CASE

PRESENTATIO
N

ROLL NO 138 & 145

 • 65-year-old man presented
with intermittent abdominal
pain, bleeding per rectum
from 1 month. Patient had
history of weight loss and loss
CASE of appetite. On clinical
examination patient had a
mass of size 5x3 cm in the
right lilac fossa. How Will you
approach and manage this
patient?
DIAGNOSIS ?
INTRODUCTION AND AETIOLOGY CLINICAL FEATURES

COLORECTAL CANCER

INVESTIGATION AND STAGING TREATMENT

 1.5 m long
Anatomy Extend from Ileocecal junction to
the Anus
of the Comprises of 4 layers including
Large the
Intestine • Mucosa
• Submucosa
• Muscularispropria
• Serosa
CONSIST
OF 7
PARTS
WHAT IS COLORECTAL CANCER?

Malignant tumor that originates in the colon or rectum.

Characterized by the uncontrolled growth of abnormal cells in

the lining of these structures.

The most commonly affected layer in colorectal cancer is the

mucosa or the inner lining of the colon or rectum.

According to the World Health Organization (WHO), it is the

third most commonly diagnosed cancer globally
EPIDEMIOLOGY

Age: The incidence of colorectal cancer increases with age,

mostly in individuals aged 50 years and older

Sex: Traditionally, colorectal

medical therapy failscancer
to controlhas been ifmore
symptoms, there common in
men than women.
are complications such as toxic colitis or
perforation

Geographical factors: This is mainly attributed to the adoption

of a Westernized diet and lifestyle.

Socio-Economic factor: Mostly seen in higher socio-economic

class because of dietary preference and lifestyle.
AETIOLOGY

• the exact etiology

of colorectal
cancer is not fully
understood, but
several risk
factors have been
identified:
RISK FACTORS

Lifestyle
Family
Age and dietary
history
factors

Inflammato
Genetic
ry bowel Polyps
factors
diseases
GENETIC FACTORS
Certain inherited genetic syndromes, such as Lynch syndrome and
familial adenomatous polyposis (FAP), increase the risk of developing
colorectal cancer.
Familial adenomatous polyposis (FAP) accounts for 1% of colorectal
cancer cases.
Hereditary non-polyposis colorectal cancer (HNPCC), sometimes
called Lynch syndrome, accounts for approximately 5% to 10% of all
colorectal cancer cases.
Mutations in specific genes, such as APC and KRAS, are also
associated with an increased risk.
 POLYPS
• Benign growths on the inner
wall of the colon and rectum.
They are fairly common in
people over age 50. Some
types of polyps increase a
person's risk of developing
colorectal cancer.
• the risk of malignant change
in benign polyp depend on
many factors including: size,
number of polyp, histological
type
• the risk of cancer
development is more common
in villous type of adenomas
than in tubular type also
presence of epithelial
 CLINICAL FEATURES

RIGHT SIDE LEFT SIDE

RECTAL CANCER
CARCINOMA CARCINOMA
• BLEEDING PER RECTUM
• RIF PAIN • ALTERATION OF BOWEL • PALPABLE MASS ON
• MASS ON RIF HABIT RECTAL EXAMINATION
• MALENA ON • BLEEDING PER RECTUM • SPURTIAL DIARRHOEA
• LOSS OF WEIGHT • LOSS OF WEIGHT
ULCERATIVE FORM
• LOSS OF WEIGHT • LOWER AND LIF PAIN • TENESMUS
• NAUSEA VOMITING
ANOREXIA
• APPENDICITIS
 COLORECTAL CANCER CLINICAL
FEATURES

RIGHT COLON RECTUM LEFT COLON

• TENESMUS
• CONSTIPATIO
• DIARRHEA • BLOOD AND
N
• ANEMIA MUCOUS
• BLEEDING PR
DISCHARGE
 PRESENTATION
Patient may
Metastasis
present as an
presentation
emergency case in
includes:
the form of
• Acute intestinal • Jaundice
obstruction • Fistulae
• Perforation • Cough
result in fecal
peritonitis
 INVESTIGATIONS

