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

2. 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)

3. 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

4. Colorectal Cancer
Histopathology
Adenocarcinoma

5. Risk Stratification
Risk factors
Diet
Fibre
Red meat
Alcohol
Smoking

6. Risk Stratification
Risk factors
Past history
adenoma

7. Risk Stratification Risk factors Family history Hereditary Familial
FAP
HNPCC
Familial

8. 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

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

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

11. 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

12. Clinical Presentation
Right sided carcinoma
Anaemia
Mass

13. 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

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

15. 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!

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

17. 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

18. 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

19. 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

20. 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,

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

22. MDT meeting Multidisciplinary team meeting
Surgery vs non-surgical options

23. 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

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

25. 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

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

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

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

29. 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

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

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

32. 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

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

34. Polyp cancers

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

36. 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.

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

38. Predicted rectal cancer stage …
MDT
Determines treatment

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

40. 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)

41. 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)

42. Summary – outcomes from colorectal cancer

43. Outcomes should be better
EUROCARE II STUDY
EUROCARE III STUDY