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General Surgery
Tumors of the Colon
Built from Maingot's Abdominal Operations
What’s inside
15 sections · 183 slides
Overview
- Topics covered
What a colon tumor is
Growth patterns, malignant potential and the classification used throughout
- Growth patterns that define a tumor
- Origin of colonic tumors
- Colorectal lesions by malignant potential
- Classification of epithelial tumors of the colon
- Non-epithelial and secondary tumors of the colon
Epidemiology
How common colorectal cancer is, and how that varies by place, sex, age and ethnicity
- Frequency of colorectal cancer
- Geographical variation, sex and age
- Time trends and ethnicity
Risk factors
The dietary, lifestyle, personal and family factors that raise or lower risk
- Risk categories used for screening
- Comparison of major colorectal cancer risk categories
- Risk factors associated with colon cancer
- Dietary fibre, meat and fat
- Fruit, vegetables and micronutrients
- Aspirin and COX-2 inhibitors
- Bile acids, smoking, alcohol and other factors
- Personal and family history
- Lifetime risk of colorectal cancer by family history
- Inflammatory bowel disease
- Colorectal cancer risk in ulcerative colitis
- Cumulative incidence of colorectal cancer in pancolitis
- Ureterocolostomy and previous radiation
Prevention and screening
Why screening works, which tools are used, and how often
- Rationale for screening programmes
- Steps of the adenoma-carcinoma sequence
- Screening schedule by risk group
How colon cancer develops
Genetic instability, mismatch repair and the adenoma-carcinoma model
- Carcinogenesis as a multistep process
- Germline and somatic mutations
- Two types of genetic instability
- Mismatch repair and the two-hit hypothesis
- The adenoma-carcinoma model
- Genetic model for colorectal tumorigenesis
Hereditary and familial colon cancer
Sporadic, familial and inherited patterns, and the syndromes behind them
- Sporadic and familial colon cancer
- Familial adenomatous polyposis
- Disease outside the colon in FAP
- Hereditary nonpolyposis colon cancer
- Cancer risks and genes in HNPCC
- Amsterdam and Bethesda criteria
- Amsterdam Criteria I and II for HNPCC
- Definitions of benign and malignant tumors and of a polyp
- Revised Bethesda guidelines for microsatellite instability testing
- Bethesda guidelines: the family history criteria
- Inherited syndromes that raise colon cancer risk
- Hamartomatous polyposis syndromes
- Peutz-Jeghers syndrome
- Juvenile polyposis syndrome
- Cowden and Bannayan-Riley-Ruvalcaba syndromes
- Cronkite-Canada syndrome
Polyps
Size, attachment, architecture, depth of invasion and how each is managed
- Definition and categories of a polyp
- Risk of invasive carcinoma by polyp size
- Pedunculated and sessile polyps
- Adenomatous polyps
- Behaviour of adenomas
- Carcinoma rate by adenoma size and histological type
- Haggitt classification of invasion
- Haggitt levels of invasion in pedunculated and sessile polyps
- Kudo levels of submucosal invasion
- Depth of submucosal invasion in sessile malignant polyps
- Flat and depressed adenomas
- Hamartomatous and inflammatory polyps
- Hyperplastic polyps
- Malignant potential of hyperplastic polyps
- Grading dysplasia and invasive cancer
- Goals and limits of polypectomy
- Managing a malignant polyp
- Treatment decision after a malignant polyp is removed
Colorectal cancer: pathology and staging
Histological types, patterns of spread and the TNM system
- Adenocarcinoma as the dominant histology
- WHO histopathologic classification of colorectal cancers
- Mucinous, signet ring and small cell cancers
- Where colon cancers sit and how they spread
- TNM staging of colon cancer
- Depth of invasion through the bowel wall
- Definitions of the T and N categories
- Nodal subgroups, distant metastasis and residual tumor
- Stage groupings for colon cancer
Non-epithelial and secondary tumors
Lipomas, carcinoids, GISTs, lymphoma and tumors reaching the colon from elsewhere
- Lipomas of the colon
- When a lipoma needs treatment
- Carcinoid and neuroendocrine tumors
- Carcinoid behaviour and carcinoid syndrome
- Diagnosing and treating carcinoid tumors
- Gastrointestinal stromal tumors
- Lymphoid tumors of the colon
- Kaposi sarcoma and smooth muscle tumors
- Secondary tumors reaching the colon
Surgical anatomy of the colon
Segments, blood supply, lymphatic drainage and the structures at risk
- Segments and the rectosigmoid junction
- Arterial and venous supply
- Lymphatic drainage of the colon
- Blood supply and lymphatic drainage of the colon
- Lymphatic node groups of the colon and rectum
- Retroperitoneal relations and structures at risk
Clinical presentation and investigations
Why symptoms come late, what to examine, and which tests answer which question
- Late presentation of colorectal cancer
- Right-sided and left-sided symptoms
- Distribution of single colon primary cancer by stage
- Red flags and the differential diagnosis
- History and general examination
- Abdominal and rectal examination
- The acutely unwell patient
- Goals of investigation and first-line endoscopy
- Colonoscopy
- Limits of colonoscopy
- Contrast enema
- CT colonography and capsule study
- Imaging for local extent and metastases
- Laboratory tests and tumor markers
Treatment
Indications, preparation for surgery and the operative technique
- Indications and goals of surgery
- Local control and metastases
- Planning the operation
- Blood transfusion
- Mechanical bowel cleansing
- Antibiotic prophylaxis
- Thromboembolic prophylaxis
- Tubes, stoma siting and pain planning
- Objective of a curative resection
- Standard resections of the colon
- Synchronous cancers and underlying disease
- Positioning, incision and exploration
- Mobilising the right colon
- Mobilising the left colon and splenic flexure
- Ligating the feeding vessels
- Level of ligation and dividing the bowel
- Anastomosis, diversion and drains
- Laparoscopy versus open surgery
- Laparoscopic technique and sentinel nodes
Emergencies and advanced disease
Obstruction, perforation, bleeding and the locally advanced or metastatic tumor
- Emergency presentation of colon cancer
- Obstructing colon cancer: assessment
- Operating on an obstructed colon
- Staged procedures and colonic stenting
- Stenting outcomes, perforation and bleeding
- Locally advanced disease and metastases
Recovery, adjuvant treatment and outcome
Postoperative care, complications, chemotherapy after surgery and survival
- Fast-track postoperative care
- Wound care, discharge and adjuvant timing
- Mortality and types of complication
- Early postoperative complications
- Infectious and abdominal complications
- Recognising an anastomotic leak
- Managing an anastomotic leak
- Rationale for adjuvant chemotherapy
- 5-FU with leucovorin
- Irinotecan, oxaliplatin and FOLFOX
- Toxicity and capecitabine
- Targeted agents and radiotherapy
- Five-year survival by stage
- 93.2%
- Five-year survival for single and synchronous colon cancer primaries
- Key points: risk and prevention
- Key points: pathology and staging
- Key points: surgery and outcome
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- Maingot's Abdominal Operations, 12th Edition