Colo rectal cancer management

Dr Bachar RAAD MD, FACS.

RCMC YanbuSurgical Club

DEC.2014.

Epidemiology:

In the world, CRC is the third most common cause of cancer death, responsible for 639000 death annually.(1)

In USA 1 in every 17 people will develop CRC at some point in life.(2)

Incidence in men is 61 per 100,000 as compared to 45 per 100,000 females.

Distribution of colon cancer is 18% in right colon , 9 % transverse colon , 5% descending colon, 25% sigmoid colon, and 43% in the rectum

1- World health organization mortality database. World health organization. (Accessed 9 Dec 2009.)

2- Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ. Cancer statistics, 2009. CA cancer J Clin. 2009;59:225-49.

Etiology

Dietary constituents and supplements: Dietary fat, Red meat, Alcohol, Fruits and Vegetable, Fiber, Calcium and Vit. D, Folate, Aspirin and NSAI drugs.

Obesity with an up to twofold increased risk of CRC.

Physical activity: greater PA is associated with reduced risk of CRC.

Smoking with two to threefold elevation of adenoma risk.

Cholecystectomy: the association with CRC in inconsistent, but seems to be strongest for cancer of the proximal colon.

Inflammatory bowel disease and family history: ulcerative colitis, crohn, polyposis.

Screening

There is clear evidence that CRC can be prevented by detecting and removing adenomatous polyps and that detecting early stage cancers reduce mortality from the disease.*

* Newcomb P, Norfleet R, Storer B, Surawicz T, Marcus P. Screening sigmoidoscopy and colorectal cancer mortality. J Natl Cancer inst. 1992;84:1572-5.

Screening

2008, US Preventive

Task Force recommendation.

2008, US Preventive Task Force recommendation.

Clinical presentation

In symptomatic patients the most common presenting symptoms are:

1- Abdominal pain (most common).

2- Change in bowel habits.

3- Rectal bleeding and occult blood in stool.*

*-Breat RW, Steel GD, Merck HR, et al. Manengement and survival of patients with adenocarcinoma of colon and rectum. J Am Coll Surg.1995;181:225-36

Staging and Prognostic factors

The original staging system for colorectal cancer was reported by Cuthbert Dukes’ in 1930 and it has three stages A,B and C.

Modified Dukes’.

Subdividing Dukes’.

Astler-coller modification.


TNM staging is the system developed by the American joint committee of cancer.

T

Tis : carcinoma in situ.

T1 : Invasion into submucosa.

T2 : Invasion into muscularis propria.

T3 : invasion into subserosa.

T4 : Invasion to other organs.

N

N0 : No Lymph nodes / N1 : 1-3 Lymph nodes/ N2: >4 Lymph nodes

M

M0 : No metastasis / M1 : Distant metastasis


Typically, the combination of T, N, and M will lead to one of the four stages based on the combination of findings.

Stage 0 Tis, N0, M0.

Stage 1 T1 or T2, N0, M0.

Stage 2 T3 or T4, N0, M0.

Stage 3 any T, N1 or N2, M0.

Stage 4 any T, any N, M1.


In addition to TNM staging, the histologic grade of the tumor as well as the completeness of the resection should be assessed. The absence or presence of residual tumor following resection is designated by the letter R, as indicated below, and should be indicated in the operative report:• R0—complete tumor resection with all margins histologicallynegative• R1—incomplete tumor resection with microscopicsurgical resection margin involvement (margins grosslyuninvolved)• R2—incomplete tumor resection with gross residualtumor that was not resected (primary tumor, regionalnodes, macroscopic margin involvement).*

*-Nelson H, Petrelli N, Carlin A, et al. Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst. 2001;93:583–596.

Clinical Prognostic Factors

Age, as many cancers, colon cancer incidence increases with increasing age.

Symptoms, obstruction and perforation are poor prognostic signs, overall 5-years survival is 33%.*

Blood transfusion, can cause immunosuppression.

Adjacent organ involvement.

*-Chen HS, Sheen-Chen SM, obstruction and perforation in colo rectal adenocarcinoma, analysis of prognosis. Surgery, 2000;127:370-6.

Histologic Factors

Histologic grade, poorly differentiated tumors have a worse prognosis stage for stage compared to better differentiated tumors.*

Tumor budding, undifferentiated portion of tumors at the leading invasive edge, associated with a high risk of recurrence.*

Mucin production; Signet-cell histology. Venous, perineural, lymph nodes invasion. Positive margins.

*-Cooper HS, Slemmer JR, Surgical pathology af carcinoma of colon and rectum. Semin oncol. 1991;18:367-80.

*- Nakamura T, Mitomi H, Kickuchi S, et al. evaluation of use fullness of tumor budding on the prediction of metastases to the lungs and liver after curative excision of colorectal cancer, Hepatogastroenterology, 2005;52:1432-5.

Carcinoembryonic Antigen, CEA.*

A glycoprotein absent in normal mucosa, but present in 97% of patients with colo-rectal cancer.

