance. An oncologic resection should be performed in all carcinoids larger than 2 cm unless contraindicated by clinical circumstances. Tumors of smaller than 1 cm size may be managed locally, whereas the management of lesions measuring 12 cm remains controversial.

PATHOLOGY AND STAGING

POTENTIALLY MALIGNANT NONEPITHELIAL TUMORS OF THE COLON Gastrointestinal Stromal Tumors (GISTs)

most common mesenchymal tumors of the gastrointestinal tracts and originate from the intestinal pacemaker cells, the interstitial cells of Cajal.
60% n the stomach 29% in the small intestine 2% in the colon, rectum, and rectovaginal septum 9% in the esophagus.

Symptoms are nonspecific and include pain, obstruction, bleeding, and a mass. Determination of CD117 expression is of practical importance because positivity correlates with a tumor response to treatment with imatinib (Gleevec). Surgical resection is the primary treatment for localized GISTs that are resectable without mutilation. Recurrent and locally advanced or metastatic tumors are treated increasingly with imatinib in a palliative, adjuvant, or neoadjuvant setting.

PATHOLOGY AND STAGING

POTENTIALLY MALIGNANT NONEPITHELIAL TUMORS OF THE COLON

Nodular Lymphoid Hyperplasia

numerous polyps in the small and large intestine, rarely in the stomach, which consist of enlarged submucosal lymphoid follicles.

Associated diseases are immune deficiencies of various origins (eg, tumors, hematoproliferative disorders, immunoglobulin A deficiency, and human immunodeficiency virus [HIV] infection)
Recurrent infections (eg, giardiasis) appear to promote the nodular lymphoid hyperplasia. Immunocompetent patients usually are asymptomatic, and the nodular lymphoid hyperplasia is an incidental finding. Nodular lymphoid hyperplasia has been associated with an increased subsequent incidence of lymphoma (small bowel).

PATHOLOGY AND STAGING

MALIGNANT NONEPITHELIAL TUMORS OF THE COLON Lymphoma

Primary malignant lymphoma of the colon is uncommon and accounts for only 0.2 0.4% of all colonic malignancies and 1015% of all primary lymphomas of the gastrointestinal tract, which themselves account for about 30% of extranodal lymphomas.

The most frequent colonic location is the cecum (70%), followed by the rectum and ascending colon.

B-cell lymphomas (85%) : mantle cell lymphoma has a worse prognosis, whereas mucosa-associated lymphoid tissue (MALT) lymphomas have a better prognosis T-cell lymphomas (15%).

While surgical treatment may be indicated for some localized tumors, many authors consider medical management to be the primary treatment. It may include new approaches such as anti-infectious treatment for MALT lymphoma or reconstitution of the patient's immune status, for example by means of antiretroviral treatment in HIVassociated B-cell lymphoma.

PATHOLOGY AND STAGING

Kaposi Sarcoma
associated with herpesvirus-8 (HHV-8) infection in conjunction with immunosuppression (eg, HIV/AIDS, chronic steroid or immunosuppressant medication, etc). The incidence in organ transplant recipients is about 0.50.6% but most frequently involves the skin. Extremely rarely, however, the anorectum or intestines are involved and shows characteristic bluish-purple submucosal nodules. Treatment primarily aims at improving the immune status, but chemotherapy and, rarely, radiotherapy may be indicated in patients in whom the immune status cannot be restored.

Smooth Muscle Tumors

rare and occur most commonly in the form of a pedunculated leiomyoma of the muscularis mucosa. Leiomyosarcomas, which consist histologically of spindle cells that resemble smooth muscle cells, are even less frequent but are characterized by an extremely aggressive and rapidly fatal growth pattern. Whenever possible, oncologic resection and adjuvant chemotherapy are the treatment of choice.

