دي دردشة عن الColorectal Cancer تنفع لمستوى طلبة الطب او اللي داخلين MRCS لو شوفتوه مفيد ممكن نكمل و ندعو ناس تحضر الدردشة دي لايف.. اعملو شير لو شايفينه مفيد.. تقييمكو و رايكو مفيد جدا.. tفيديوالمحاضرة علي اليوتيوب https://www.youtube.com/watch?v=npmaXS0e1nQ

1. Colorectal
cancer
Basics

2. Colorectal Cancer
• Symptoms
• Signs
• Pathology / Staging
• Investigations
• Treatment

3. Diagnosis / Workup
• Colon cancer = Colonoscopy + Staging CT TAP
• Colon Cancer = Flexible sigmoidoscopy + Virtual colonoscopy + Staging CT
TAP
• Colon cancer = Flexible sigmoidoscopy + Ba Enema (Major Comorbidities)
• Rectal Cancer = Colonoscopy + MRI (EUS for ?? Endoscopic resection) +
Staging CT TAP
• Colonoscopy or Flexible sigmoidoscopy for tissue diagnosis
• Fitness for bowel prep/Colonoscopy ??Fitness for operation

4. Diagnosis
The referral timelines referenced in the NICE guideline are as follows:
• Immediate: an acute admission or referral occurring within a few
hours, or even more quickly if necessary.
• Urgent: the patient is seen within the national target for urgent
referrals (currently 2 weeks).
• Very urgent: to happen within 48 hours
• Non-urgent: all other referrals.

5. Diagnosis
• Refer people using a suspected cancer pathway referral (for an
appointment within 2 weeks) for colorectal cancer if:
• They are aged 40 and over with unexplained weight loss and abdominal pain
or
• They are aged 50 and over with unexplained rectal bleeding or
• They are aged 60 and over with:
• Iron-deficiency anaemia or
• Changes in their bowel habit
• Tests show occult blood in their faeces (new NICE recommendation for
2015).

6. Diagnosis
• Consider a suspected cancer pathway referral (for an appointment within
2 weeks) for colorectal cancer in people with a rectal or abdominal mass
(new NICE recommendation for 2015).
• Consider a suspected cancer pathway referral (for an appointment within
2 weeks) for colorectal cancer in adults aged under 50 with rectal bleeding
and any of the following unexplained symptoms or findings:
• Abdominal pain
• Change in bowel habit
• Weight loss
• Iron-deficiency anaemia (new NICE recommendation for 2015).
• Offer testing for occult blood in faeces to assess for colorectal cancer in
adults without rectal bleeding or have unexplained symptoms but do not
meet the criteria for a suspected cancer pathway.

7. Diagnosis
• Age
• Unexplained weight loss
• Abdominal pain
• PR bleeding
• Change of bowel habits
• Iron deficiency anaemia
• Mass
• +ve FOB
• ?? Family history

8. Diagnosis
• Screening group
• Symptomatic group
• Complicated group (Obstruction, bleeding and metastasis)

9. Diagnosis / Workup
• Colon cancer = Colonoscopy + Staging CT TAP
• Colon Cancer = Flexible sigmoidoscopy + Virtual colonoscopy + Staging CT
TAP
• Colon Cancer = Flexible sigmoidoscopy + Ba Enema (Major Comorbidities)
• Rectal Cancer = Colonoscopy + MRI (EUS for ?? Endoscopic resection) +
Staging CT TAP
• Colonoscopy or Flexible sigmoidoscopy for tissue diagnosis
• Fitness for bowel prep/Colonoscopy ??Fitness for operation

10. Diagnosis / Workup
• No PET CT
• No Staging laparoscopy
• Do not use the PR exam finding in the staging assessment

11. Staging

13. T category T criteria
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis
Carcinoma in situ, intramucosal carcinoma (involvement of lamina propria
with no extension through muscularis mucosae)
T1
Tumor invades the submucosa (through the muscularis mucosa but not
into the muscularis propria)
T2 Tumor invades the muscularis propria
T3 Tumor invades through the muscularis propria into pericolorectal tissues
T4
Tumor invades* the visceral peritoneum or invades or adheres
¶
to
adjacent organ or structure
T4a
Tumor invades* through the visceral peritoneum (including gross
perforation of the bowel through tumor and continuous invasion of tumor
through areas of inflammation to the surface of the visceral peritoneum)
T4b Tumor directly invades* or adheres
¶
to adjacent organs or structures