Digital
Rectal Fecal occult Blood &
plainX-ray
Examinatio blood(FOB) electrolytes
n (DRE)

Barium Intrarectal
CT-SCAN MRI
enema USS
 Double contrast
barium Enema

• Does not require sedation

• Avoids risk of perforation
• More limited in detecting small
lesions
• All lesions need to be
confirmed by colonoscopy and
biopsy
• Performed with sigmoidoscopy
• Second line in patients who
failed cannot undergo
colonoscopy
 Double
contrast
Barium Enema
• Colon Annular
carcinoma of the
sigmoid colon.The
lumen of the sigmoid is
narrowed severely by
the circumferential mass
with mucosal
destruction and the
overhanging edges or
shouldering at the tumor
margins.
CT SCAN OF
COLON
CANCER
• Contrast-enhanced
CT showing liver
metastases.
• Several low-density
metastases from the
colonic primary
tumor involve both
Lobes of the Liver.
 Pre-operative CT
cecal wall thickening
and infiltration of
the Pericolic fat

CT SCAN
OF COLON
CANCER
ENDOSCOPIES
Colonosco
py

• Can visualize lesions

<5mm
• - Small polyp scan be
removed or at later
stage by endoscopic
mucosal resection
• - Performed under
sedation
• - Warn: bowel
prep ,abdominal
bloating/discomfort
afterwards, no driving
 SIGMOIDOSCO
PY
• Sigmoidoscopy: Rigid
sigmoidoscope reach to only the distal
30cm of the colon, but flexible
sigmoidoscope can reach up to 60cm
where 70% of tumor can detected.
• Sigmoidoscope is important
investigation & should be performed
in cases of bleeding & mucus
discharged from the rectum also
biopsy can be taken for histological
 BIOPSY
Colonoscopy biopsy: A colonoscope, a long, flexible
tube with a camera at the end, is inserted through the
rectum to reach the colon. During the procedure,
small tools can be used to remove tissue samples
from suspicious areas.

Excisional biopsy: In some cases, if a tumor or polyp is

easily accessible, it may be removed entirely during a
minimally invasive surgery
GRADING
MODIFIED DUKE CLASSIFICATION:
THE MOST SIMPLE AND PRACTICAL
WAY OF STAGING THE TUMOUR
StageI:T1 N0 MO; T2 NO MO
StageII:T3 NO MO;T4 NO MO
StageIII: anyT,N1-2,MO
StageIV: anyT,anyN,M1
• The treatment of
colorectal cancer typically
involves a combination of
surgery, chemotherapy,
and radiation therapy. Treatment of
Colorectal
Cancer
GOAL OF TREATMENT
• Treatment is defined by stage and type of cancer
present
Goals of treatment
Goals of treatment for advanced
for early disease disease
•Remove cancer cells •Slow or stop the
•Kill cancer cells growth of cancer cells
•Keep the cancer cells •Manage quality of life
from returning concerns
Surgery

Local Excision: This procedure is typically used for small,

early-stage rectal tumors that are confined to the
innermost lining of the rectum.

Transanal Excision

Transanal Endoscopic Microsurgery (TEM)

 Transanal Excision: This Transanal Endoscopic
approach involves accessing Microsurgery (TEM): This
the tumor through the anus technique involves the use of
and removing it using a specialized microsurgical
specialized instruments. It is system to remove larger
suitable for tumors located rectal tumors. TEM allows for
low in the rectum. better visualization and
precision in tumor removal
compared to traditional
trans-anal excision.
 COLECTOMY
Colectomy: Colectomy involves the removal of a portion of the
colon affected by the tumor. There are several types of
colectomies:

Partial Colectomy:

Total Colectomy:

Subtotal Colectomy:
 Partial Subtotal
Colectomy: This Colectomy: This
procedure involves Total Colectomy:
procedure involves
the removal of a In cases where the
the removal of a
segment of the entire colon is
significant portion
colon containing affected by the
of the colon along
the tumor along tumor, a total
with the rectum,
with a margin of colectomy may be
but a small
healthy tissue on performed. This
proximal segment
either side of the procedure involves
of the colon is left
tumor. The the removal of the
intact and
remaining ends of entire colon along
connected to the
the colon are then with the rectum.
ileum (small
reconnected. intestine).
 PROCTECTOMY

