MANAGEMENT of Colorectal Cancer Ian Adam Consultant Colorectal Surgeon Sheffield Teaching Hospitals NHS Trust

Colorectal Cancer Epidemiology Third most common cancer Second most common cancer death after lung cancer Most common in Western Societies Generally affect patients > 50 years (>90% of cases)

Colorectal Cancer Epidemiology Lifetime risk 1 in 10 for men 1 in 14 for women 1 in 17 lifetime risk of death from colorectal cancer

Colorectal Cancer Histopathology Adenocarcinoma

Risk Stratification Risk factors Diet Fibre Red meat Alcohol Smoking

Risk Stratification Risk factors Past history adenoma

Risk Stratification Risk factors Family history Hereditary Familial FAP HNPCC Familial

Risk Stratification Risk category (for asymptomatic pts) Familial screening offered > 1 in 10 risk of death 1o relative < 40 two 1o relative at any age HNPCC FAP other mutations identified No screening – 1o relative with colorectal cancer >40, any 2o relative

Clinical Presentation What problems would a cancer in the bowel cause? Bleed Mucous Narrowing Metastasise Depends on location of cancer

Clinical Presentation Rectal carcinoma PR bleeding, mucus Later …. Thin stool Tenesmus

Clinical Presentation Left sided and sigmoid carcinoma Change of bowel habit Diarrhoea Alternating constipation + diarrhoea Thin/altered stool PR bleeding Blood in or on stool Altered blood

Clinical Presentation Right sided carcinoma Anaemia Mass

Differential diagnosis Anorectal pathology Haemorrhoids, anal fissure, anorectal cancer, anal prolapse Colonic pathology Colorectal polyp/cancer Diverticular disease Angiodysplasia Colitis (IBD, infective, pseudomembranous colitis, ischaemic, radiation) Small intestine and stomach pathology Massive upper GI bleed  haematochezia Meckel’s diverticulum, small bowel angiodysplasia

Emergency Presentation 20% Obstruction Absolute constipation Colicky abdominal pain Abdominal distension Vomiting (faeculent)

Investigations to find a cancer 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, horse-radish, vitamin C and NSAIDs for 3 days before test Research evidence: use for screening and NOT diagnosis NICE guidelines: suggests a diagnostic role!

Investigations to find a cancer Tumour markers CEA Useful for monitoring progress BUT not specific enough for diagnosis

Investigations to find a cancer Colonoscopy Gold standard Permits biopsy of lesions, removal of small polyps Uncomfortable – patients can have sedation Needs full bowel preparation Consent: bleeding, infection, perforation (1 in 1000), missed diagnosis, failed procedure, anaesthetic/medical risks

Investigations to find a cancer Double contrast barium enema 2nd line alternative to colonoscopy Does not require sedation Avoids risk of perforation More limited in detecting small lesions

Investigations to find a cancer CT colonoscopy Aka CTC, CT colonogram, CT pneumocolon, CTC, virtual colonoscopy 2nd line alternative to colonoscopy in the elderly Does not require sedation Avoids risk of perforation Limited in detecting small lesions but good at excluding cancers

What to do if you find a cancer Multidisciplinary team meeting Consensus meeting of all individuals responsible for care (weekly) Colorectal surgeon Oncologist Radiologist Gastroenterologist Colorectal Nurse Practitioner Stomatherapist Dedicated point of referral Telephone, fax, email

MDT meeting Multidisciplinary team meeting Staging investigations Bloods (FBC, LFT’s, CEA) CT chest, abdomen & pelvis

MDT meeting Multidisciplinary team meeting Surgery vs non-surgical options

MDT meeting Multidisciplinary team meeting Surgery vs non-surgical options Surgery Only chance of cure Offer if no metastatic spread and no inoperable intraperitoneal disease Balance against risk c. 2/3 offered operation

MDT meeting Multidisciplinary team meeting Surgery vs non-surgical options Non-surgical options Best supportive care Palliative chemotherapy

Surgical management Pre-operative Pre-assessment clinic Sort out all issues with medical management including diabetes, clotting, steroids etc. CPET Bowel prep – picolax Antibiotics prophylaxis (single perioperative dose) Cefuroxime & Metronidazole Gentamicin DVT/PE prophylaxis Low molecular weight heparin td stockings Intraoperative measures

Operative technique Conventional laparotomy Open Conventional laparotomy Good access, straightforward, widely performed

Operative technique Laparoscopic c. 50% of cases suitable Shorter length of stay More expensive equipment Now mainstream treatment in most centres

Operative technique Robot c. 1/3 of cases suitable No definite evidence that its any better than laparoscopic The future?

Post-op MDT meeting Post-operative Review histology TNM Dukes Offer Dukes C (positive lymph nodes) adjuvant chemotherapy Offer patients with stable liver metastases delayed liver surgery

Where we do it differently … Obstructing colon cancers Polyp cancers Rectal cancers

Obstructing colon cancers Obstructing colon carcinoma 10% Right and transverse colon open resection and primary anastomosis Good results

Obstructing colon cancers Obstructing colon carcinoma 10% Left sided obstruction Hartmann’s procedure – proximal end colostomy (LIF) + oversewing distal bowel + reversal in 6 months 20% mortality, 50% never reversed

Obstructing colon cancers Obstructing colon carcinoma 10% Left sided obstruction Colonic stent to relieve obstruction Resect without stoma later

Polyp cancers

Rectal Cancer Problematical Difficult to excise Many inoperable at presentation Operative complications common Local recurrence high

Rectal Cancer Factors influencing choices Height of lesion distance from dentate line <5cm requires usually requires anal excision Patient factors males more difficult – narrow pelvis Incontinence from childbirth injuries etc.

Rectal Cancer Mesorectal staging MRI Predicted TMN stage for the rectal cancer

Predicted rectal cancer stage … MDT Determines treatment

Predicted rectal cancer stage … Small lesion with clear lymph nodes T1 Not into muscle wall Transanal endoscopic microsurgery (TEM)

Predicted rectal cancer stage … Early low lesion T2-3 Into muscle wall or only just through Minimal nodal involvement Low anterior resection Abdomino-perineal excision of rectum (APER)

Rectal Cancer Everything else Most T3 Any significant lymph nodes Any invasion Long-course chemoradiotherapy 5-FU 8 weeks sandwich treatment Repeat MRI If operable APER Occasionally low anterior resection (but high leak rate)

Summary – outcomes from colorectal cancer

Outcomes should be better EUROCARE II STUDY EUROCARE III STUDY