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Title: Please, silence your pagers


1
Please, silence your pagers
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(No Transcript)
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Surgery, after all, is an affair of the spirit
it is a fierce test of a mans technical skill,
sometimes, but, in a grim or long fight, it is
above all a trial of the spirit and there are
few things that cannot be conquered if a mans
heart is set on victory. Sir Berkeley
Moynihan
4
Uncommon Colorectal Tumors
  • Lymphoma
  • Leiomyosarcoma
  • Carcinoid
  • Anal Canal Cancer
  • Anal Margin Cancer
  • Squamous Carcinoma of the Anus
  • Pagets Disease
  • Bowens Disease
  • Anorectal Mucosal Melanoma

5
Colon CancerNew in Diagnosis and Management
  • Boris V. Vinogradsky, MDDepartment of
    SurgeryMedical College of OhioToledo, Ohio
  • October 20, 2001

6
Colorectal carcinoma comprises 13 of all
cancers, and is the second-leading cause of
cancer related death in the United States
Colorectal cancer causes 10 of all cancer
deaths
7
For general population the lifetime risk of being
diagnosed with colorectal cancer is 5.6 and the
risk of dying from it is 2.5In 2000, 130 200
cases were diagnosed and 56 600 people died of
the diseaseBetween 1990 and 1995 the incidence
of colorectal cancer decreased 2.3 per year
8
History
  • 1710 Morgagni Suggested excision of rectal cancer
  • 1714 Littre Concept of colostomy
  • 1776 Pillore Cecostomy for obstructing
    carcinoma
  • 1823 Reybard First successful colon resection and
    anastomosis
  • 1879 Martini Concept of Hartmanns procedure
  • 1882 Bryant Staged extraperitoneal operation
  • 1885 Kraske Transsacral approach
  • 1898 Bevan Performed first APR
  • 1898 Halsted Concept of aseptic anastomosis

Polk HC, Carcinoma of the Colon and Rectum, 1959
9
History
1908 Moynihan En bloc resection1909 Dobson Estab
lished routes of lymphatic spread1923 Fischer Ai
r-contrast Ba enema1926 Lockhart First staging
classification1926 Dukes Adenoma-to-carcinoma
sequence1932 Dukes Staging1939 Dixon Introduce
d LAR1941 McIntyre Extended study of regional
metastases1943 Wangensteen Pre-op bowel
preparation1954 Astler-Coller Modified Dukes
classification
Polk HC, Carcinoma of the Colon and Rectum, 1959
10
History 1961 Hirschowitz Introduced
fibrogastroscope1967 Turnbull Introduced Stage D
of colon cancer1968 Muir Intraoperative colonic
lavage1973 Wolff Polypectomy through
colonoscope1986 Mullis PCR1990 Laparoscopic
colectomy1991 Groden Identification of the APC
gene
Wu JS, Fazio VW, Dis Colon Rectum, Nov 2000
11
Colon Cancer Distribution
1. 75 2. 18 3. 5 4. 1 5. 1
Cameron JL, Current Surgical Therapy, 7th Ed, 2001
12
Board Question 1
  • Of the following, the most significant risk
    factor for colorectal cancer is
  • A. Low-Ca diet
  • B. High-fiber diet
  • C. Tobacco
  • D. High-fat diet

13
Risk factors
  • 75 of cases are sporadic
  • High-fat diet
  • Inflammatory Bowel Disease
  • About 1 of patients with cancer had inflammatory
    bowel disease
  • Chronic ulcerative colitis confers higher risk
    than Crohns disease, and 30 times higher risk
    than that of the general population
  • Previous Colon Carcinoma
  • Second primary colon Ca develops 3 times more
    frequently

14
Risk factors
  • History of First-Degree Relatives with Bowel
    Cancer
  • Average risk of general population is 5
  • Family history of colon cancer or advanced
    adenoma increases the risk 2-8 times
  • The risk is higher, if more than one relative is
    affected and, if cancer developed earlier than at
    the age of 45
  • People with known family history but without
    known genetic syndrome comprise 15-20 of
    patients at high risk

15
Polyps
  • Approximately 30 of adults in Western countries
    have adenomatous polyps
  • Most lesions are less than 1 cm in size
  • 60 of people have single adenoma
  • 40 have multiple adenoma
  • 60 of lesions located distal to splenic flexure
  • 24 of patients with adenomatous polyp left
    untreated will develop cancer in this polyp
    within 20 years

16
Polyps
  • Non-neoplastic
  • Hyperplastic
  • Multiple
  • Sessile
  • Less than 1 cm in diameter
  • No cellular atypia
  • Patients with distal hyperplastic polyps may have
    proximal adenomas
  • Inflammatory
  • Regenerating epithelium is seen
  • Mucosal

17
Polyps
  • Juvenile
  • Seen in children younger than 10 years of age
  • Hamartomatous
  • Aquired
  • 75 are found in the rectum
  • Red and pedunculated
  • Mucus filled
  • Frequent hematochezia

