Maj Ajay Kumar

Resident Surgery

TOPIC
SURGICAL ANATOMY
EPIDEMIOLOGY
RISK FACTORS
MOLECULAR BIOLOGY
PATHOLOGY
CLINICAL PRESENTATION
MANAGEMENT
SCREENING & PREVENTION

Surgical Anatomy

Arterial

Venous

Lymphatic

One of the most common malignancy in the western

world after age of 50
In US:-3th most common in men (after lung and prostate )
and women (after breast and lung)
2nd most common cause of death(after lung cancer)

INDIA
Urban

Male- 1.5 to 6.9 /100,000

Female- 2.5 to 7.4 /100,000

Rural

Male-1.6 to 2.4 /100,000

Female- 1.1 to 1.3 /100,000

National Cancer Registry Programme (ICMR) for Population based cancer

registries for the years 2004-05

AGE: >50
GENDER: M>F
RACE/ETHNICITY: Western country
GENETIC FACTOR: FAP(100%)

HNPCC(80%) (Lynch Syndrome)

ADENOMATOUS POLYP: Premalignant(Type and size)
PERSONAL or FAMILY HISTORY of colorectal cancer or

colorectal polyp

LIFE STYLE FACTORS: Fat(Total and Animal)

Low fibre
Obesity and sedantary
INFLAMATORY BOWEL DISEASE:
UC- 3.5% >> Duration( 25% at 25 years, 65% at 40 years)
>>Pancolic disease
>>Active
>>Inflammation
CD- High grade dysplasia
Bypassed segment
Wu JS, Fazio VW, 2000

FAMILIAL SETTING
General U.S. population
One first-degree relative* with colon
cancer

APPROXIMATE LIFETIME RISK OF

COLON CANCER
6%
Two- to threefold increased

Two first-degree relatives* with colon

cancer

Three- to fourfold increased

First-degree relative* with colon cancer

diagnosed 50 yr

Three- to fourfold increased

One second- or third-degree

relative,with colon cancer

1.5-fold increased

Two second- or third-degree

relatives,with colon cancer

Two- to threefold increased

One first-degree relative* with

adenomatous polyp

Twofold increased

From Burt RW: Colon cancer screening. Gastroenterology 119:837853, 2000

Fearon-Vogelstein adenoma-carcinoma multistep model

Larger size : Tubular <1cm --<5% Villous >2cm 50%

Residual benign tissue

Observation of Polyp progressing to malignancy
Concurrent polyp in patient of Ca colon

Decrease chance of developing Cancer after Polypectomy

FAP>> 100% risk
Peak incidence : Polyp- 50 years

: Cancer- 60 years

MUTATION TYPE

GENES INVOLVED

TYPE OF DISEASE CAUSED

Germline

APC

Familial adenomatous polyposis

MMR

HNPCC (Lynch syndrome)

Somatic

1.Oncogenes:
2.myc
3.ras
4.src
5.erbB

Sporadic disease

1.Tumor suppressor genes:

2.TP53
3.DCC
4.APC
1.MMR genes:
2.bMSH2
3.bMLH1
4.bPMS1
5.bPMS2
6.bMSH6
7.bMSH3

Genetic polymorphism
DCC, Deleted in colorectal carcinoma.

APC

Familial colon cancer in Ashkenazi

Jews

Class
Inflammatory
Metaplastic
Harmartomatous
Neoplastic

Varieties
Inflammatory polyps
Metaplastic or hyperplastic polyps
PeutzJeghers polyp Juvenile polyp
Adenoma
Tubular
Sessile
Tubulovillous
Villous
Pedunculated
Adenocarcinoma
Carcinoid tumour

Adenomatous Polyps and Villous Adenoma: Size, Histological Type, and

Percent of Carcinoma

Histologic Type

Size

<1 cm

12 cm

>2 cm

Tubular adenoma 1% (1382)

10.2% (392)

34.7% (101)

Intermediate type 3.9% (76)

7.4% (149)

45.8% (155)

Villous adenoma

10.3% (39)

52.9% (174)

9.5% (21)

Muto T et al, 1975

FAP:
1%
>100 colorectal adenomas
APC gene (5q21)
Risk- 100%
Extra-intestinal : Desmoid tumor, Osteoma, CHRPE
Thyroid, Gastric, Duodenal, Ampullary and Brain
Treatment- Restorative proctocolectomy with IPAA

