Colon Cancer

Colorectal Cancer
Colon: Anatomy
• Originally a mid-line structure, the large
intestine undergoes rotation during
embryological development : the ascending
colon,descending colon and rectum are
essentially retroperitoneal structures
• LI differs from SI by: appendices epiploicae(fat-
filled peritoneal tags) and the taenia coli(three
ribbon-like thickenings of the
thin longitudinal muscle)
• The large intestine (1.5m)consists of
• The caecum(7cm), vermiform appendix,
• Ascending colon(10-20cm), hepatic flexure,
• Transverse colon(40-70cm), splenic flexure,
• Descending colon(20-30cm),
• Sigmoid colon(50-80cm),
• Rectum(15cm) and anal canal(3-5cm)
CAECUM
• Sacculated segment (Latin caecus, “blind”)
• Projects downward as a 6- to 8-cm blind
pouch below the entrance of the ileum.
• Ileum terminates in posteromedial aspect of
cecum
• Angulation between these two structures is
maintained by superior and inferior ileocecal
ligaments.
Ascending Colon
• Approximately 15 cm long.
• Ascends, from level of the ileocecal junction to
right colic or hepatic flexure, laterally to psoas
muscle and anteriorly to iliacus, quadratus
lumborum, and lower pole of the right kidney.
• Covered with peritoneum anteriorly and on
both sides.
• On its posterior surface, devoid of
peritoneum, which is instead replaced by an
areolar tissue (fascia of Toldt).
• In lateral peritoneal reflection, this process is
represented by the white line of Toldt, which is more
evident at the descending-sigmoid junction.
• This line serves as a guide for the surgeon when
ascending, descending, or sigmoid colon is mobilized.
• At visceral surface of right lobe of the liver and
lateral to gallbladder, ascending colon turns sharply
medially and slightly caudad and ventrally to form
right colic (hepatic) flexure.
Transverse Colon
• Approximately 45 cm long
• Longest segment of the large bowel.
• It crosses the abdomen, with an inferior curve immediately
caudad to the greater curvature of the stomach.
• Transverse colon is completely invested with peritoneum, but
greater omentum is fused on its anterosuperior aspect.
• Because of the risk for hemorrhage, mobilization of the splenic

flexure should be approached with great care, preceded by
dissection upward along descending colon and medially to
laterally along transverse colon toward the splenic flexure.
• This flexure, when compared with the hepatic flexure, is more
acute, higher, and more deeply situated.
Descending Colon
• Courses downward from the splenic flexure to the brim
of the true pelvis, a distance of approximately 25 cm.
• Similarly to ascending colon, descending colon is
covered by peritoneum only on its anterior and lateral
aspects.
• Posteriorly, it rests directly against the left kidney and
the quadratus lumborum and transversus abdominis
muscles.
• Descending colon is narrower and more dorsally
situated than the ascending colon.
Sigmoid Colon
• Commonly a 35- to 40-cm-long, mobile, omega-
shaped loop completely invested by peritoneum
• The rectosigmoid junction has been frequently
regarded by surgeons as an indistinct zone, a
region comprising the last 5–8 cm of sigmoid and
the uppermost 5 cm of the rectum
• Rectosigmoid junction, macroscopically identified
as the point where the taenia libera and the taenia
omentalis fuse to form a single anterior taenia and
where both haustra and mesocolon terminate, is
situated 6–7 cm below the sacral promontory.
Rectum
• The rectum is approximately 12 to
15 cm in length.
• Three distinct submucosal folds,
the valves of Houston, extend into
the rectal lumen.
• Anteriorly, Denonvilliers' fascia
separates the rectum from the
prostate and seminal vesicles in
male and from the vagina in
female.
• The dentate or pectinate line marks the transition point between
columnar rectal mucosa and squamous anoderm.
• The 1 to 2 cm of mucosa just proximal to the dentate line shares

histologic characteristics of columnar, cuboidal, and squamous
epithelium and is referred to as the anal transition zone.
• The dentate line is surrounded by longitudinal mucosal folds, known

as the columns of Morgagni, into which the anal crypts empty.
These crypts are the source of cryptoglandular abscesses
Blood Supply
• Superior and inferior mesenteric arteries
nourish entire large intestine
• Limit between 2 territories is junction
between proximal two-thirds and distal third
of transverse colon.
• This represents the embryologic division
between midgut and hindgut.
• Superior mesenteric artery originates from
aorta behind superior border of pancreas at L-
1 and supplies cecum, appendix, ascending
colon, and most of the transverse colon.
• From its right side arises the colic branches: middle, right, and ileocolic
arteries.
• Ileocolic, most constant of these vessels, bifurcates into a
1) superior or ascending branch, which communicates with descending
branch of the right colic artery
2) Inferior or descending branch, which gives off the anterior cecal,
posterior cecal, and appendicular and ileal divisions.
• Right colic artery may also arise from the ileocolic or middle colic arteries
and is absent in 2% to 18%
• Supplies ascending colon and hepatic flexure through its ascending and
descending branches, both of them joining with neighboring vessels to
contribute to marginal artery.
• Middle colic artery is highest of three colic
branches of the superior mesenteric artery,
arising close to the inferior border of the
pancreas.
 Right branch supplies the right transverse colon
and hepatic flexure, anastomosing with the
ascending branch of the right colic artery.
 Left branch supplies the distal half of the
transverse colon.
COLLATERAL
• Splenic flexure comprises
watershed between midgut and
hindgut supplies (Griffiths’ critical
point)
• This anastomosis is of variable
magnitude, and it may be absent in
about 50% of cases.
• For this reason, ischemic colitis
usually affects or is most severe
near the splenic flexure.
• Another potential area of
discontinuity of marginal artery is
the Sudeck’s critical point, situated
between lowest sigmoid Artery and
superior hemorrhoidal arteries;
• Arc of Riolan was vaguely defined as
the communication between superior
and inferior mesenteric arteries
• Meandering mesenteric artery is a
thick and tortuous vessel that makes
a crucial communication between the
middle colic artery and the ascending
branch of the left colic artery
• Presence of meandering mesenteric
artery indicates severe stenosis of
either the superior mesenteric artery
(retrograde flow) or inferior
mesenteric artery (antegrade flow).
Arterial Supply of the colon
Venous Drainage
Lymphatic Drainage
Arterial supply RECTUM
• The superior rectal artery arises from the
terminal branch of the inferior mesenteric
artery and supplies the upper rectum.
• The middle rectal artery arises from the