14. N category N criteria
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1
One to three regional lymph nodes are positive (tumor in lymph nodes
measuring ≥0.2 mm), or any number of tumor deposits are present and all
identifiable lymph nodes are negative
N1a One regional lymph node is positive
N1b Two or three regional lymph nodes are positive
N1c
•No regional lymph nodes are positive, but there are tumor deposits in
the:Subserosa
•Mesentery
•Nonperitonealized pericolic, or perirectal/mesorectal tissues
N2 Four or more regional nodes are positive
N2a Four to six regional lymph nodes are positive
N2b Seven or more regional lymph nodes are positive

16. Risk of local recurrence for rectal tumours as
predicted by MRI
Risk of local recurrence Characteristics of rectal tumours predicted by
MRI
High •A threatened (<1 mm) or breached resection margin or
•Low tumours encroaching onto the inter-sphincteric
plane or with levator involvement
Moderate •Any cT3b or greater, in which the potential surgical margin is
not threatened or
•Any suspicious lymph node not threatening the surgical
resection margin or
•The presence of extramural vascular invasion
[a]
Low •cT1 or cT2 or cT3a and
•No lymph node involvement

17. 5 key elements
• T3 = Tumor invades through the muscularis propria into pericolorectal
tissues / Imaging
• N+ / Imaging
• Risk / Pathology
• Patient fitness / Clinical
• MDT

19. Options
• Surgery
• Chemotherapy
• Radiotherapy
• Curative intent
• Palliative intent
• Best supportive care

20. Patients whose primary rectal tumour appears
resectable at presentation
• Discuss the risk of local recurrence, short-term and long-term morbidity and late
effects with the patient after discussion in the multidisciplinary team
(MDT). [2011]
• Do not offer short-course preoperative radiotherapy (SCPRT) or
chemoradiotherapy to patients with low-risk operable rectal cancer (see table 1
for risk groups), unless as part of a clinical trial. [2011]
• Consider SCPRT then immediate surgery for patients with moderate-risk operable
rectal cancer (see table 1 for risk groups). Consider preoperative
chemoradiotherapy with an interval to allow tumour response and shrinkage
before surgery for patients with tumours that are borderline between moderate
and high risk. [2011]
• Offer preoperative chemoradiotherapy with an interval before surgery to allow
tumour response and shrinkage (rather than SCPRT), to patients with high-risk
operable rectal cancer (see table 1 for risk groups). [2011]

21. Discuss with the patient

23. • Lymphatics

28. • https://www.cancer.org/cancer/colon-rectal-cancer/treating/by-
stage-colon.html
• https://www.acpgbi.org.uk/patients/conditions/laparoscopic-
colorectal-surgery/
• https://www.acpgbi.org.uk/patients/conditions/rectal-cancer/
• https://www.acpgbi.org.uk/patients/conditions/colonic-cancer/
• https://www.acpgbi.org.uk/patients/conditions/having-a-stoma/
• https://www.sages.org/publications/patient-information/patient-
information-for-laparoscopic-colon-resection-from-sages/

29. References
• Gastrointestinal tract (lower) cancers - recognition and referral - Last
revised in August 2017 https://cks.nice.org.uk/gastrointestinal-tract-
lower-cancers-recognition-and-referral
• Colorectal cancer: diagnosis and management - Last
updated: December 2014
https://www.nice.org.uk/guidance/cg131/chapter/1-
Recommendations
• https://www.facebook.com/algarra7/ ‫اح‬َّ‫ر‬َ‫ج‬‫ال‬
• https://www.nature.com/articles/6601231 Performance status score:
do patients and their oncologists agree?