PATHOLOGY AND STAGING

SECONDARY TUMORS TO THE COLON

Endometriosis May involve the colon or rectum in approximately 15 20% and may mimic colonic carcinoma. lesions are rarely larger than 5 cm, involve the subserosa and muscle coats, and may project into the lumen of the bowel. When endometrial tissue extends through to the colonic mucosa, biopsy may be mistaken for adenocarcinoma. Invasion from Extracolonic Cancers Locally advanced tumors from noncolonic primary cancers may directly invade the colon and cause symptoms suggestive of colon cancer (bleeding, obstruction, fistula). These tumors originate from organs in close adjacency to the colon (female organs, bladder, prostate, kidneys, pancreas, duodenum, liver).

Metastatic Cancer Carcinomas from other primary sites may metastasize to the colon and occasionally mimic a primary colon cancer.
lobular breast cancer stomach cancer ovarian cancer malignant melanoma Leukemia(can be diagnosed by the hematopoetic infiltrates).

PATHOLOGY AND STAGING

STAGING OF COLON CANCER

Four clinical stages (IIV) based on the TNM (tumor-nodemetastasis) system, which has just recently been updated by the American Joint Committee on Cancer (AJCC)
(1) the depth of tumor invasion (T) into or through the layers of the intestinal wall with or without invasion of adjacent organs (2) the number of regional lymph nodes involved (N) (3) the presence or absence of distant metastases (M).

Independent parameters are

Historical classifications such as Dukes and Astler-Coller are still sporadically in use but largely have been and should be abandoned

PATHOLOGY AND STAGING

PATHOLOGY AND STAGING

PATHOLOGY AND STAGING

Treatment by stage of colon cancer

For colon cancers that have not spread to distant sites, surgery is usually the primary or first treatment. Adjuvant (additional) chemotherapy may also be used. Most adjuvant treatment is given for about 6 months.

Stage 0

Since these cancers have not grown beyond the inner lining of the colon, surgery to take out the cancer is all that is needed.
polypectomy (removing the polyp) local excision through a colonoscope. Colon resection (colectomy) may occasionally be needed if a tumor is too big to be removed by local excision.

Stage I

These cancers have grown through several layers of the colon, but they have not spread outside the colon wall itself (or into the nearby lymph nodes).

Partial colectomy surgery to remove the section of colon that has cancer and nearby lymph nodes is the standard treatment. No need for adjuvant therapy.

TREATMENT BY STAGE /COLON CA

Stage II
Many of these cancers have grown through the wall of the colon and may extend into nearby tissue. They have not yet spread to the lymph nodes.
Surgery (colectomy) may be the only treatment needed. adjuvant chemotherapy if cancer has a higher risk of coming back because of certain factors, such as:
high grade when viewed under a microscope. growth into nearby organs. The surgeon did not remove at least 12 lymph nodes. The cancer had obstructed the colon. perforation in the wall of the colon.

The main options for chemo for this stage include 5-FU and leucovorin (alone) or capecitabine, but other combinations may also be used. In case of inability to remove all of the cancer because it was growing into other tissues,radiation therapy may be advised to try to kill any remaining cancer cells.

TREATMENT BY STAGE /COLON CA

Stage III spread to nearby lymph nodes, but it has not yet spread to other parts of the body.
Surgery (partial colectomy) followed by adjuvant chemo is the standard treatment for this stage.
Either the FOLFOX (5-FU, leucovorin, and oxaliplatin) or CapeOx (capecitabine and oxaliplatin) regimens are used most often, but some patients may get 5-FU with leucovorin or capecitabine alone based on their age and health needs.

radiation therapy if surgeon thinks some cancer cells might have been left behind after surgery. In people where surgery is CI, radiation therapy and/or chemo may be options.

TREATMENT BY STAGE /COLON CA

Stage IV

spread from the colon to distant organs and tissues. Colon cancer most often spreads to the liver, but it can also spread to other places such as the lungs, peritoneum (the lining of the abdominal cavity), or distant lymph nodes.