18
Polyps
Wu JS, Fazio VW, Dis Colon Rectum, Nov 2000
19
Genetics of Colon Cancer
  • Three major categories of genes
  • Oncogenes
  • Tumor suppressor genes
  • Mismatch repair genes
  • Two major pathways
  • Inactivation of tumor suppressing APC gene
  • Alterations in DNA mismatch repair genes
  • Major benefit of genetic studies is the ability
    to do a presymptomatic testing

Wu JS, Fazio VW, Dis Colon Rectum, Nov 2000
20
Polyps
Greenfield LJ. Surgery Scientific Principles and
Practice, 1997
21
Polyps
  • Neoplastic (adenomatous)
  • Benign or malignant
  • Nearly all carcinomas of the colon develop in
    previously benign polyps
  • Polyps can cause intussusception, bleeding,
    diarrhea and obstruction
  • Malignant polyp has invasion through muscularis
    mucosae layer
  • Polyps larger than 2 cm harbor cancer 25 of the
    time, although 65 of malignant polyps are less
    than 2 cm in size

22
Polyps
  • Tubular Adenoma
  • 75-87 of all polyps
  • Mild cellular atypia
  • 20 have severe atypia
  • Less than 5 are malignant
  • May be pedunculated or sessile
  • Complex branching glands on histology

23
Polyps
  • Tubulovillous Adenoma
  • 8-15 of polyps
  • 20-25 of them are malignant
  • Intermediate malignant potential
  • Both branching and villous (fingerlike) glands on
    histology

24
Polyps
  • Villous Adenoma
  • 5-10 of all polyps
  • Usually located in the rectum
  • Usually larger than 2 cm in size
  • High malignant potential
  • 35-40 are malignant
  • May cause mucous diarrhea with hypokalemic
    alkalosis and hypoalbuminemia

25
Polyps
  • Polyp size and malignant potential
  • Adenomas
  • Adenomas 1-2 cm - 9.5
  • Adenomas 2 cm - 46.0
  • Level of dysplasia and malignant potential
  • Mild - 5.7 risk of developing a malignancy
  • Moderate - 18.0
  • Severe - 34.5

M.D.Anderson Surgical Oncology Handbook, 2001
26
Polyps
  • Haggits classification of the depth of
    invasion
  • Invasion limited to the tip of the polyp (Level
    1)
  • Invasion of the neck
  • Invasion into the stalk
  • Invasion into the submucosa beneath the
  • base of the polyp (Level 4)
  • Single most important prognostic factor for
    mesenteric lymph node involvement
  • Sessile polyps are levels 4 and above

27
Polyps
Greenfield LJ. Surgery Scientific Principles and
Practice, 1997
28
Polyps Hamartomatous Polyposis
SyndromesIntestinal hamartoma is a focal
malformation, overgrowth of epithelial cells,
usually pedunculated, with the stalk lined with
normal mucosaDoes not cause compression of
adjacent tissueMinimal malignant potentialNo
need for resection
29
Polyps
  • Hamartomatous Polyposis Syndromes
  • Cronkhite-Canada Syndrome
  • Cowdens Disease
  • Basal Cell Nevus Syndrome
  • Neurofibromatosis (Type I Von Recklinghausens
    disease)
  • Peutz-Jeghers Syndrome

30
Board Question 2
  • All the following are true regarding familial
    polyposis (FAP), EXCEPT
  • A. It is associated with an increased risk of
    polyps anywhere in the GI tract
  • B. Essentially, 100 of untreated colons will
    ultimately manifest invasive cancer
  • C. Other than retinal pigmentation,
    extraintestinal manifestations are unusual
  • D. Less than 1 of patients have no prior family
    history of polyposis
  • E. The colon is carpeted with hundreds of polyps

31
Polyps
  • Hereditary Polyposis Syndromes
  • Familial adenomatous polyposis is the best
    characterized syndrome that carries a 100 risk
    of cancer development unless colon is
    prophylactically resected
  • Autosomal-dominant disease
  • Accounts for 1 of colorectal cancers
  • Affects 1 in 7,000 people
  • Germline mutation of the APC gene on chromosome 5
  • Aneuploid and more aggressive

32
Polyps
  • Hereditary Polyposis Syndromes
  • All associated with extraintestinal
    manifestations and multiple benign and malignant
    tumors of other organs
  • Gardners syndrome
  • Turcots syndrome
  • Oldfields syndrome

33
Effect of COX 2 Inhibitors in Patients with FAP
  • 6 months of treatment of patients with FAP with
    Celebrex reduced the number of polyps by 28 and
    the polyp burden was reduced by 31
  • Other NSAIDs and Aspirin have been used with the
    similar results

