Coloractal Cancer is the most common malignancy of the gastrointestinal system. In this presentation brief information about this cancer is supplied. may useful for medical students

1. Colorectal Cancer
M. N. Jalalian
Medical Intern
Tehran University of Medical
Sciences

2.  Most common malignancy of GI
 Aging
 Dominant
 after age 50
 Hereditary Risk Factors
 20% with a family history
 FAP, HNPCC
 Environmental and Dietary Factors
 Saturated or polyunsaturated fats
 Inflammatory Bowel Disease
 long-standing colitis
 Other Risk Factors
 Cigarette smoking, Ureterosigmoidostomy, Acromegaly,
Pelvic irradiation
Epidemiology and Risk Factors

3.  Familial Adenomatous Polyposis
 Attenuated FAP
 Hereditary Nonpolyposis Colon Cancer (Lynch
Syndrome)
 Familial Colorectal Cancer
Inherited Colorectal Carcinoma

4.  Definition:
 An autosomal dominant condition with numerous
polyps and increased risk of colorectal cancer
 A known family history of FAP with even one
adenomatous polyp …or
 Developing hundreds to thousands of adenomatous
polyps shortly after puberty (without a family history)
Familial Adenomatous Polyposis

5.  1% of all colorectal adenocarcinomas
 mutation in the APC gene (5q)
 75% of cases
 25% without a family history
 Lifetime risk of colorectal cancer 100% by age 50 years
 Treatment is surgical
 Most patients elect to have an ileal pouch–anal
anastomosis
FAP

6.  fewer polyps (usually 10 to 100)
 The right colon
 Cancer risk 50%
 APC mutation testing + in 60%
 Screening by colonoscopy
 Unknown family mutation
 at age 13–15y, then every 4y to age 28y.
 Treatment is surgical
 Total abdominal colectomy with ileorectal anastomosis
Attenuated FAP

7.  Definition:
 An AD genetic condition
 High risk of colorectal carcinoma at an early age
(average age: 40–45 years) & other cancers
 More common than FAP
 70% develop cancer
HNPCC (Lynch Syndrome)

8.  Is based on family history
 The Amsterdam criteria:
 3 affected relatives (one must be a first-degree relative
of one of the others)
 in 2 successive generations of a family
 one patient diagnosed before age 50 years.
HNPCC
Diagnosis

9.  Screening
 Colonoscopy
 annually
 At age 20–25y / 10y younger than the youngest age at
diagnosis in the family.
 Transvaginal ultrasound / Endometrial aspiration biopsy
 Annually
 age 25–35y
HNPCC
Cntd...

10.  Total colectomy with ileorectal anastomosis
 once adenomas or a colon carcinoma is diagnosed
 prophylactic colectomy
 prophylactic hysterectomy
 bilateral salpingo-oophorectomy
 women who have completed childbearing
HNPCC
Treatment

11.  10–15% of colorectal cancer
 Risk of cancer increases with a family history.
 Double with one first degree relative (12%)
 35% with 2 first degree relatives
 Screening Colonoscopy
 every 5 y
 at age 40y / 10y before the age of the earliest
Familial Colorectal Cancer

12.  Nonspecific
 a change in bowel habits
 rectal bleeding
 Abdominal pain
 Bloating
 Obstruction is more likely in Left-sided tumors
 unexplained anemia
 weight loss
Clinical Presentation

13. Tumor stage (T) Definition
T0 No evidence of cancer
Tis Carcinoma in situ
T1 Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades through muscularis
propria into subserosa or into
nonperitonealized pericolic or perirectal
tissues
T4 Tumor directly invades other organs or
tissues or perforates the visceral
peritoneum of specimen
Staging

14. Nodal stage (N) Definition
NX Regional lymph nodes cannot be
assessed
N0 No lymph node metastasis
N1 Metastasis to one to three pericolic or
perirectal lymph nodes
N2 Metastasis to four or more pericolic or
perirectal lymph nodes
N3 Metastasis to any lymph node along a
major named vascular trunk
Staging
Distant metastasis (M)
MX Presence of distant metastasis cannot
be assessed
M0 No distant metastasis
M1 Distant metastasis present

15. Staging & 5-year suvival
Stage TNM 5-Year Survival
I T1–2, N0, M0 70–95%
II T3–4, N0, M0 54–65%
III Tany, N1-3, M0 39–60%
IV Tany, Nany, M1 0–16%

16.  Colonoscopy
 Synchronous disease up to 5%
 Chest and Abdominal/pelvic CT scan
 distant metastases
 Routine Blood tests and CEA
 Endorectal ultrasound / Pelvic MRI
 The ultrasound T and N stage of rectal cancer
Preoperative Evaluation

17.  The objective is
 remove the primary tumor with clean borders
 And its lymphovascular supply
 Chemotherapy
 Stages III and IV
 Stage II if
 Young patient
 Bad histology
 Radiotherapy
 Greatly used for rectal cancers
Treatment

18.  Stage 0 (Tis, N0, M0)
 Polipectomy with clean margins
 Stage I: The malignant polyp (T1, N0, M0)
 Polipectomy by endoscope (low risk of LN metastasis)
 Segmental colectomy
 Stages I and II: Localized colon carcinoma (T1–3, N0, M0)
 The majority cured with surgical resection
 Adjuvant chemotherapy
 young patients
 “high-risk” histologic
THERAPY FOR COLONIC CARCINOMA

19.  Stage III: Lymph Node Metastasis (T any, N1, M0)
 Surgery
 adjuvant chemotherapy
 Stage IV: Distant metastasis (T any, N any, M1)
 metastases limited to the liver
 Resection
 adjuvant chemotherapy
 The remainder
 Palliative therapy

20.  Stage I: Localized rectal carcinoma (T1–2, N0, M0)
 Polypectomy
 low risk of metastasis
 Radical resection
 High-risk patients
 Stage II: Localized rectal carcinoma (T3–4, N0, M0)
 total mesorectal resection (only)
 Resection and chemoradiation
 neoadjuvant therapy
 Adjuvant therapy
Therapy for Rectal Carcinoma

21.  Stage III: Lymph node metastasis (T any, N1, M0)
 Resection
 neoadjuvant chemoradiation
 Adjuvant chemoradiation
 Stage IV: Distant metastasis (T any, N any, M1)
 Mostly palliative

22.  A full colonoscopy
 within 12 months
 If normal, every 3-5y
 CEA
 every 2–3 months for 2 years
 If +  CT scan
 Transrectal sonography
 Rectal Cancer
 Every 4 months for 4 y
Follow-Up and Surveillance

23. THANK YOU FOR YOUR ATTENTION