Patients with disease confined to mucosa and sub mucosa will have elevated CEA level in 40-60% of cases.

If CEA level does not fall postoperatively then occult metastases may be present, (adj therapy).

A CEA level greater than 15 mg/ml predicts an increasing risk of metastases.

A normal CEA level preoperative may become elevated with metastases or recurrences.

*- The standard practice task force, The American Society of Colon and Rectal Surgeons. Practice parameters for the surveillance and follow up of patients with colo rectal cancer. Dis Colon Rectum, 2004;47:807-17.

Preoperative Preparation

The tow most important prognostic indicators remain the degree of bowel wall invasion and status of the lymph nodes.

Effective preparation requires knowledge of patient’s physiologic status, tumor location, and clinical stage.


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Localization of the tumor and its histopathology are important in selecting an operative plan and the optimal resection margins. Colonoscopy is widely used today and represents

the optimal means of detecting a cancer. CT allows the localization of lesions, identification

of local organ invasion and distant metastasis. Endoluminal US and MRI has become extremely

useful in staging of rectal cancer. Combined PET/CT appears to provide the most

accurate detection of liver metastases (97%).*

*-Orlacchio A, Scillaci O, Fusco N, et al. Role of PET/CT in detection of liver metastases from colorectal cancer. Radiol Med. 2009;114:571-85.


Mechanical cleansing combined with oral antibiotics reduces the concentration of anaerobic and aerobic bacteria within the colon and decreases the incidence of wound infection from 35 to 9%.*

*- Matheson DM, Arabi Y, Baxter-Smith D, et al. Randomized multicentric trial of oral bowel preparation and antimicrobials for elective colorectal operations. Br J Surg 1978;65:597-600.


Bucher and al. reviewed 565 patients with mechanical bowel preparation versus 579 without a preparation, demontrated a higher anastomotic leak rate in the mechanical prep group.*

Slim and al. reported an updated review and meta-analysis of randomized controlled trials of patients. They found no difference between the groups for anastomotic leak rate or the incidence of pelvic or abdominal abscess.*

*- Guenaga KF, Matos D, Castro AA,et al. mechanical bowel preparation for elective colorectal surgery. Cohrane database SystRev. 2003:CD001544.

*- Slim K, Vicaut E, Launay savary MV, et al.abdated systematic review and meta analysis of randomized clinical trials on the role of bowel preparation before colo rectal surgery. Ann Surgery 2009;249:203-9.


While there is no enough data to make recomendations for the use of bowel preperation in colorectal surgery, we conclude that the routine use of mechanical bowel preparation should be abondoned, and replaced by liquid diet for three days before elective surgery with appopriateantimicrobials medications.

Surgical Technique

The principles of oncologic resection are a wide mesenteric resection achieved by ligating the feeding artery at its origin with adequate distal and proximal margins.

With the recommendation of a minimum of 12 lymph nodes should be examined.*

*-Nelson H, Petrelli N, Carlin A, et al. Guidelines 2000 for colon and rectal cancer surgery. J Natl cancer inst. 2001;93:583-96.

Surgical Technique

Right hemi colectomy: the terminal

ileum should be divided 10-15 cm

proximal to the ileocecal valve to

allow for good vascular supply,

the transverse colon is divided

to the right of the main trunk of

the middle colic artery or to the

left for Extended RT hemi colectomy.

Surgical Technique

Left hemi colectomy: lateral to medial

or medial to lateral approach.

Inferior mesenteric artery should be

ligated at its origin, and the inferior

mesenteric vein ligated near the

ligament of Treitz.

Identification of the left ureter.

Bowel transected with at least 5 cm

proximal margin and distal site

on the top of the rectum.

Surgical Technique

Total colectomy with ileorectal anastomosis:

Applied to circumstances, where the patient has been diagnosed with HNPCC, attenuated Familial Adenomatous Polyposis, metachronous cancers in separate colon segments, and in acute malignant distal colon obstructions with unknown status of the proximal bowel.

Surgical procedures and principles in rectal surgery.

The result is that primary resection and anastomosis without a colostomy or ileostomy are the rule rather than exception.

Palliation should be the goal in a patient for whom curative resection is not possible:

If patient is a reasonable operative risk.

If the primary lesion is not resectable.

Significant metastatic disease and the primary tumor is small.

A colonic stent can be used if the patient needs to be relieved of an partial obstruction.

Stent is just temporary maneuver, patient for reevaluation after chemo or chemo-radio therapy for diversion or resection.

Variability in outcome in rectal surgery is based on:

Surgeon and hospital volume.

Total mesorectal excision.

Distal margins and radial margins.

Lateral lymph nodes dissection.

Selection of appropriate therapy for rectal cancer.

Surgeon and hospital volume.

