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Colorectal Cancer
Thomas Badenoch
Learning Objectives
Objectives
- Define
- Describe Epidemiology
- Understand Aetiology
- List Clinical Features
- Principles of Investigation and Management
- Questions
Definition
- Cancer colon and rectum
- 50% recto-sigmoid region
- Older patients more proximal
Definition
Adenocarcinoma
- Derived from epithelial gland cells
- 95-98% of all Colorectal cancer
- Subtypes- Mucinous (10-15%), Signet Ring Cell(1%)
Adenocarcinoma
Rare Types
- Neuroendocrine Tumours (Carcinoid)
- 1% Total
- More common in small bowel
- Lymphoma
- Non-Hodgkin lymphoma
- 5% of all Lymphomas
- Men>Women
- Gastro-Intestinal Stromal Tumours (GIST)
- Rare
- Form of Sarcoma
- Most common in stomach and small bowel, followed by rectum
- Leimyosarcoma
- Melanoma
Epidemiology
Incidence
Common
- 4th most common (3rd for each sex)
- 42,000 cases annually (11%)
- 75 and over, peak 85-89
- Small decrease in incidence over last 10-years
Mortality + Survival
Mortality
- 2nd commonest cause of cancer death
- 3rd most common for each sex
- Since 1970s decreased by 50% females, 41% males
Survival
- 78% at one year
- 58% at five years
- 53% at ten years
- Below the European average
Aetiology
- Interplay of many factors
- Majority sporadic
- Age greatest risk factor
Aetiology
Genetic
- Large number of mutations
- Commonest:
- APC (Tumour suppressor gene)
- p53 (Tumour suppressor gene)
- KRAS (Oncogene)
- Mismatch repair (MMR)
Congenital
List some!
Congenital
2-5% of total Colorectal cancers
Family History
One 1st Deg. relative RR 2.24
Two 1st Deg. relatives RR 3.97
Hereditary Nonpolyposis (HNPCC)/ Lynch Syndrome
- Autosomal dominant
- Colorectal, Endometrial, Gastric, Ovarian
- Amsterdam Criteria
Familial Adenomatous Polyposis
- Autosomal dominant
- Multiple benign polyps
Gardner's Syndrome
- Subtype FAP
- Osteomas, thyroid ca, epidermoid cysts, fibromas
Acquired
Epigenetic mutation more frequent
- Reduction in enzyme repair expression
- Age related
- Chemotherapy sensitivity
IBD
- Crohn's- 2% at 10 years, 8% at 20, 18% at 30
- UC - 16% over 30 years
Environmental
List some!
Environmental
- Age
- Obesity - also worse outcomes
- Smoking
- Diet- poor fibre, red/processed meat
- Poor physical activity
- Alcohol
- Previous Ca
- Endocrine - Diabetes, acromegaly
Clinical Features
Asymptomatic Patient at Screening
Symptomatic in Community
Emergency Presentation
Symptoms
Early vs Late
Proximal vs Distal
Symptoms
List some!
Time
Anaemia (Up to 10% have CRC)
Change in bowel habit
PR bleeding
Pain
Weight loss
Distention
Vomiting
Location
Right Sided
- Anaemia
Left Sided
- Ribbon/loose stools
- Obstruction
Rectal
- Pain
- PR bleeding
- Tenesmus
Management
MDT Approach
- Patient Specific
- Disease Specific
Management
Investigations
Diagnostic vs Staging
Name some!
Investigations
Full History and Examination
- Risk factors
- Family History
- PR exam
Diagnostic
Bloods
- FBC, U+Es, LFTs
- Carcinoembryonic Antigen (CEA)
Colonoscopy
- Physiological burden
- Operator dependent (6% miss rate)
- Complications - sedation, perforation
- Biopsy
CT Colon
- Endoluminal view
- Well tolerated
Barium Enema
- Less used
Staging
CT Thorax, Abdomen and Pelvis
MRI Pelvis
PET Scan
Staging
Stage
Stage 1
- Mucosa and submucosa involved. It has not spread to the lymph nodes.
Stage 2
- 2A No lymph nodes or nearby tissue. Limited to muscularis propria,
- 2B No lymph nodes, but visceral peritoneum involved.
- 2C No lymph nodes, but it has grown to nearby organs or structures.
Stage 3
- 3A One to three lymph nodes involved. No distant spread.
- 3B One to three lymph nodes, visceral peritoneum or other organs or structures involved. Or four or more nearby lymph nodes but limited to bowel.
- 3C Visceral peritoneum involved. Four or more nearby lymph nodes, but not distant sites.
Stage 4
- 4A Spread to one distant site, such as the liver or lungs.
- 4B Spread to two or more distant sites, such as the lungs and liver.
Grade
G1 - Well differentiated (Low grade)
G2 - Moderately differentiated (Intermediate grade)
G3 - Poorly differentiated (High grade)
G4 - Undifferentiated (High grade)
Grade
Treatment
Surgical Resection
- Counselling, stoma care
- Laparoscopic vs open
Systemic Therapy
- FOLFOX
- CapeOX
Colon
Stage 1-2
- Resection
- En bloc lymph node
Stage 3
- Plus adjuvant chemo
Stage 4 resectable metastasis
- Synchronous/staged resection
- Pre/post-op adjuvant
- Peritoneal disease
Stage 4 unresectable
- Palliative
Rectal
Stage 1
- Transanal procedures
- Anterior resection
Stage 2 - 3
- Pre-op chemoradiotherapy
Stage 4 resectable mets
- Synchronous/staged resection
- Pre/post-op adjuvant
- Peritoneal disease treatment
Stage 4
- Palliative
References
Questions?
https://www.nice.org.uk/
https://bestpractice.bmj.com/
www.cancerresearchuk.org
www.mayoclinic.org
www.cancercenter.com
www.pathologyoutlines.com
www.webpathology.com