In most cases surgery is unlikely to cure these cancers. However, if only a few small areas of cancer spread (metastases) are present in the liver or lungs and they can be completely removed along with the colon cancer, surgery may help prolonging life and may even cure . Chemo is typically given as well, before and/or after surgery. In some cases, hepatic artery infusion may be used if the cancer has spread to the liver. If the metastases cannot be surgically removed because they are too large or too many , chemo may be tried first to shrink the tumors to allow for surgery. Chemo would then be given again after surgery. Another option may be to destroy tumors in the liver with cryosurgery, radiofrequency ablation, or other non-surgical methods. If the cancer is too widespread to try to cure it with surgery, operations such as a colectomy or diverting colostomy may still be needed in some cases. This can relieve or prevent blockage of the colon Sometimes, such surgery can be avoided by inserting a stent (a hollow metal or plastic tube) into the colon during colonoscopy to keep it open. For advanced cancers, radiation therapy may also be used to help prevent or relieve symptoms such as pain. While it may shrink tumors for a time, it is very unlikely to result in a cure.

TREATMENT BY STAGE /COLON CA

Recurrent colon cancer

Recurrence may be local (near the area of the initial tumor), or it may affect distant organs. If the cancer comes back locally, surgery (often followed by chemo) can sometimes help . If the cancer can't be removed surgically, chemo may be tried first. If it shrinks the tumor enough, surgery may be an option. This would again be followed by more chemo. If the cancer comes back in a distant site, it is most likely to appear first in the liver. Surgery may be an option in some cases. If not, chemo may be tried first to shrink the tumor(s), which may then be followed by surgery.

If the cancer is too widespread to be treated surgically, chemo and/or targeted therapies may be used Surgery may still be needed at some point to relieve or prevent blockage of the colon and to prevent other local complications. Radiation therapy for symptomatic relief is also a possible option.

TREATMENT BY STAGE /COLON CA

Treatment by stage of rectal cancer

Surgery is usually the main treatment for rectal cancers that have not spread to distant sites. Additional treatment with radiation and chemotherapy (chemo) may also be used before or after surgery. Stage 0
At this stage the cancer has not grown beyond the inner lining of the rectum. Removing or destroying the cancer is all that is needed. Polypectomy(removing the polyp), local excision, or transanal resection and should need no further treatment.

Stage I
In this stage, the cancer has grown through the first layer of the rectum into deeper layers but has not spread outside the wall of the rectum itself. Stage I includes cancers that were part of a polyp. If the polyp is removed completely, with no cancer in the edges, no other treatment may be needed. If the cancer in the polyp was high grade ,or there were cancer cells at the edges of the polyp, more surgery may be advised. More surgery may also be advised if the polyp couldnt be removed completely or if it had to be removed in many pieces, making it hard to see if there was cancer at the edges.

For other stage I cancers, surgery is usually the main treatment.

Either a low anterior resection (LAR), proctectomy with colo-anal anastomosis, or an abdominoperineal resection (APR) may be done, depending on exactly where the cancer is found within the rectum . Adjuvant therapy is not needed after these operations, unless the surgeon finds the cancer is more advanced than was thought before surgery. If it is more advanced, a combination of chemo and radiation therapy is usually given.

TREATMENT BY STAGE/RECTAL CA

For some small T1 stage I rectal cancers, another option may be removing them through the anus without an abdominal incision (transanal resection or transanal endoscopic microsurgery).
If the tumor turns out to have high-risk features (such as a worrisome appearance under the microscope or if cancer is found at the edges of the removed specimen), another surgery, such as those used to treat stage II cancers, may be advised. In some cases, adjuvant chemoradiation (treatment with radiation and chemo together) is advised for patients having such surgery. 5-FU is the chemo drug most often used. If surgery is CI:
endocavitary radiation therapy (radiation given using a device placed into the rectum through the anus) brachytherapy (placing radioactive pellets directly into the cancer). However, this has not been proven to be as effective as surgery.