Steinbach G et al, N Engl J Med, June 2000 Janne
PA et al, N Engl J Med, June 2000
34
Polyps
  • Hereditary non-polyposis colorectal cancer
    (HNPCC)
  • Lynch I and II syndromes
  • Accounts for 5 of colorectal cancers
  • Diploid
  • Amsterdam criteria
  • 3 relatives (1 first-degree relative of the
    others) affected
  • These 3 people should be in two generations
  • One of them should develop colon Ca by the age of
    50

35
Polyps
  • Hereditary non-polyposis colorectal cancer
    (HNPCC)
  • Autosomal-dominant disease
  • Germline mutation of the hMLH1, hPMS1, hPMS2 and
    hMSH2 genes on chromosomes 2, 3 and 7
  • Lynch I - isolated colonic involvement
  • Lynch II - associated with other malignancies -
    endometrial, ovarian, gastric and small bowel
  • Both behave as fairly benign cancers
  • 70 of lesions are proximal to splenic flexure

Wu JS, Fazio VW, Dis Colon Rectum, Nov 2000
36
Polypectomy
  • Characteristics of lesions amenable to
    colonoscopic treatment
  • Arise in a pedunculated polyp
  • Well- or moderately differentiated
  • Have no venous or lymphatic invasion
  • Haggitts level 1-3
  • Have negative resection margin

Cameron JL, Current Surgical Therapy, 7th Ed, 2001
37
Polypectomy
  • Level 1-3 polyps can be removed without risk of
    metastases
  • Partial snare excision can be done to confirm
    presence of the invasive cancer
  • Resection margin is the most important factor of
    treatment outcome 2 mm margin is adequate
  • Poor histologic differentiation is an absolute
    indication for colon resection
  • Follow-up colostomy should be performed in 3-6
    months

38
Surveillance After Polypectomy
  • Colonoscopy and/or BE can be used
  • The detection of polyps by BE is significantly
    related to the size of the adenomas
  • Colonoscopy was more accurate than BE
  • Importance of this superiority is unclear since
    only 3 of lesions were larger than 1 cm

Winaver SJ and the National Polyp Study Work
Group, N Engl J Med, 2000
39
Alma Mater
40
Screening
  • Screening is a stratification of risk among
    apparently asymptomatic average-risk individuals
  • 20 of the general population are at risk of
    developing adenomatous polyps
  • Fecal occult blood test and endoscopy are the
    most widely employed screening tools
  • Colonoscopy is cost-effective, if a 10-year
    interval is used once the colon is cleared of
    polyps
  • CEA has no role in screening for primary lesions

M.D.Anderson Surgical Oncology Handbook, 2001
41
Colonoscopy
Courtesy of Dr. Strobel, Dept of Pathology,
St.Vs Hospital
42
Screening
  • Recommendations
  • Average-Risk Patients (start at the age of 50)
  • Annual fecal occult blood testing (FOBT)
  • If () colonoscopy or DCBE/flex sig
  • Flexible sigmoidoscopy every 5 years
  • If () colonoscopy
  • Combined FOBT and flexible sigmoidoscopy
  • Double-contrast Ba enema (DCBE) every 5 years
  • Colonoscopy every 10 years

M.D.Anderson Surgical Oncology Handbook, 2001
43
Screening
  • High-Risk Patients (asymptomatic)
  • Same as for average-risk but start at the age of
    40
  • High-Risk Patients (family history of FAP)
  • Genetic counseling and testing
  • Gene carriers flex sig every 12 months starting
    at puberty
  • High-Risk Patients (family history of HNPCC)
  • Colonoscopy every 1-2 years starting at the age
    of 25, or 5 years before the earliest age of
    onset of any cancer in a family, whichever is
    earlier and every year after 40

M.D.Anderson Surgical Oncology Handbook, 2001
44
Screening
  • High-Risk Patients (history of adenomatous
    polyps)
  • 1 cm polyp(s) repeat initial exam in 3 years
  • 2nd exam NL, or small, single or tubular
    adenoma repeat exam in 5 years
  • 2nd exam multiple polyps repeat exam per
    clinical judgment
  • High-Risk Patients (history of colon cancer)
  • Colonoscopy within 1 year of surgery
  • 2nd exam NL - repeat initial exam in 3 years
  • 3rd exam NL - repeat initial exam in 5 years

M.D.Anderson Surgical Oncology Handbook, 2001
45
Colonoscopy
Courtesy of Dr. Strobel, Dept of Pathology,
St.Vs Hospital
46
Colonoscopy in Screening for Colon Cancer
  • Overall shift towards right-sided colon lesions
    was noted recently
  • Of the 1,765 patients in patients over 50 years
    of age with no lesions distal to splenic flexure
    48 (2.7) had advanced proximal lesions, 30 of
    those were cancers
  • 62 of patients with advanced proximal neoplasms
    had no distal lesions

Lieberman DA et al, N Engl J Med, 2000 Imperiale
TF et al, N Engl J Med, 2000
47
Pathology
  • More than 90 of colon cancers are
    adenocarcinomas
  • The most frequently used grading system is based
    on the degree of formation of glandular
    structures, nuclear polymorphism, and number of
    mitoses
  • Morphologic variants
  • Ulcerative
  • Exophytic
  • Annular (scirrhous)
  • Submucosal infiltrative (linitis plastica type)