HNPCC:
3%
MMR Genes : hMSH2(2p21), hMLH1(3p21, hMSH6(2p16-21),
hPMS2(7p21)
Lynch I- Cancer of proximal colon in younger age
Lynch II- associated with extracolonic cancers eg.-endometrial,
ovarian, gastric, small intestine, pancreatic, ureteral
and renal

Clinical Criteria for HNPCC

Amsterdam Criteria
At least three relatives with colon cancer and all of the following:
One affected person is a first-degree relative of the other two
Two successive generations affected
At least one case of colon cancer diagnosed before age 50 yr
FAP excluded
Modified Amsterdam Criteria
Same as the Amsterdam criteria, except that cancer must be
associated with HNPCC (colon, endometrium, small bowel,
ureter, renal pelvis) instead of specifically colon cancer

Bethesda Criteria
The Amsterdam criteria or one of the following:
Two cases of HNPCC-associated cancer in one patient,
including synchronous or metachronous cancer
Colon cancer and a first-degree relative with HNPCCassociated cancer and/or colonic adenoma (one case of cancer
diagnosed before age 45 yr and adenoma diagnosed before age
40 yr)
Colon or endometrial cancer diagnosed before age 45 yr
Right-sided colon cancer that has an undifferentiated pattern
(solid, cribriform) or signet-cell histopathologic
characteristics diagnosed before age 45 yr
Adenomas diagnosed before age 40 yr

Hamartomatous Polyposis Syndrome:

<1%
Peutz-Jeghers Syndrome
LKB1 gene
Pigmentation around lips, buccal mucosa, sinus,
bronchial and bladder polyp
Sex cord, Lung and Pancreatic adenocarcinoma

SPORADIC:
Most common
Cause and pathogenesis is same( Adenoma Carcinoma
sequence)
Elderly
Limited

OPD

Anaemia, weakness
Alteration of bowel habit
Hematochezia/ melena
Abdominal lump/ pain, weight loss
Colovesical/ colovaginal fistula

ER
Intestinal obstruction
Perforation

Locations
Sigmoid- Obstruction
Tenesmus/passage of blood or mucus
Bladder symptoms
Transverse- mistaken as Stomach growth(
position/anaemia)
Caecum/Ascending- Anaemia (Fe
)
Mass in RIF
Obstruction(intussusception)

Constitutional symptoms/Mets:
LOA, LOW, malaise
Hepatomegaly, Jaundice
Ascites
Lung/Skin/Bone/Brain

Bowel obstruction
Perforation

MANAGEMENT

Investigations
Faecal occult blood
Guaiac test(Hemoccult) based on pseudoperoxidase
activity of haematin
Sensitivity of 40-80%; Specificity of 98%
Dietary restrictions avoid red meat, melons, radish, vitamin
C and NSAIDs for 3 days before test
Immunochemical test (Heme Select, Hemolex)
based on antibodies to human haemoglobins
Used for screening and NOT diagnosis

Assessment of entire colonic mucosa

Polyps
Synchronous lesion (3%)

Underlying colonic disease

Biopsy

Therapeutic role
Polypectomy
Cauterisation/ laser ablasion of active bleeding
point
Placement of self-expanding stent in obstruction
Disadvantage
25% risk of missing smaller lesions
10% incidence of failure to reach caecum
Risk of severe bleeding and colonic perforation (1 in
2000)
B0wel preparation and sedation required
Require expertise

Barium-air double contrast study

Water soluble contrast(gastrografin) used
Accurate determination of anatomic location
of lesion
Better passage through severly obstructing lesion
Disadvantage
Inability to take biopsy &
to detect small lesion

Virtual colonoscopy or
CT

Capsule
endoscopy

Investigation for staging &

metastasis
USG/ CECT/ MRI abdomen
Liver metastasis
Ascites
Hydronephrosis
Gross para-aortic lymph node involvement

CXR/ CT chest lung metastasis

PET scan

Transverse colon mass - luminal

narrowing and marked wall
thickening

Caecal mass with necrosis

Lung metastases

CEA:
Prognostic marker
Baseline and follow up
Complete resection
Residual disease
Recurrence

Not sensitive and specific

COLON CANCER STAGING

Dukes classification
A- Limited to rectal wall
B- Through bowel wall but not invading peritoneal serosa
surface
C - Lymph nodes involved
D Advanced/Metastatic

AJCC(TNM)
STAGE
FEATURES
Primary Tumor (T)
TX
Primary tumor cannot be assessed
T0