When hospital with highest quartile of volume (more than 20 procedures annually) were compared with those with lowest quartile (fewer than seven procedures annually), there were statistically significant differences in colostomy rates (29.5 versus 36.6%), 30 day post operative mortality (1.6 versus 4.8%), and overall 2 years survival (83.7 versus 76.6%).*

* Hodgson DC, Zhang W, Zaslavsky AM, et al. Relation of hospital volume to colostomy rates and survival for patients with rectal cancer. J Natl cancer inst. 2003;95:(01):708-16.


Post operative impotence and retrograde ejaculation or both have been observed in 25-75% of cases when blunt dissection done causing damage of pelvic autonomic sympathic and paras. nerves.

By contrast after TME with careful nerve sparing dissection, impotence has been reported in

only 10-29% of cases.*

*Masui H, Ike H, Yamaguchi S, et al. Male sexual function after autonomic nerve-preserving operation for rectal cancer. Dis Colon Rectum, 1996;39(10):1140-5.

Distal and radial margins

The first line of rectal cancer spread is upward

along the lymphatic course.

A 2-cm distal margin is generally justifiable over 5-cm proximal margin.

A frozen section analysis of the distal margin must be performed to comfirm a cancer free margin.

Lateral lymph nodes dissection

A complete clearance of lateral lymph nodes or extended lateral lymph nodes dissection for lying rectal cancer is a controversial topic.

Associated with a much higher rate of urinary and sexual dysfunctions as compared to standard TME.

Become a routine practice in Japan.

Selection of appropriate therapy for Rectal Cancer.

Presently the surgeon has three major curative options:- Local excision,- Sphincter-saving abdominal surgery,- Abdominoperineal Resection, APR.

Each patient with rectal cancer should be individually evaluated, and a technical plan is customized to their stage, gender, age, and body habitus.

T1 invasion into the submucosa.T2 invasion into the muscularispropria.T3 invasion the mesorectal fat. T4 invasion of other organs.

Special circumstances

Laparoscopic colon resection for Cancer*Laparoscopic technique has been used for more than 15 years.Faster return of bowel function, shorter length of stay, less narcotic use.Conversion did not have any negative impact on the oncologic outcome.With adequate experience, laparoscopic colectomy for colon cancer is safe and provides similar outcomes to open colectomy.

*- Buunen M, Veldkamp R, Hop W, et al. survival after laparoscopic surgery versus open for colorectal cancer. Lancet oncol, 2009;10:44-52.


Acute obstructionThe associated bacterial overgrowth coupled with possible impairment of blood flow in the proximal bowel has been the primary factors that have classically dictated resection and proximal diversion.

Colonic stent can serve as bridge to elective surgery in patient with operable cancer.

Emergency surgery is associated with operative mortalities as high as 23% and reduce quality of life.*

*- Morino M, Bertello A, Garbarini A, et al. malignant colonic obstruction managed by endoscopic stent decompression followed by laparoscopic coloctomy. Surg Endosc 2002;16:1483-7.


Prophylactic Oophorectomy,

The debate continue regarding the relative risk and benefits of a prophylactic oophorectomy in female patient with colorectal cancer.

The risk of micro metastatic implants in the ovary increases with tumor stage and approaches the 10%.*

*-Mackeigan JM, Ferguson JA. Prophylactic oophorectomy and colorectal cancer in premenopausal patients. Dis Colon Rectum 1979;22:401-5.


Colon Cancer and AAA.Vascular surgeons preferred to repair the AAA first, whereas the nonvascular surgeons preferred colectomy.

Any aneurysm >6 cm should be repaired first or synchronously with the colon resection, to avoid rupture.

Endo vascular repair followed by colectomy within the next couple of days, or under a single anesthetic time, and this is being increasingly supported by the literature.*

*-Veraldi GF, Minicozzi A, Genco B, et al. endovascular treatment in patient with AAA and synchronous neoplasm. ChrItaly, 2008;60:23-31.


Colon cancer and liver metastases,The risk of simultaneous colectomy and hepatectomy do not appear to be excessive in selected patients operated by expert surgeons, and long term survival rates seem to be similar.*

16% of previously unresectable patients can be down staged and eventually undergo curative resection with as high as 40% 5-years survival.*

When metastatic disease is not resectable, upfront chemotherapy without resection of primary lesion may be reasonable approach.

*- Adam R, Delvart V, Pascal G, et al. Rescue surgery for unresectable colorectal liver metastases down staged by chemotherapy: a model long time survival. Ann Surg. 2004;240:644-57.

Outcome of surgery for colorectal cancer

Overall 5-years survival rates after major surgery for colorectal cancer are as follow: stage I, 85-100%; stage II, 60-80%; stage III, 30-50%.

The risk of locoregional recurrence following colectomy should be below 5%.

Summary

Surgery of colonic cancer has been increasingly better defined and the data clearly support the benefits of wide mesenteric resection, clear radial margins, and resection of adherent adjacent organs.

To allow accurate staging, 12 nodes or more should be examined.

Attention to surgical detail coupled with improved perioperative care strategies, are essential to minimize operative morbidity and mortality.

THANK YOU…

Colo rectal cancer management

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