internal iliac artery
• The inferior rectal artery arises from the

internal pudendal artery, which is a branch
of the internal iliac artery.
• A rich network of collaterals connects the

terminal arterioles of each of these
arteries, thus making the rectum relatively
resistant to ischemia
Venous drainage
• The superior rectal vein drains into the portal system via the
inferior mesenteric vein.
• The middle rectal vein drains into the internal iliac vein.
• The inferior rectal vein drains into the internal pudendal vein,
and subsequently into the internal iliac vein.
• A submucosal plexus deep to the columns of Morgagni forms

the hemorrhoidal plexus and drains into all three veins
Lymphatic drainage
• Parallels the vascular supply
• Lymphatic channels in the upper and middle rectum drain

superiorly into the inferior mesenteric lymph nodes
• Lymphatic channels in the lower rectum drain both

superiorly into the inferior mesenteric lymph nodes and
laterally into the internal iliac lymph nodes.
Nerve supply of the large intestine
• like the lymphatics, follows the course of the main
vessels
• The right colon :
• sympathetic :lower six dorsal ganglia via the superior
mesenteric plexus
• parasympathetic :fibres from the coeliac branch of the
posterior vagus nerve.
• The left colon and rectum :the upper three lumbar
ganglia via the inferior mesenteric, superior
hypogastric and inferior hypogastric plexuses
Epidemiology
• 2nd most common in the UK ,3rd most common
in US and worldwide,
• 140 000 and 40000 new cases of colorectal
cancer diagnosed each year in the USA and UK
respectively.
• Colon cancer occurs in hereditary, sporadic,
and familial form
Etiology/Risk factor
• Exact unknown : Life time risk 5%

• Environmental & Genetic factors
• a high-fat and low-fiber diet , poultry and red
meat (haem and N-nitroso compounds)- ↑risk
• Obesity, Smoking and Alcohol-↑risk
• Coffee,Calcium and aspirin intake:↓ risk
• vegetables and fruits: protective, anti
oxidative and anti proliferative agents such as
isothiocyanates in cruciferous vegetables ( eg ,
broccoli)
• Inflammatory bowel disease
• Colecystectomy : ↑risk (d/t ↑ fecal bile salt)
Genetic factors
• FAP:APC gene, Chromosome 5q21,p53, Kras
mutation
• HNPCC: Lynch Syn,Turcot Syn, DNA mismatch
repair gene mutation(hMLH1, hMSH2,
hMSH3, hPMS1, hPMS2, and hMSH6)
• Peutz Jegher syndrome
• MYH (mutY homolog gene mutation)-
associated polyposis and juvenile polyposis
Colorectal Cancer Genetics
Adenoma Carcinoma sequence
Pattern of development of hereditary Colon Cancer
S.N Characteristics Right Colon Cancer Left Colon Cancer
1. Age Older Younger
2. Sex Female >M Male
3. Histology Sessile serrated Tubular,Villious adenoca
adenomas,poorly diff.
mucinous adenoca
4. Morphology Flat type,difficult to screen Polypoid type,facilitates
detection in screening
5. Mutation Microsatellite Chromosomal
Instability(MSI)-high and instability(CIN) hightimors
MMR def tumors
6. Immunogenicity High with T cell infiltration Low
7. Response to Due to high Ag load respnd Respond well to
Adjuvant therapy to Immunotherapy conventional Chemo
8. Site of metastasis Peritoneal Liver and Lung
9. Prognosis Poor but better in early Relatively better in late
stage stage
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Colon Cancer

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Colorectal Cancer

• Because of the risk for hemorrhage, mobilization of the splenic

• The 1 to 2 cm of mucosa just proximal to the dentate line shares

• The dentate line is surrounded by longitudinal mucosal folds, known

• The middle rectal artery arises from the

• The inferior rectal artery arises from the

• A rich network of collaterals connects the

• A submucosal plexus deep to the columns of Morgagni forms

• Lymphatic channels in the upper and middle rectum drain

• Lymphatic channels in the lower rectum drain both

• Exact unknown : Life time risk 5%

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