TREATMENT BY STAGE/ RECTAL CA

Stage II

Many of these cancers have grown through the wall of the rectum and may extend into nearby tissues. They have not yet spread to the lymph nodes.

surgery such as a LAR, proctectomy with colo-anal anastomosis, or APR(abdominoperineal resection), (depending on where the cancer is in the rectum), along with both chemo and radiation therapy. Most doctors now favor giving the radiation therapy along with chemo before surgery (neoadjuvant treatment), and then giving adjuvant chemo after surgery, usually for a total of 6 months of treatment). The chemo given with radiation is usually either 5-FU or capecitabine (Xeloda). The chemo after surgery may be the FOLFOX regimen (oxaliplatin, 5-FU, and leucovorin), 5-FU and leucovorin, CapeOx (capecitabine plus oxaliplatin) or capecitabine alone. If neoadjuvant therapy shrinks the tumor enough, sometimes a transanal full-thickness rectal resection can be done instead of a more invasive low anterior resection or abdominoperineal resection. This may allow the patient to avoid a colostomy. A problem with using this procedure is that it doesn't allow the surgeon to see if the cancer has spread to lymph nodes or further in the pelvis. For this reason, the procedure generally isn't recommended.

TREATMENT BY STAGE/RECTAL CA

Stage III

These cancers have spread to nearby lymph nodes but not to other parts of the body. Most often, radiation therapy is given along with chemo before surgery (called chemoradiation). This may shrink the cancer, often making surgery more effective for larger tumors. It also lowers the chance of recurrence.

Giving radiation before surgery also tends to lead to fewer problems than giving it after surgery. The rectal tumor and nearby lymph nodes are then removed, usually by low anterior resection, proctectomy with colo-anal anastomosis, or abdominoperineal resection, depending on where the cancer is in the rectum.
In rare cases where the cancer has reached nearby organs, a pelvic exenteration may be needed. Radiation therapy and chemo are usually part of treatment as well. As in stage II, many doctors now prefer to give the radiation therapy along with chemo before surgery because it lowers the chance that the cancer will come back in the pelvis and has fewer complications than radiation given after surgery. This treatment may also make surgery more effective for larger tumors. After surgery, chemo is given, usually for about 6 months. Sometimes, this chemo is also given before the chemoradiation and surgery.

TREATMENT BY STAGE/RECTAL CA

Stage IV The cancer has spread to distant organs and tissues such as the liver or lungs. Treatment options for stage IV disease depend to some extent on how widespread the cancer is.

If there's a chance that all of the cancer can be removed (for example, there are only a few tumors in the liver or lungs), treatment options include:
Surgery to remove the rectal lesion and distant tumors, followed by chemo (and radiation therapy in some cases) Chemo, followed by surgery to remove the rectal lesion and distant tumors, usually followed by more chemo and radiation therapy Chemo and radiation therapy, followed by surgery to remove the rectal lesion and distant tumors, followed by more chemo

Surgery to remove the rectal tumor would usually be a low anterior resection, proctectomy with colo-anal anastomosis, or abdominoperineal (AP) resection, depending on where it's located. If the only site of cancer spread is the liver, chemo given directly into the artery leading to the liver (hepatic artery infusion). This may shrink the cancers in the liver more effectively than if the chemo is given intravenously or by mouth. If the cancer is more widespread and can't be completely removed by surgery, treatment options may depend on whether the cancer is causing a blockage of the intestine. If it is, surgery may be needed right away. If not, the cancer will likely be treated with chemo.

TREATMENT BY STAGE/RECTAL CA

Recurrent rectal cancer

Recurrent cancer means that the cancer has returned after treatment. It may come back locally or in distant organs, like the lungs or liver. If the cancer does recur, it is usually in the first 2 to 3 years after surgery. If the cancer comes back locally (in the pelvis), it is treated with surgery to remove the cancer, if it is possible. This surgery is often more extensive than the initial surgery. In some cases radiation therapy may be given during the surgery (intraoperative radiotherapy) or afterward. Chemo may also be given (as well as radiation therapy aimed at the tumor if it was not used before). If the cancer comes back in a distant site, treatment depends on whether it can be removed (resected) by surgery. If the cancer can be removed, surgery is done. Neoadjuvant chemo may be given before surgery .Chemo is then given after surgery as well. When the cancer is in the liver, chemo may be given through the hepatic artery leading to the liver. If the cancer can't be removed by surgery, chemo is usually the first option. The regimen used will depend on what a person has received previously and on their overall health. Surgery may be an option if the cancer shrinks enough. This would be followed by more chemo. If the cancer doesn't shrink with chemo, a different drug combination may be tried. As with stage IV cancer, surgery or other approaches may be used at some point to relieve symptoms and avoid long-term complications such as bleeding or blockage of the intestines.

