16/12/2012Mr. Ravi-Kumar Stafford General

Hospital 1

ABC of CRCABC of CRC(Colo-Rectal Carcinoma)(Colo-Rectal Carcinoma)

Mr Ravi-KumarMr Ravi-Kumar

Consultant SurgeonConsultant SurgeonColoproctology, Laparoscopy Coloproctology, Laparoscopy

& General& General

11/12/2012Mr. Ravi-Kumar Stafford General

Hospital 2

Incidence Aetiology Pathogenesis Heritable cancers/ FH Clinical presentation Role of screening Treatment options Recent advances

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 3

Colorectal cancer is second commonest cancer causing death in the UK

20,000 new cases per year in UK - 40% rectal and 60% colonic

Some cases are hereditary (5%) Most related to environmental factors - dietary

red meat, animal fat & lack of fibre Role of alcohol, smoking, obesity and lack of

exercise Role of micro-nutrients

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 4

Most cancers believed to arise within pre-existing adenomas

Risk of cancer greatest in villous adenoma Of all adenomas - 70% tubular, 10% villous and 20%

tubulo-villous Series of mutations results in epithelial changes from

normality, through dysplasia to invasion

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 5

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 6

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 7

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 8

1% due to Familial Adenomatous Polyposis coli (FAP)

4% due to Hereditary Non-Polyposis Colon Cancer (HNPCC)

Definition- at least 3 relatives affected (one of whom is a first degree relative of the other two)

At least one under the age of 50 Potential HNPCC- relatives of people with

CRC under 45 or multiple cases

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 9

Not a germ-line mutation Still a cluster of cases in various generation Not enough to fall under HNPCC or FAP Risk to be stratified and screened

accordingly

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 10

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 11

Age- disease of old age Peak age incidence 60-80 More & more younger patients are being

diagnosed with CRC (still makes only 5% of all cases)

Strong FH – younger age presentation IBD – increased incidence esp. With

extensive UC

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 12

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 13

Bleeding PR- o Mixed in with the stoolso Dark red in colouro Even one episode of bleeding may be

significant in the elderlyo Rarely massive lower GI bleed

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 14

Increased stool frequency Diarrhoea alternating with constipation Tenesmus Abdominal pain Incontinence

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 15

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 16

Abdominal pain Diarrhoea alternating with constipation

40% of all cancers present as a surgical emergency with either obstruction or perforation

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 17

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 18

Anaemia –iron deficiency Mass- RIF Increasing in incidence of right sided

tumours FH

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 19

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 20

May present with fistulation into nearby viscera- colovaginal, colovescical, coloenteral fistulae

Poor appetite Weight loss

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 21

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 22

FAST TRACK – FAXED REFERRAL

Bleeding PR lasting over 6/52 in anyone over the age of 60

Loose stools lasting over 6/52 in anyone over 60

Both symptoms in anyone even under 60

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 23

FAST TRACK – FAXED REFERRAL

Mass in the RIF Mass in the rectum Unexplained iron deficiency anaemia

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 24

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 25

To diagnose Colonoscopy – Gold standard

To Stage Contrast CT- Thorax, abdomen and Pelvis MRI Pelvis in addition to stage rectal cancer

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 26

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 27

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 28

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 29

Developed by Cuthbert Duke in 1932 for colorectal cancers

Dukes staging of colorectal cancer

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 30

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 31

TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ: intraepithelial or invasion of lamina

propria T1 Tumor invades submucosa T2 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

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 32

N0 No regional lymph node metastasis.

N1 Metastases in 1–3 regional lymph nodes. N2 Four or more regional lymph nodes.

NX Regional lymph nodes cannot be assessed.

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 33

M0 No distant metastasis.

M1 Distant metastasis.

M1a Metastasis confined to 1organ or site (e.g., liver, lung, ovary, non-regional node).

M1b Metastases in >1 organ/site or the peritoneum.

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 34

Little improvement over the last 30 years in general

How can we improve the prognosis? Considerable improvement achieved

recently in rectal cancer treatment Role of screening

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 35

TME- better surgical technique Better staging- MRI, EUS, CT Selective use of pre-operative

Radio/chemotherapy MDT

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 36

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 37

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 38

Right Hemicolectomy Ext. Right Hemicolectomy Transverse Colectomy Left Hemicolectomy Sigmoid colectomy Subtotal colectomy

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 39

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Free to register and thousands of video clips can be viewed for free

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 40

Laparoscopic vs. open Fast Track / enhanced post-op recovery

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 41

Pre-op- Counseling, Carbohydrate load Per-op – Less opiates, epidurals, Goal

directed fluid therapy, Transverse incision Post-op- Analgesic ladder, Less tubes, IVI for

less than 24 hours, early feeding and promote mobility

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 42

04/21/23Mr. Ravi-Kumar Stafford General

Hospital 43