M.D.Anderson Surgical Oncology Handbook, 2001
48
Pathology
Courtesy of Dr. Strobel, Dept of Pathology,
St.Vs Hospital
49
Pathology
Courtesy of Dr. Strobel, Dept of Pathology,
St.Vs Hospital
50
Natural history
  • At diagnosis
  • 10 of patients will have in situ disease
  • 33 will have local disease
  • 33 will have regional disease
  • 25 will have metastases
  • 50-60 will develop metastases over their
    lifetime
  • Overall 5-year survival is about 50

M.D.Anderson Surgical Oncology Handbook, 2001
51
Diagnosis
  • Colon Cancer
  • Clinical evaluation includes colonoscopy with
    biopsy, BE, CXR, CBC, UA
  • CT of the abdomen and pelvis, LFT and CEA are
    controversial
  • Only 15 of patients with liver metastases have
    abnormal LFT
  • 40 of patients without liver metastases have
    abnormal LFT
  • Intraoperative liver US is the most accurate
    method of detection of metastases
  • 15-20 of liver metastases are nonpalpable
  • 10-15 of liver lesions are missed on pre- and
    intraoperative evaluation

M.D.Anderson Surgical Oncology Handbook, 2001
52
Ultrasound in Colorectal Cancer Diagnosis
Staren ED, Ultrasound for the Surgeon, 1997
53
Ultrasound in Rectal Cancer Diagnosis
  • Sensitivity and specificity
  • Depth of invasion 55-97 and 24-100
  • Identification of LN() 57-89 and 64-100
  • Indications
  • Tumors that satisfy criteria for local excision
  • Accessible, no larger than 4 cm
  • Demonstrate minimal invasion of the rectal wall
  • Not associated with nodal metastases

Staren ED, Ultrasound for the Surgeon, 1997
54
Ultrasound in Rectal Cancer Diagnosis
Cameron JL, Current Surgical Therapy, 7th Ed, 2001
55
CEA in Colorectal Cancer
  • CEA testing is recommended for monitoring of
    recurrence at 2-3 months intervals for 2 years
    after diagnosis of Stage II or III tumors
  • CEA first detected resectable recurrences more
    frequently than any other tests and was the most
    cost effective approach for identifying
    potentially resectable disease
  • Poorly differentiated tumors may not make CEA

Benson AB, J Clin Oncol, 2000
56
CEA in Colorectal Cancer
  • 20-30 of patients with recurrent disease have
    normal CEA level
  • 60-90 of asymptomatic patients with elevated CEA
    will have recurrent disease
  • 12-60 of them will have resectable disease at
    the time of laparotomy
  • 30-40 of these patients will survive 5 years
    following resection of the recurrence

M.D.Anderson Surgical Oncology Handbook, 2001
57
Immunoscanning (radioimmunodetection)
  • First suggested by Goldenberg in 1974
  • Accomplished by obtaining whole body or spot
    planar gamma scans on patient who has been
    injected intravenously with an antibody that has
    been labeled or conjugated with a gamma-emitting
    radionuclide. Antibodies were engineered for two
    antigens TAG-72 and CEA.
  • HAMA is the most serious limitation
  • Can only be used once
  • Initial enthusiasm faded

58
Immunoscanning
Indium-111 (OncoScint) or Technetium-99
(CEA-Scan) can be used
59
RIGS
  • In patients with rising CEA levels and negative
    metastatic work-up an exploratory laparotomy
    should be performed
  • I-125 labeled antibodies to CEA injected 6 weeks
    before the second-look surgery and detected
    intraoperatively by a hand-held gamma probe
  • Detection is accurate in 81 of patients
  • To date, no study has demonstrated a survival
    advantage with this technique
  • Radioimmunoguided Surgery

M.D.Anderson Surgical Oncology Handbook, 2001
60
Virtual Colonoscopy
  • Novel technique where overlapping transaxial
    helical CT images reconstructed following a
    standard bowel preparation and air insufflation
  • 2-D multiplanar reformations and 3-D endoluminal
    images are viewed
  • Sensitivity for detection of lesions 10 mm in
    size was 75-91
  • Successful in 90 of patients with occlusive
    colon cancer

Brink JA et al,Contemporary Surgery, May 2000
61
Virtual Colonoscopy
Brink JA et al,Contemporary Surgery, May 2000
62
PET scanning
  • New controversial imaging technology currently in
    use only as a research tool
  • Relies on the increased uptake of glucose (FDG)
    in tumors compared with normal tissues
  • Expensive and has not yet been approved for
    general use