TREATMENT BY STAGE/ RECTAL CA

Definitions of where the sigmoid colon ends and the rectum begins have not always been uniform. The best definition of the rectosigmoid junction from a functional as well as surgical viewpoint is the confluence of the teniae coli.
However, the inability to visualize this anatomic reference point endoscopically recently led the NCI and other expert committees to define the rectum for the purpose of uniformity in clinical trials as the last 1215 cm above the anal verge as measured by rigid sigmoidoscopy. Arterial blood supply to the colon:
superior mesenteric artery (SMA) inferior mesenteric artery (IMA) which communicate in a watershed area in the splenic flexure (artery of Drummond)

The rectum has additional branches from the internal iliac vessels.

SURGICAL ANATOMY OF THE COLON

With a significant degree of anatomic variation, the major vascular stalks to the colonic segments consist of
ileocecal and right colic artery (last branch of the SMA) the middle colic artery (second branch of the SMA) the left colic artery (first branch of the IMA) superior hemorrhoidal artery (distal branch of the IMA).

venous blood supply :

peripherally follows the arterial branches more centrally divides into the superior mesenteric vein and the inferior mesenteric vein, which connect at separate levels to the portal system.

Lymphatic drainage: lymphatic follicles in the colonic submucosa>colonic muscle wall>epicolic nodes> paracolic lymph nodes(follow the blood vessels to the bowel) > along the major arteries to the principal lymph nodes at the level of the arterial runoff from the aorta. These lymph node groups consist of the celiac, the superior mesenteric, and the inferior mesenteric groups of lymph nodes.

SURGICAL ANATOMY OF THE COLON

The colon is only a partially intraperitoneal organ. Only the transverse colon and the sigmoid colon are fully peritonealized and have a free mesocolon.
structures most at risk :
1-during a right hemicolectomy :right ureter and the duodenum 2-during a transverse colon resection: the SMA/SMV (and its branches) and the gastroepiploic vessels at the gastric curvature. During a takedown of the splenic flexure, the spleen, pancreas, and left kidney During a left colon or sigmoid resection: the left ureter, the gonadal vessels, and the hypogastric nerves.

SURGICAL ANATOMY OF THE COLON

Principles of Surgical Management

Goals:

achieve cure , extension of survival or at least disease-free survival In the case of a precursor pathology with or without an underlying disease (eg, ulcerative colitis or FAP), to prevent the cancer and ideally to remove the risk-bearing disease. In a palliative setting, the goal is to prolong the period of symptom-free survival.

Local tumor control generally is the primary treatment objective to prevent local tumor complications, that is, obstruction, perforation, fistula formation, bleeding, and pain.
Even in the presence of distant metastases in the liver or lung, resection of the primary tumor remains a reasonable priority. Because solitary or a limited number of metastases in the liver or lung often may be treated surgically by partial organ resection or metastasectomy with a cure rate of up to 35%, their presence should not necessarily alter the surgical approach to do a curative resection at the primary site.

Surgery

PREPARATION FOR SURGERY

Transfusion Bowel cleansing Antibiotic Prophylaxis Thromboembolic Prophylaxis Urinary Catheters/Stents Nasogastric Tube Placement of a nasogastric tube is not necessary on a routine basis for patients undergoing resection of the colon or rectum and should be avoided unless they present with a complete or partial bowel obstruction). Preemptive Pain Management Effective pain management is an important factor not just for patient comfort but to reduce the incidence of postoperative pulmonary complications

Surgery

GENERAL TECHNICAL PRINCIPLES

Removing the cancerous segment of colon, the mesentery with the primary feeding vessel and the lymphatics, and any organ with direct tumor involvement. Because the lymphatics run with the arterial supply of the colon, the primary artery supplying the segment of the colon to be resected is divided at its origin. Ligation at the origin of the vessel ensures inclusion of apical nodes, which may convey prognostic significance for the patient.