No evidence of primary tumor

Tis

Carcinoma in situintraepithelial or invasion of lamina

propria

T1
T2

Tumor invades submucosa

Tumor invades muscularis propria

T3

Tumor invades through the muscularis propria into

pericolorectal tissues

T4a

Tumor penetrates to the surface of the visceral peritoneum

T4b

Tumor directly invades or is adherent to other organs or

structures

Regional Lymph Nodes (N)

NX

Regional lymph nodes cannot be assessed

N0

No regional lymph node metastasis

N1

Metastasis in one to three regional lymph nodes

N1a

Metastasis in one regional lymph node

N1b

Metastasis in two or three regional lymph nodes

N1c

Tumor deposit(s) in the subserosa, mesentery, or

nonperitonealized pericolic or perirectal tissues without
regional nodal metastasis

N2

Metastasis in four or more regional lymph nodes

N2a

Metastasis in four to six regional lymph nodes

N2b

Metastasis in seven or more regional lymph nodes

M0

No distant metastasis

M1

Distant metastasis

M1a

Metastasis confined to one organ or site (e.g., liver,

lung, ovary, nonregional node)

M1b

Metastases in more than one organ/site or the

peritoneum

Edge S, Byrd D, Compton C, et al (eds): AJCC cancer staging manual, ed 7,

New York, 2010, Springer

Stage Grouping
STAGE

DUKES

MAC

0
I

Tis
T1
T2
T3
T4a
T4b
T1-T2
T1
T3-T4a
T2-T3
T1-T2
T4a
T3-T4a
T4b
Any T
Any T

N0
N0
N0
N0
N0
N0
N1/N1c
N2a
N1/N1c
N2a
N2b
N2a
N2b
N1-N2
Any N
Any N

M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M1a
M1b

A
A
B
B
B
C
C
C
C
C
C
C
C

A
B1
B2
B2
B3
C1
C1
C2
C1/C2
C1
C2
C2
C3

IIA
IIB
IIC
IIIA

IIIB

IIIC

IVA
IVB

Histologic Grade (G)

GX
Grade cannot be assessed
G1
Well differentiated
G2
Moderately differentiated
G3
Poorly differentiated
G4
Undifferentiated
Residual Tumor (R)
R0

Complete resection, margins histologically negative, no

residual tumor left after resection (e.g., primary tumor,
regional nodes)

R1

Incomplete resection, margins histologically involved,

microscopic tumor remains after resection of gross
disease (primary tumor, regional nodes)

R2

Incomplete resection, margins macroscopically involved

or gross disease remains after resection (e.g., primary
tumor, regional nodes, or liver metastasis)

TREATMENT OF COLON
CARCINOMA

Surgery is the mainstay of treatment

Objective:
Local tumor control
Prevent local tumor complication
Resection of primary is priority even in
presence of distant metastasis
Contraindication:
Widespread dissemination
General health condition

Transfusion: starting Hb
Patient physiology
Blood loss

Bowel Preparation: PEG

1-2 days before surgery
Electrolytes

Antibiotic prophylaxis: Aerobes and Anaerobes

Oral/IV
1-2 hrs before incision 36 hrs post-op

Thromboembolic prophylaxis:

>Mechanical
>LMWH/UFH

Urinary Catheter
NG tube
Stoma site
Preemptive pain management

1.

Curative resection by removing cancerous segment of the

colon and its mesentery .

2.

Ligation of vessels at their origin to include apical nodes

in the specimen.

3.

5 cm distal and proximal margin from the tumor.

4. En bloc resection when adjacent organs are involved.

Tumor Location Resection

Description of Extent
Cecum
Right hemicolectomy Terminal ileum to mid
transverse colon, right
flexure included

Major Blood Vessel

Safety Margin
Ileocolic artery, Right 5 cm
colic artery, Right
branch of mid colic
artery
Ascending colon Right hemicolectomy Terminal ileum to mid Ileocolic artery, Right 5 cm
transverse colon, right colic artery, Right
flexure included
branch of mid colic
artery
Hepatic flexure Extended right
Terminal ileum to
Ileocolic artery, Right 5 cm
hemicolectomy
descending colon
colic artery, Mid colic
(distal to left flexure) artery
Transverse
Extended right
Terminal ileum to
Ileocolic artery, Right 5 cm
colon
hemicolectomy
descending colon
colic artery, Mid colic
(distal to left flexure) artery
(Transverse colon
Transverse colon
Mid colic artery
resection)
(including both
flexures)
Splenic flexure Extended left
Right flexure to
Mid colic artery, Left 5 cm
hemicolectomy
rectosigmoid colon
colic artery, Inferior
(sigmoid, beginning of mesenteric artery
rectum)
Descending
Left hemicolectomy
Left flexure to sigmoid Inferior mesenteric
5 cm
colon
colon (beginning of
artery, Left branch of
rectum)
mid colic artery
Sigmoid colon Rectosigmoid
Descending colon to
Superior hemorrhoidal 5 cm
resection
rectum
artery, Inferior