Proctectomy
: Proctectomy • Anterior Resection
involves the • Abdominoperineal
removal of the Resection (APR)
rectum. There
are three • Total Mesorectal
main types of Excision (TME)
proctectomy:
 Total Mesorectal
Anterior Abdominoperineal Excision (TME):
Resection (APR):
Resection: This TME is a specialized
This procedure is
procedure is performed when the technique used
performed when tumor is located in the during rectal cancer
the tumor is lower part of the surgery. It involves
rectum or anal canal. the meticulous
located in the
The rectum, anus, and removal of the
upper or middle part of the sigmoid entire layer of tissue
part of the rectum. colon are removed. A surrounding the
The rectum is permanent colostomy rectum
removed, and the is then created, with (mesorectum) to
remaining colon is the end of the colon
ensure complete
attached to an
sutured to the opening (stoma) on
tumor removal and
anal canal. the abdominal wall. reduce the risk of
local recurrence.
 Adjuvant
Chemotherapy:
Neoadjuvant
Refers to the use of Chemotherapy:
chemotherapy after
surgical removal of Neoadjuvant
the tumor to kill any chemotherapy is
remaining cancer the use of
CHEMOTHERA cells and reduce the chemotherapy
risk of recurrence. before surgery,
PY recommended for
with the goal of
patients with stage
III and high-risk shrinking the
stage II colorectal tumor and
cancer making it easier
• Fluorouracil (5-FU) to remove
• Oxaliplatin surgically.
• Leucovorin (folinic
acid):
Palliative Chemotherapy:
Palliative chemotherapy is used to
relieve symptoms, control the
growth of the tumor, and improve
overall quality of life in patients
with advanced, metastatic
colorectal cancer.
FOLFOX, FOLFIRI (fluorouracil,
leucovorin, and irinotecan), and
combination therapies with
targeted agents such as
bevacizumab (anti-VEGF) or
cetuximab (anti-EGFR).
 Antiangiogenesis therapy:
Starves "the tumor by
disrupting its blood supply This
therapy is given along with
chemotherapy. Bevacizumab
NEW (Avastin).
THERAPY Targeted Therapy: Treatment
designed to target cancer cells
while minimizing damage to
healthy cells.
Cetuximab(Erbitux)
 Diet: low in fat, high in fruits and
vegetables and fiber

PREVENTIO Supplements: Vitamin A, E,C, folate,

selenium, calcium
N
Life habits: activity, normal body weight,
avoid smoking, and excessive alcohol

Medications: Aspirin and other NSAIDs,

post menopausal hormonal replacement,
HMG-CoA inhibitors
SCREENING
Colonoscopy(current
ly the best way to Virtual
Sigmoidoscopy
prevent and detect colonography
colorectal cancer)

Fecal occult blood Double contrast Digital rectal

test barium enema examination
• Screening tests can find colorectal cancer
early, when treatment works best. When
colorectal cancer is detected in the
earliest stage of the disease, the survival
rate is 96%.
THE FOLLOWING AGE 65 years

PROVISIONAL
DIAGNOSIS CAN BE
MADE PAIN INTERMITTENT PAIN
BLEEDING PER RECTUM
FOR 1 MONTH

• INFLAMATORY BOWEL DISEASE

SITE OF THE PAIN RIGHT ILIAC FOSSA

• DIVERTICULITIS

SIZE MASS OF SIZE 5X3 cm

• COLORECTAL CANCER

• ADENOMATOUS POLYP
 REFERENCE
• BAILEY AND LOVE SHORT PRACTICE ON SURGERY 27th EDITION
• SABISTON TEXTBOOK OF SURGERY 21st EDITION
• VISHRAM SINGH TEXTBOOK ON ANATOMY
• PICTURE COURTESY
1. GOOGLE IMAGES
2. NETTERS ATLAS