COLORECTAL CARCINOMA Bernard M. Jaffe, MD Professor of Surgery Emeritus

EPIDEMIOLOGY 1.4 Million People/Year, 700,000 Deaths 2 nd Most Common Cancer in Women (9.2%) 3 rd Most Common Cancer in Men (10%) Overall, 3 rd Most Common Malignancy More Common in Developed Nations 5% of Americans, Mean Age 61 Years

RISK FACTORS 75-95% No Genetic Risk Factors Risk Factors- Older Age, Male Gender High Intake of Fat, Red Meat Alcohol (>1 Drink/Day) Obesity Smoking Insufficient Activity?

GENETICS <5% of Total Cases HNPCC (Lynch Syndrome) 3% FAP, Gardner’s Syndrome <1% of Total >90% Develop Carcinoma Without Treatment 2 or More 1 st Degree Relatives, 2-3 Fold Increase in Carcinoma

POLYPS Almost All Adenomatous Most Common Precursor Types- Villous Adenoma (30%) Tubulovillous Tubular (<5%) >5 Years to Become Malignant Hamartomatous- Minimal Risk

INFLAMMATORY DISEASES Ulcerative Colitis 30% Develop Carcinoma >20 Years of Disease Predictable by Degree of Dysplasia Terrible Prognosis Crohn’s Disease Less Likely, But Increased Risk

SCREENING Can Reduce Likelihood by >60% Not 100% Fecal Occult Blood Testing q2years Positive Result→ Colonoscopy Mortality Decreased by >20% Cheap but Imperfect Air Contrast Barium Enema Not Recommended Sigmoidoscopy Misses 43% of Lesions

SCREENING Colonoscopy Every 10 Years, Ages 50–75 Years Polyps Found/Removed, Every 3-5 Years High Risk Patient- Ages Virtual Colonoscopy (CT)- Imperfect Expensive Radiation Exposure Purely Diagnostic

SYMPTOMS Depends on Location in Bowel Right- Anemia, Weakness Left- Increased Constipation Blood in Stool Narrowed Stool Caliber Weight Loss Anorexia

HEMATOCHESIA- DIAGNOSIS Young Patient Hemorrhoids Anal Fissure Inflammatory Disease Hamartoma Rare Carcinoma Older Patient Polyps Carcinoma Diverticulosis A-V Malformation Ischemia Hemorrhoids

DIAGNOSIS Colonoscopy vs. Sigmoidoscopy Depends on Site of Lesion Biopsy Imaging- CT Abdomen, Pelvis, ?Chest MRI for Pelvic Lesions PET Scan Rarely Needed CEA NOT Diagnostic

OPERATIVE TREATMENT Almost All Laparoscopically Cecum, Ascending, R Transverse Right Hemicolectomy Left Transverse Left Hemicolectomy Sigmoid, Proximal Rectum Low Anterior Resection

GOALS OF OPERATION Lesion Resection With Adjacent Tissue 5cm Colon Margin (2cm Acceptable) Vascular Anastamosis Removal of Maximal Lymph Nodes (>12) Possible Resection of Liver Metastases Hysterectomy, Oophorectomy in Women Check for Cholelithiasis

INVASION OF ADJACENT STRUCTURES Vagina- Resection with Closure Uterus- Hysterectomy, Oophorectomy Ureter- Resection with Reimplantation, Ureteroureterostomy Dome of Bladder- Resection with Closure Trigone of Bladder- Pelvic Exenteration Multiple Structures- Pelvic Exenteration

RECTAL CANCER Depends on Nodes and Depth of Invasion Determined by MRI, Transrectal Ultrasound Superficial Lesion- Transanal Excision Deep Lesion or Positive Nodes- Mesorectal Excision Sphincter Saved if 5cm from Verge Low Anastamoses Protected by Ileostomy Abdominoperineal Resection if Lower

DEPTH OF INVASION Important Determinant of Prognosis T is - In Situ (No Invasion) T 1 - Mucosa/Submucosa T 2 - Muscularis Propria T 3 - Serosa T 4 - Adjacent Structures

NODAL METASTASES Critical Determinant of Prognosis N X Can’t be Assessed N 0- No Positive Nodes N Positive Nodes N 2- >4 Positive Nodes N 3 - Any Positive Nodes Along Major Vascular Trunk

PROGNOSIS Stage TNM I T1-2, N0, M0 II T3-4, No, M0 III Any T, N1-3, M0 IV Any T, Any N, M1 5 Year Survival 70-90% 54-65% 39-6-% 0-15%

ADJUVANT THERAPY Stages III and IV Possibly Stage 2- To Be Determined 5-FU/Capecitabine and Leukovorin/Levamisole Increase Survival, Disease-Free Survival Newer Agents- Irimotecan, Oxiliplatin Radiation for Positive Margins on Solid Tissues

USE OF CEA Not Reliable for Initial Screening BUT Elevation More Common With Extensive Disease Should Return to 0 Post-Resection Post-Op Increase Means Tumor Recurrence

INCREASED FOLLOW-UP CEA CT Scan/MRI of Abdomen, Pelvis Chest PET Scan Colonoscopy Laparotomy If No Lesion Identified Mesentary/Adjacency Most Likely Site Resection Yields 30% 5-Year Survival

LIVER METASTASES Presence Determines Prognosis Mean Month Survival 15% Stage IV Have Disease Limited to Liver 25% of Them Candidates for Resection Resection IF Limited to One Lobe of Liver OR <5 Lesions, Each <3cm Total Resection, 5-Year Survival 20-40%