M.D.Anderson Surgical Oncology Handbook, 2001
63
Board Question 3
  • Regarding colon cancer staging
  • A. Cancer in the head of a polyp, invading into
    the submucosa is Stage 0
  • B. Primary tumor invading the muscularis propria
    but not through is Stage I
  • C. Less than 3 lymph nodes involved is Stage II
  • D. Perforation of a tumor constitutes Stage III
  • E. Stage IV (AJCC) is equivalent to Dukes Stage
    D

64
Staging
M.D.Anderson Surgical Oncology Handbook, 2001
65
Staging
  • Extent of Resection (R) in TNM classification
  • RX - Presence of residual tumor cannot be
    assessed
  • R0 - No residual tumor
  • R1 - Microscopic residual tumor
  • R2 - Macroscopic residual tumor
  • Level of evidence IV
  • Grade of recommendation B

Journal of NCI, Vol.93, No.8, April 18, 2001
66
Staging
TNM classification for the Staging of Colorectal
Cancer 0 Tis N0 M0 I T1 (submucosa) N0 M0
T2 (muscularis) N0 M0 II T3
(serosa) N0 M0 T4 (adjacent
organ) N0 M0 III Any T N1 (1-3
nodes) M0 IV Any T Any N M1 N2 (4
nodes) N3 (LN on vascular trunk)
Cameron JL, Current Surgical Therapy, 7th Ed, 2001
67
Staging
  • Radial Margin
  • T4 lesions represent a complex group and should
    be considered separately
  • Patients who do not have histologic assessment of
    radial tumor margin or had an R1 or R2 resections
    are considered to have an incomplete resection
    for cure
  • Incomplete resection does not change the TNM
    stage, but it does affect curability
  • Level of evidence III
  • Grade of recommendation B

Journal of NCI, Vol.93, No.8, April 18, 2001
68
(No Transcript)
69
Management of Colon Cancer
  • Surgical Options
  • 90-92 of patients with colon cancer and 84 of
    patients with rectal cancer are treated
    surgically
  • In most cases surgery is performed with curative
    intent
  • Surgery is the only treatment modality that has a
    potential for cure
  • Standard resection is the only therapy required
    for early-stage cancer
  • Adjuvant Therapy
  • 5-FU is the single most effective agent for colon
    cancer

M.D.Anderson Surgical Oncology Handbook, 2001
70
Management of Colon Cancer
  • Anatomic Definitions Colon vs. Rectum
  • Colon - greater than 12 cm from anal verge by
    rigid proctoscopy
  • Rectum - 12 cm or less from anal verge
  • It is important from a stand point of local
    recurrence rates 9.6 vs. 30.7
  • Level of evidence IV-V
  • Grade of recommendation B

Journal of NCI, Vol.93, No.8, April 18, 2001
71
Management of Colon Cancer
  • Surgical Aspects
  • Abdominal Exploration
  • Should be performed in every patient and must be
    thorough
  • Includes inspection and bimanual palpation of the
    liver, peritoneal surface, omentum,
    retroperitoneum and ovaries, if present
  • The primary tumor should be checked for local
    adherence
  • Palpation of periaortic, celiac and portohepatic
    lymph nodes is important
  • Level of evidence V
  • Grade of recommendation D

Journal of NCI, Vol.93, No.8, April 18, 2001
72
Management of Colon Cancer
Wu JS, Fazio VW, Dis Colon Rectum, Nov 2000
73
Management of Colon Cancer
  • Surgical Options
  • Right hemicolectomy
  • Extended right hemicolectomy
  • Transverse colectomy
  • Left hemicolectomy
  • Low anterior resection
  • Subtotal colectomy
  • Abdominal perineal resection

Greenfield LJ. Surgery Scientific Principles and
Practice, 1997
74
Management of Rectal Cancer
  • Surgical Options
  • Transanal excision
  • Transanal endoscopic microsurgery
  • Low anterior resection
  • Abdominal perineal resection
  • Non-surgical Options
  • Endocavitary radiation
  • Laser ablation

M.D.Anderson Surgical Oncology Handbook, 2001
75
Management of Colon Cancer
  • Surgical Options
  • Ideal Bowel Resection and Margins
  • The ideal extent of a bowel resections is defined
    by removing the blood supply and lymphatics at
    the level of the origin of the primary feeding
    blood vessel
  • IMA resection at its origin is not mandated by
    available evidence
  • Ileal resection should be minimal
  • Level of evidence IV
  • Grade of recommendation D

Journal of NCI, Vol.93, No.8, April 18, 2001
76
Abdominal Perineal Resection
Wilmore DW, Scientific American Surgery, 1998
77
Management of Colon Cancer
  • Surgical Aspects
  • No-Touch Technique
  • Controversial issue
  • Turnbull et al (Ann Surg, 1967) demonstrated a
    difference in 5-year survival but the study had
    serious design flaws
  • Wiggers et al (Brit J Surg, 1988) in the
    prospective randomized trial demonstrated no
    statistically significant difference (56 vs.
    59)
  • Level of evidence II
  • Grade of recommendation B

