DISCUSS THE PATHOGENESIS OF COLORECTAL CANCER.pptx

Pathology and management of colon tumur

1. PATHOGENESIS OF COLORECTAL CANCER BY DR MOSES CLETUS GALADIMA REGISTRAR GENERAL SURGERY FEDERAL TEACHING HOSPITAL GOMBE

2. OUTLINE INTRODUCTION EPIDEMOLOGY RISK FACTORS ANATOMY PATHOGENESIS CLINICAL PRESENTATION MANAGEMENT

3. INTRODUCTION Cancer of the colon and rectum 3 rd commonest after lung and stomach in male and breast and cervix in female Account for 10% of cancer in male,9.4 in females Worlwide incidence is 1.2million and half die of the disease

4. RISK FACTORS 90% of new cases >50 years Inflammatory b o wel Disease Personal or Family History of cancer or Polyps

5. Genetic syndromes Adenomatous polyps villous, >2cm, dysplasia ?Lifestyle Risk reduction through preventive measures

6. PATHOGENESIS Adenocarcinoma 95% columnar/mucinous well/moderate/poorly differentiated/anaplastic Vascular /perineural invasion Lymphoma Sarcomas /GIST Carcinoids Melanoma

7. SPREAD Local Lymphatics Permeation upwards Mesorectal spread fan shaped Hematogenous Liver 34%, lungs 22%, adrenal 11% Transperitoneal

8. PATHOGENESIS Sporadic Hereditary Familial

9. PRESENTATION High % advanced disease 25% emergency Bleeding Acute on chronic obstruction Perforation

10. EXAMINATION Wt loss pallor Jaundice Abdominal distension, visible peristalsis Palpable abdominal mass, Hepatomegaly, ascites in advanced disease DRE findings

11. Caecal and ascending colonic tumour appendiceal mass/abscess and amoeboma ileocaecal TB, gynaecologic Transverse colonic tumour carcinoma of the stomach, pancreatic tumour

12. DD Rectum/general Ca prostate/cervix amoeboma , Schistosomiasis LGV IBD Polyps Diverticular disease

13. INVESTIGATION Endoscopy and biopsy DCBE Endoluminal ultrasonography Abdominopelvic ultrasound CT

14. Phased array MRI CEA CBC, LFT, E/U, FBS, CXR

15. MANAGEMENT GUIDELINES Diagnostic work up & Pt assessment Staging Treatment plan Informed Consent

16. Bowel preparation Ostomy visit/stoma site marking Thromboprophylaxis Definitive Treatment

17. STAGE PROGNOSIS 5yrs T N M DUKES Tis N0 M0 1 >90% T1-2 N0 M0 A IIA 60-85% T3 N0 M0 B IIB 60-85% T4 N0 M0 B IIIA 55-60% T1-2 N1 M0 C IIIB 35-42% T3-4 N1 M0 C IIIC 25-27% Any N2 M0 C IV 5-7% Any Any M1 TNM

18.   TX Cannot be assessed   T0 No evidence   Tis Carcinoma in situ   T1 Invades submucosa   T2 Invades muscularis propria   T3 Invades into the subserosa or nonperitonealized pericolic or perirectal tissues   T4 Invades other organs or structures, perforated visceral peritoneum Regional Lymph Nodes (N)   NX Cannot be assessed   N0 No regional lymph node metastasis   N1 1 to 3 regional lymph nodes   N2 4 or more regional lymph nodes Distant Metastasis (M)   MX Cannot be assessed   M0 No distant metastasis   M1 Distant metastasis TNM

19. STAGE TREATMENT I Surgery II Favorable Surgery + Adjuvant chemotherapy III & II Unfavorable T 4 Poor histological grade Elevated CEA Microsatellite Stability DCC Obstruction or perforation Threatened circumferential margin Neoadjuvant chemoradiation + Surgery + Adjuvant chemotherapy (No radiotherapy for colon cancer) IV Chemotherapy ±Surgery ± metastasectomy CRC TREATMENT

20. SURGICAL PRINCIPLES Thorough abdominal exploration Appropriate Resection with clear margins± involved adjacent organ Lymphadenectomy Re-establishment of bowel continuity

21. RECTAL CANCER SURGERY Sphincter conservation takes precedence over APR Total Mesorectal Excision (TME) Pelvic Autonomic Nerve Preservation (PANP)

22. MANUAL STAPLERS >10cm Anterior resection 7-10cm Low anterior resection 5-7cm Ultra low anterior resection Dentate TI-T2 Intersphincteric Intersphincteric Sphincters Abdominoperianal resection RECTAL CANCER SURGERY

23. CRC SURGERY Growing influence of laparoscopic surgery Multiple Tumours & HNPCC: TP+IPAA/Subtotal Colectomy. Polyp Cancer Pedunculated: polypectomy Sessile/unfavorable features: surgery

24. SURGERY FOR ADVANCE CRC Palliative resection to relieve obstructions Stenting Bypass procedures Ileocolic anastomosis Colocolic ’’ Colostomy

25. SURGERY FOR LIVER METASTASIS Hepatic resection is the treatment of choice Feasibility of complete resection [12 weeks] Extrahepatic site must be resectable Primary tumour : Resection for cure Re-evaluation for resection after neoadjuvant Solitary tumour : better prognosis

26. CRC CHEMOTHERAPY Neoadjuvant/adjuvant 5FU/LV, xeloda , Oxaliplatin Systemic Above Irinotecan Targeted therapy

27. DRUG MECHANISM TOXICITY 5-FU Thymidylate synthetase Diarrhea, stomatitis , hand/foot syndrome,neutropenia , NV Oxaliplatin DNA replication Paresthesia Irinotecan Topoisomerase I inhibitor Diarrhea, myelosuppression, alopecia Bevacizumab VEGF Bleeding, bowel perforation, arterial emboli Cetuximab , panitumumab EGF Skin, rashes, fissures, xerosis CRC CHEMOTHERAPY

28. RC RADIOTHERAPY Neoadjuvant chemoradiation Downstaging ↑ Resectability ↑Sphincter conservation ↓Local recurrence Palliation

29. POOR PROGNOSIS T4 >4 nodes positive <12 Nodes examined Poorly differentiated Lymphovascular invasion Perineural invasion Preop CEA > 5.0ng/ml Bowel obstruction Surgical margin involvement Chromosomal deletion Microsatellite stability Quality of care

30. CONCLUSION Colorectal cancer is the third most common cancer in both men and women. Tremendous strides are made regularly in the prevention, diagnosis and treatment of colorectal cancer, posing a challenge to the clinician who must stay abreast of the most recent advances

31. REFERENCE POSTGRADUATE SURGERY AL-FALLOUJI PG 275 PRINCIPLES AND PRACTICE OF SURGERY BADOE pg 564 Bailey and Love short Practices pg 1143

32. THANKS FOR LISTENING