Carcinoma Colon presentation for surgery

A cancer of the colon or rectum, located at the digestive tract's lower end.
Early cases can begin as non-cancerous polyps. These often have no symptoms but can be detected by screening. For this reason, doctors recommend screenings for those at high risk or over the age of 50 or even earlier if a family history of colon cancer is present.
Colorectal cancer symptoms depend on the size and location of the cancer. Some commonly experienced symptoms include changes in bowel habits, changes in stool consistency, blood in the stool and abdominal discomfort.
Colorectal cancer treatment depends on the size, location and how far the cancer has spread. Common treatments include surgery to remove the cancer, chemotherapy and radiation therapy. Colon cancer develops from polyps (growths) in your colon’s inner lining. Healthcare providers have screening tests and treatments that detect and remove precancerous polyps. If untreated, colon cancer may spread to other areas of your body. Thanks to these tests, early treatment and new kinds of treatment, fewer people are dying from colon cancer.

1. Carcinoma Colon Dr Nataraj Y S DEPT. OF SURGICAL ONCOLOGY SIMSRC,Bengaluru

2. Anatomy of colon

3. Rectum

4. Blood supply of colon - Artery

5. Blood supply of colon – Venous

6. Lymph nodes

7. Layers of colon

8. TUMOURS OF THE LARGE INTESTINE Polyp a clinical description of any protrusion of the mucosa. It encompasses a variety of histologically different tumors. Polyps can occur single – BENIGN synchronously in small numbers part of a polyposis syndrome

9. Adenomatous polyp

10. Adenomatous polyp The tubular adenoma like a berry on a stalk The villous adenoma like a flat spreading lesion. The risk of malignancy developing in an adenoma increases with size There is a 10% risk of cancer in a 1-cm diameter tubular adenoma one-third of large (>3 cm) colonic adenomas will have an area of invasive malignancy within them. Adenomas larger than 5 mm in diameter are usually excised because of their malignant potential.

11. Snare polypectomy

12. Familial adenomatous polyposis Familial adenomatous polyposis (FAP) is defined clinically by the presence of more than 100 colorectal adenomas, but is also characterized by duodenal adenomas and multiple extraintestinal manifestations

13. Over 80% of cases come from patients with a positive family history. The remainder arise as a result of new mutations in the adenomatous polyposis coli (APC) gene on the short arm of chromosome 5. FAP is inherited as an autosomal dominant condition Equal in men and women. The lifetime risk of colorectal cancer is 100% in patients with FAP. FAP can also be associated with benign mesodermal tumours such as desmoid tumours and osteomas. Epidermoid cysts can also occur (Gardner’s syndrome)

14. Carcinoma of the large bowel develops 10–20 years after the onset of the polyposis. Malignant change is rare before the age of 20 years. If there are no adenomas by the age of 30 years, FAP is unlikely Adolescence -surgery is usually deferred to the age of 17 or 18 years unless symptoms develop. Examination of blood relatives, including cousins, nephews and nieces, is essential Referral to a medical geneticist is essential. If over 100 adenomas are present at colonoscopy, the diagnosis can be made confidently

15. Treatment The aim of surgery in FAP is to prevent the development of colorectal cancer. SURGERY - COLECTOMY

16. Hereditary non-polyposis colorectal cancer (Lynch syndrome) HNPCC is characterised by an increased risk of colorectal cancer and also cancers of the endometrium, ovary, stomach and small intestine. It is an autosomal dominant condition caused by a mutation in one of the DNA mismatch repair genes. The most commonly affected genes are MLH1 and MSH2 . The lifetime risk of developing colorectal cancer is 80% The mean age of diagnosis is 45 years. Most cancers develop in the proximal colon. Females have a 30–50% lifetime risk of developing endometrial cancer.

17. Diagnosis - Amsterdam II criteria T hree or more family members with an HNPCC-related cancer (colorectal, endometrial, small bowel, ureter, renal pelvis) O ne of whom is a first-degree relative of the other two T wo successive affected generations; A t least one colorectal cancer diagnosed before the age of 50 years; FAP excluded Tumors verified by pathological examination Patients with HNPCC are offered regular endoscopic surveillance.

18. Carcinoma colon - Epidemiology C olorectal cancer is the second most common cause of cancer death. Approximately 35 000 patients are diagnosed with colorectal cancer every year Approximately one-third of these tumours are in the rectum and two-thirds in the colon. The burden of disease is similar in men and women.

19. Distribution of cancer

20. Adeno carcinoma sequence

21. Pathology

22. Staging colon cancer - AJCC 8 TH Edition

23. Metastasis

24. Clinical features 50 years of age Emergency presentation occurs in 20% of cases A careful family history should be taken. Those with first-degree relatives who have developed colorectal cancer before the age of 45 years may be part of one of the colorectal cancer familial syndromes. Tumours of the left side of the colon usually present with a change in bowel habit or rectal bleeding, Right side lesion present later with iron deficiency anaemia or a mass Patients commonly present with metastatic disease. Lesions of the flexures may present with vague upper abdominal symptoms for many months before symptoms suggestive of colonic disease appear

25. Investigation of colon cancer X ray barium enema CECT ABDOMEN Rigid sigmoidoscopy F lexible sigmoidoscopy Colonoscopy Virtual colonoscopy

26. X ray barium enema

27. CECT ABDOMEN

28. COLONOSCOPY

29. COLONOSCOPY

30. USES

31. VIRTUAL COLONOSCOPY

32. SURGERY- RIGHT HEMI COLECTOMY Carcinoma of the caecum or ascending colon not to injure the ureter, gonadal vessels or the duodenum. The ileocolic artery & right colic artery is ligated Distal 20 cm of ileum and the mesocolon as far as the proximal third of the transverse colon is divided

33. Extended right hemicolectomy Carcinomas of the transverse colon and splenic The extent of the resection is from the right colon to the descending colon. The mobilization is as for a right hemicolectomy but dissection continues to take down the splenic flexure and the whole transverse mesocolon is ligated

34. Left hemicolectomy S igmoid mesentery is mobilized L eft ureter and gonadal vessels must be identified and protected The splenic flexure may be mobilized The inferior mesenteric artery below its left colic branch together with the related paracolic lymph nodes is included in the resection Ligating the inferior mesenteric artery close to its origin (‘high-tie’) A temporary diverting stoma may be fashioned upstream, usually by formation of a loop ileostomy

35. Surgery for FAP The aim of surgery in FAP is to prevent the development of colorectal cancer. The surgical options are: 1 colectomy with ileorectal anastomosis (IRA) 2 restorative proctocolectomy with an ileal pouch–anal anastomosis (RPC) 3 total proctectomy and end ileostomy

36. Colectomy with ileorectal anastomosis (IRA)

37. Restorative proctocolectomy with an ileal pouch–anal anastomosis (RPC)

38. T otal proctectomy and end ileostomy

39. Emergency surgery Obstruction

40. Perforation

41. Treatment Surgery - a Hartmann’s procedure

42. Stenting

43. Metastatic disease Hepatic metastases can be resected and series have demonstrated 5-year survival of over 30% in resectable disease Isolated lung metastases may occasionally be suitable for resection In patients with widespread disease, palliative chemotherapy is offered alongside symptomatic treatment and support by a palliative care team.

44. FOLLOW UP Up to a half of all patients with colorectal cancer will develop liver metastases at some point Regular imaging of the liver (by ultrasound and CT scan) Measurement of carcinoembryonic antigen (CEA)