Journal of NCI, Vol.93, No.8, April 18, 2001
78
Management of Colon Cancer
  • Laparoscopic Colectomy
  • Benefits
  • Decreased length of stay
  • Decreased pain and narcotic usage
  • Improved cosmetic results
  • Lower cost
  • Difficulties
  • Mobile and bulky specimen
  • Inability to palpate the tumor
  • Long learning curve

Stocchi L, Nelson H, Journal of Surgical
Oncology, 1998
79
Management of Colon Cancer
  • Laparoscopic Colectomy
  • Complications
  • Bleeding
  • Major blood vessel injury
  • Ureteral injury
  • Bowel injury
  • Malrotation of anastomosis
  • Tumor not in the specimen
  • Inadequate margins and lymph node clearance
  • Trocar site recurrence

Stocchi L, Nelson H, Journal of Surgical
Oncology, 1998
80
Management of Colon Cancer
  • Surgical Options
  • Obstructing Colorectal Cancers
  • Up to 30 patients with primary colon cancer
    present with large-bowel obstruction
  • One or two-stage operations can be performed
  • Stent placement could be considered for
    preoperative decompression and for palliation of
    cancerous obstruction
  • Successful stent placement , with resolution of
    obstruction within 96 hours was achieved in 93
    of patients

Baron TH, N Engl J Med, Vol. 344, No. 22, May 2001
81
Stenting of Colon Cancer
  • Problems
  • Inability to pass a
  • guide wire through
  • the mass (up to 40)
  • Perforation (5-15)
  • Stent occlusion
  • Stent migration
  • Tenesmus

Tamim WZ, Archives of Surgery, April 2000
82
Management of Colon Cancer
  • Surgical Aspects
  • Bowel Washout
  • Performed when creation of primary anastomosis is
    planned
  • More common in emergency situations
  • Takes about 45-60 minutes
  • Does not decrease local recurrence or anastomotic
    implantation rates

Wu JS, Fazio VW, Dis Colon Rectum, Nov 2000
83
Management of Colon Cancer
  • Surgical Aspects
  • Inadvertent Perforation
  • Has been reported in 8-26 of cases
  • Increases local recurrence rate and decreases
    survival
  • Lesion should be considered T4, and Stage III, if
    it occurs during resection
  • Resection should be considered complete (R0) if
    margins and resected lymph nodes are negative
  • Inadvertent perforation must be carefully
    documented
  • Level of evidence III
  • Grade of recommendation B

Journal of NCI, Vol.93, No.8, April 18, 2001
84
Management of Colon Cancer
  • Surgical Options
  • Lymphadenectomy
  • In all cases for cure, the lymph node resection
    should be radical, nodes should be removed en
    bloc
  • Nodes should be excised to the level of a primary
    feeding vessel
  • Nodes suspected of being positive outside of the
    field of resection should have a biopsy
  • Extended radical lymphadenectomy is not indicated
  • A minimum of 12 negative nodes have to be
    examined to confirm that disease does not involve
    the nodes
  • Level of evidence III-IV
  • Grade of recommendation C

Journal of NCI, Vol.93, No.8, April 18, 2001
85
Management of Colon Cancer
  • Surgical Aspects
  • Oophorectomy
  • Ovarian metastases occur in up to 7 of patients
  • Grossly abnormal ovaries or ovaries with direct
    extension of the tumor should be removed
  • May be an option in patients who receive
    preoperative XRT or who are postmenopausal
  • Routine prophylactic oophorectomy is not
    indicated
  • Level of evidence IV
  • Grade of recommendation D

Journal of NCI, Vol.93, No.8, April 18, 2001
86
Sentinel Lymph Node Biopsy in Colon Cancer
  • SLN identification was successful in 98,8 of
    patients and 34 of them were positive for cancer
  • In 52 of positive cases SLN was the only
    positive node
  • False-negative rate in this study was 9
  • SLN identification upstaged 8 of patients from
    Stage I-II to Stage III. These patients received
    adjuvant therapy

Saha S et al, Ann Surg Oncol, 2000
87
Treatment of Locally Advanced Colon Cancer
  • Surgical Aspects
  • En bloc Resection of Adherent Tumors
  • Adherence to adjacent intraabdominal structures
    encountered in 15 of patients, up to 84 of
    adhesions are malignant
  • Urinary bladder is the most commonly involved
    organ
  • Lesions that are treated as T4 by en bloc
    resection but that contain only inflammatory
    adhesions are not considered to be T4 lesions
  • Local recurrence rate is 36 (with) vs. 77
    (without EBR)
  • 5-year survival is 61 vs. 23
  • Level of evidence III
  • Grade of recommendation B

Journal of NCI, Vol.93, No.8, April 18, 2001
88
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Management of Rectal Cancer
  • Surgical Aspects
  • Mesorectal Excision
  • Mesorectum - lymphovascular, fatty and neural
    tissue that is circumferentially adherent to the
    rectum, starting at the level of sacral
    promontory
  • Resection should be done under direct vision
  • 4-cm fresh distal mesorectal margin should be
    obtained
  • Circumferential margin involvement indicates
    advanced disease, not inadequate surgery
  • Level of evidence III
  • Grade of recommendation C