Right hemicolectomy
Cecum
Ascending colon

Extended right hemicolectomy

Hepatic flexure
Transverse colon

LEFT
HEMICOLECTOMY:Descending colon

RECTOSIGMOID
RESECTION:SIGMOID COLON

Earlier recovery of bowel function.

Reduced blood loss.
Less post operative pain.
Comparable long term oncologic outcome.

Prerequisite for successful anastomosis:

1. Meticulous technique
2. Well vascularized tissue
3. Apposition without tension
4. Good nutritional status of the patient

20 % patients presents as emergency with tumor related

complication.
Can be managed in two stage procedure
First stage defunctioning illeostomy /colostomy.

Resection of tumor after optimization of the patient and

reconstruction.
Self expanding metallic stents.

Peri-operative mortality: 3.5-6%

Intra-op: Injury to ureter, spleen, bowel, duodenum

Early post-op: General: Pulmonary and Cardiac

Bleeding/Non-specific infection/Dehiscence
related infection
Abdominal: Delayed return of bowel function

Fascial dehiscence
Anastomotic leak(1-2%)

 Stage II with one or more poor prognostic factor

<12 lymph node sampling
T4 lesion
Poorly differentiated histology
Bowel perforation

Stage III and above

FOLFOX
5 FU

Leucovorin
Oxaliplatin
The American Society of Clinical Oncology (ASCO)

Effective for metastatic disease/stageIV

Cetuximab/Panitumumab: Epithelial growth factor
receptor(EGFR) blockers
Inactive in patients with K-RAS mutation
Bevacizumab: Vascular endothelial growth factor
receptor(VEGF) blocker

RADIOTHERAPY
Does not play a primary role in adjuvant setting in colon
cancer.
May be considered as a loco regional control in selected
locally advanced disease.

85 % of recurrences occur within 2 year.

Stage I cancer:
Colonoscopic examination at 1 year.
Repeat colonoscopy at 5 year
CEA level every 3 months during first 2 years

Stage II cancer:
CEA level every 3 months for 2 years then every 6 months for
total 5 years.
Annual CT scans of the abdomen and chest for at least the first
3 years.

SCREENING

PREDISPOSING
CONDITION

RISK OF CRC

SCREENING
RECOMMENDATION

Ulcerative colitis

Increases with duration

of disease

Colonoscopy and biopsy,

25% at 25 yrs,
35% at 30 yrs,

every 1-2 yrs, beginning

8 yrs after onset of pan
colitis, and
12-15 yrs after the onset
of left sided colitis

45% at 35 yrs,
65% at 40 yrs

Crohns disease

Less than UC

At least 30 biopsy
specimens should be
obtained
Periodic colonoscopy
and biopsy

LIFE TIME CANCER RISK SCREENING

INVESTIGATION

RECOMMENDATION

Colorectal cancer,80%

Colonoscopy

Every 2 yrs, from age 20

yrs
Annually after age 40 yrs,
or 10 yrs younger than
earliest case in family

Endometrial cancer,4060%

Pelvic examination, TVS,

Endometrial aspiration

Every 1-2 years, from age

25-35 yrs

Upper urinary tract

cancer,4-10%

USG, urine analysis

Every 1-2 yrs, from age 3035 yrs

GB and biliary cancer,

2-18%
CNS cancer, <5%
Small bowel cancer, <5

No recommendation

LIFE TIME CANCER

RISK

SCREENING
INVESTIGATION

RECOMMENDATION

Colorectal cancer,100%

colonoscopy

Annualy,from age 10-12

years

Duodenal or periampullary UGIE

cancer,5-10%

Every 1-3 years from the age

of 20-25 year

Pancreatic cancer,2%

USG abdomen

Periodic

Thyroid cancer,2%

Physical examination

Annually

Gastric cancer,<1%

UGIE

As for periampullary
carcinoma

CNS cancer,<1%

Physical examination

Annually

Hyperventilation

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