Surgery

The length of bowel and mesentery resected is dictated by tumor location and distribution of the primary artery, but a radical resection of a colonic tumor should achieve at least a 5-cm clearance at the proximal and distal margin. tumors located in "border zones" should be resected with both neighboring lymphatics to encompass possible bidirectional spread. If a tumor is adherent to or invading an adjacent organ such as the kidney or small bowel, an en bloc resection should be performed

Surgery

When synchronous cancers are present in the colon, an extended resection or even total colectomy, with ideally only one anastomosis, should be performed.
Occasionally, two separate resections (eg, right hemicolectomy and low anterior resection) with two anastomoses are preferable to preserve colon length and to avoid postcolectomy diarrhea. Cancer on the basis of an underlying pancolonic disease (eg, ulcerative colitis or FAP) requires a total proctocolectomy with either an ileoanal pull-through procedure or an ileostomy

A limited wedge resection may be considered for an unfit patient or for palliative resection in those with widespread tumor. This will relieve the patient's symptoms and prevent future obstruction and bleeding from the primary tumor.

Surgery

INTRAOPERATIVE SURGICAL TECHNIQUE Positioning

left-sided colonic resections: modified lithotomy position, which gives access to the anus (eg, for a stapled anastomosis) and allows an assistant or the surgeon to stand between the legs for retraction or an excellent view to mobilize the splenic flexure, respectively. The same positioning obviously also can be used for all other colon resections, but a supine position usually is sufficient and faster. Laparoscopic procedures typically require the operating table to be tilted and moved to steep Trendelenburg's position; appropriate fixation and securing of the patient is therefore mandatory.

Surgery

Incision

open procedure: the peritoneal cavity is most commonly entered through a midline laparotomy incision. Proctocolectomy: infraumbilical incision in order to provide good exposure for the pelvic dissection. more proximal segmental colon resection: short but higher midline incision may be more convenient. Right Hemicolectomy : transverse incision or a subcostal incision For a laparoscopic procedure, a first camera trocar is placed in either Veress needle or in open Hasson technique. The site should be chosen such that additional working ports can be placed along a circle with the target in the center.

Surgery

Exploration

abdomen is explored systematically to determine the resectability of the tumor. Special attention is addressed to the presence of distant metastases in the liver, peritoneal carcinomatosis, or additional synchronous lesions throughout the large intestine. Other accessible organ systems are assessed equally, for example the gallbladder and the female reproductive organs.

Surgery

careful exploration of the abdomen mobilization of the colon starts on the right side. On the right side, the ureter is at fairly low risk and routinely falls away; however, special care is needed to avoid damage to the third part of the duodenum.

Surgery

the colon is mobilized completely from its retroperitoneal attachments from the terminal ileum to the upper rectum. Elevation of the colon allows identification of all primary feeding vessels. Before transsection and ligature of the vessels, the remote location of the ureter is confirmed .

it is advisable to place preoperative ureteral stents to allow better identification.

The whole vascular stalk may be ligated.

Surgery

Once the vessels have been ligated, the bowel may be divided by means of cutting linear stapling devices at the previously determined levels.
Intraoperative frozen sections of the resection margins should be requested whenever there is any doubt about the completeness of the resection.

Surgery

Reconstruction/Diversion

After the resection has been completed, either the bowel ends can be reanastomosed or the proximal end may be brought out as an ostomy.

Prerequisites for a successful anastomosis are meticulous technique, well-vascularized and healthy appearing tissues, apposition of bowel ends without any tension, and good nutritional status of the patient with an albumin level greater than 3.0 mg/dL. Constructing an anastomosis under tension and/or with poor blood supply increases the risk of an anastomotic leak that may cause an infection and sepsis.

Surgery

Drains

Placement of drains is more often a matter of personal preference than of scientific objectiveness. Most bowel anastomoses, even colocolonic anastomoses, do not need to be drained. The use of drains generally may be recommended when a pelvic dissection and anastomosis have been performed and accumulation of fluid and blood in the dependent areas around the anastomosis should be avoided.

SURGERY