Journal of NCI, Vol.93, No.8, April 18, 2001
90
Management of Rectal Cancer
  • Surgical Aspects
  • Distal and Proximal Bowel Margins
  • Distal intramural spread beyond 1 cm was reported
    in only 4-10 of rectal cancers
  • Distal spread beyond 1 cm is associated with
    advanced and aggressive disease
  • Associated poor prognosis is not improved by a
    wider margin
  • 2-cm margin of resection is adequate
  • Level of evidence III-IV
  • Grade of recommendation B

Journal of NCI, Vol.93, No.8, April 18, 2001
91
Board Question 4
  • A 55-year old female with rectal cancer, 6 cm
    from the anal verge, less than a 30 of rectal
    circumference, non-fixed and uT2 depth on
    endorectal ultrasound. Biopsy showed a
    well-differentiated lesion with lymphatic
    invasion
  • The patient should undergo an APR.
  • TRUE OR FALSE?

92
Management of Rectal Cancer
  • Surgical Aspects
  • Ileo- or coloanal anastomosis with J-pouch
  • Can be done after sphincter-preserving operation
    to improve continence
  • Preservation of ileocolic artery is mandatory
  • Proximal diversion is indicated, if
  • anastomosis is less than 5 cm above the anal
    verge
  • patient has received preoperative XRT
  • patient is on steroids
  • integrity of the anastomosis is in question
  • any episode of hemodynamic instability occurred
    intraoperatively

M.D.Anderson Surgical Oncology Handbook, 2001
93
Recurrent and Metastatic Disease
  • 95 of recurrences occur within 5 years of
    surgery
  • After surgery, 80 of failures have a component
    of metastatic disease
  • Liver is the site of first recurrence in 35 of
    patients, lungs - in 20 of patients
  • Local failure occurs as a first site in 15 of
    patients with Stage II or III disease
  • The high risk of distant disease mandates
    systemic adjuvant therapy
  • Tumors at high risk for local recurrence may
    benefit from radiotherapy

Cameron JL, Current Surgical Therapy, 7th Ed, 2001
94
Recurrent and Metastatic Disease
  • Adjuvant Therapy
  • Still evolving and controversial subject,
    especially for patients with Stage II lesions
    (may be indicated for high-risk patient with
    Stage II (B2) lesions)
  • 5-FU is the most effective single agent for colon
    carcinoma
  • Adjuvant therapy trials using 5-FU in combination
    with vinblastine and/or semustine produced
    conflicting results

M.D.Anderson Surgical Oncology Handbook, 2001
95
Adjuvant Therapy
  • 5-FU/Levamisole
  • PRS of 12 month course of 5-FU/Lev compared with
    surgery alone in patients with Stage II and III
    tumors showed 41 decrease in recurrence and 33
    decrease in mortality for Stage III disease
  • 5-FU/Leucovorin
  • A 6 months course of 5-FU/Leu showed results
    similar to 5-FU/Lev regimen. PRS of this
    combination have not yet been completed
  • Prospective randomized study

M.D.Anderson Surgical Oncology Handbook, 2001
96
Adjuvant Therapy
Greenfield LJ. Surgery Scientific Principles and
Practice, 1997
97
Adjuvant Therapy
  • Postoperative Radiation (Colon)
  • The role is not yet defined
  • Patients at high risk for local recurrence (T4No
    T3-4N1-3) may benefit from abdominal radiation
  • Administration of XRT remains at the discretion
    of treating physician and patient
  • Postoperative Radiation (Rectum)
  • There was only one trial that showed decrease in
    local recurrence from 25 to 16 in the
    postoperative XRT arm
  • Despite the performance of several large PRS,
    survival, local pelvic control, and extrapelvic
    recurrence rates have not been improved
    consistently by radiation

M.D.Anderson Surgical Oncology Handbook, 2001
98
Adjuvant Therapy
  • IORT
  • Increases local control rate (77)
  • Allows shielding of sensitive
  • structures
  • Lowers the dose of radiation
  • (20 vs. 45-50 Gy)
  • Allows accurate treatment of
  • focal areas at risk

M.D.Anderson Surgical Oncology Handbook, 2001
99
Management of Colorectal Cancer
  • Complications of Surgical and Adjuvant Therapy
  • Nonspecific (bleeding, infection, adjacent organ
    injury)
  • Anastomotic leak occurs in 5-10 of cases
  • Anastomotic strictures
  • Sexual and urinary dysfunction in 15-25
  • Mortality rate from surgery varies from 2 to 6
  • Radiation enteritis and dermatitis, 5-FU
    stomatitis
  • Hematologic toxicity
  • Wound and stoma complications

M.D.Anderson Surgical Oncology Handbook, 2001
100
The best trio in colorectal cancer management
101
Board Question 5
  • All of the following will be considered relative
    contraindications to hepatic metastasectomy in
    colon cancer EXCEPT
  • A. More than 4 metastases in one lobe
  • B. Concomitant lung mets
  • C. 6 cm solitary metastasis in right lobe
  • D. Disease-free interval of 3 months
  • E. Primary tumor stage III

102
Colorectal Cancer Metastatic to the Liver
  • Resection
  • Curative hepatic resection requires a
    circumferential tumor-free margin of 1 cm
  • Resection is contraindicated in the presence of
    celiac/portal nodal metastases, extrahepatic
    disease and/or more than 5 liver metastases (now
    relative)
  • Disease-free interval less than 1 year is a poor
    prognostic indicator
  • Resection should be considered only in patients
    who have responded to preoperative systemic
    therapy

Cameron JL, Current Surgical Therapy, 7th Ed, 2001
103
Colorectal Cancer Metastatic to the Liver
  • Intraarterial Therapy (HAIC)
  • 95 of blood supply of metastases comes from
    hepatic artery
  • Floxuridine is the principal agent
  • Internal or external pumps can be used
  • Chemotherapy-related complications occur in up to
    25 of patients
  • There is no improvement in survival after HAIC
  • Hepatic Arterial Infusion Chemotherapy

Cameron JL, Current Surgical Therapy, 7th Ed, 2001
104
Metastatic Colorectal Cancer
  • Prognostic Factors
  • Vessel count in the specimen tissue and
    corresponding expression of VEGF (Vascular
    Endothelial Growth Factor) correlated with time
    of recurrence
  • The mean tumor vessel count for patients who
    remained disease-free (20) was significantly
    (precurrence (33)

Takahashi Y et al, Archives of Surgery, Vol 132,
No 5, May 1997
105
Metastatic Colorectal Cancer
  • Patients with sequentially detected hepatic and
    pulmonary metastases are good candidates for
    aggressive metastasectomy
  • Simultaneous detection of these metastases does
    not warrant resection

Nagakura S et al, J Am Coll Surg, August 2001
106
Survival After Resection of Colorectal Metastases
  • Disease recurrence in 3 years after resection
    occurs in up to 85 of patients
  • Operative mortality is 2-5
  • 5-year survival is 23-27
  • 10-year survival is 20
  • Disease-free patient survival beyond 5 years
    represents patient cure in up to 80 of cases

Jamison RL et al, Archives of Surgery, May 1997
107
Nonresective Destructive Techniques
  • Cryosurgical ablation (CSA) therapy
  • Radiofrequency ablation (RFA) therapy
  • Advantages and disadvantages of each technique
    have not yet been statistically determined
  • Laparoscopy and intraoperative US are essential
    in staging patients with liver metastases
  • These techniques allow treatment of multiple
    lesions and perivascular lesions
  • RFA combined with CSA reduces the morbidity of
    multiple freezes
  • Lesion size is limited to 8 cm and a 1-cm
    vascular margin is mandatory

Bilchik AJ et al, Archives of Surgery, June 2000
108
Cryosurgical Ablation (CSA)
Cameron JL, Current Surgical Therapy, 7th Ed, 2001
109
Cryosurgical Ablation (CSA)
Bilchik AJ et al, Archives of Surgery, June 2000
110
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Survival
  • Overall 5-year survival is about 50
  • Nodal involvement is the primary determinant of
    5-year survival
  • Stratified survival
  • 90 for T1-T2 and 80 for T3 LN (-) local disease
  • 27-69 for LN () disease (1 vs. 6 nodes)
  • 5 for distant disease

M.D.Anderson Surgical Oncology Handbook, 2001
112
Survival
Greenfield LJ. Surgery Scientific Principles and
Practice, 1997
113
Factors Affecting Survival
  • Perforation
  • Obstruction
  • Poor tumor differentiation
  • Mucinous or signet ring histology
  • Venous invasion
  • Perineural invasion
  • DNA non-diploid tumor
  • Allelic loss

Wu JS, Fazio VW, Dis Colon Rectum, Nov 2000
114
Microsatellite Instability
  • High frequency of microsatellite instability was
    found in 17 of specimens and it was associated
    with a significant survival advantage
    independently of all standard prognostic factors,
    including tumor stage

Gryfe R et al, N Engl J Med, 2000
115
Survival
Overall and tumor-free survival of the series (A)
and after palliative and curative resections (B)
60 vs. 38 (Dukes B) and 57 vs. 29 (Dukes C
lesions)
Allison D et al, J Surg Oncol, 1996
116
Follow-up
Greenfield LJ. Surgery Scientific Principles and
Practice, 1997
117
Acknowledgments
  • Dr. Edgar Staren
  • Dr. David Allison
  • Dr. Abed Alo
  • Dr. William Strobel
  • Jeff Coomer

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