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1、Colon cancer1Epidemiology3rd most common cancer in males and femalesAccounts for 11% of cancer deaths.In 2000, 130,200 cases (colon and rectum).Lifetime risk 6%.2EpidemiologyRare before the age of 40y, rapid increase at 50y.At presentation 37% localized, 37% regional, 20% metastatic.1 and 5y surviva
2、l is 80% and 61% overall.IBD, FAP, HNPCC, are at inc risk3ascending colon 11%transverse colon 4%descending colon 9%sigmoid colon and rectum 76% 4World 50-60%25-30% Poland5year survival5Introduction:Many colorectal cancers are thought to arise from Many colorectal cancers are thought to arise from ad
3、enomatousadenomatous polypspolyps in the colon. These in the colon. These mushroom-like growths are usually mushroom-like growths are usually benignbenign, but , but some may develop into cancer over time.some may develop into cancer over time.Polyps may be small and produce few, if any, Polyps may
4、be small and produce few, if any, symptoms. Regular screening tests can help symptoms. Regular screening tests can help prevent colon cancer by identifying polyps before prevent colon cancer by identifying polyps before they become cancerous. they become cancerous. 67Your best chance for surviving c
5、olorectal cancer is detecting it early. When found early, there is nearly a 90 percent chance for cure.8Symptoms:There often are no symptoms of colorectal cancer in its early stages. Most colorectal cancers begin as a polyp. As polyps grow, they can bleed or obstruct the intestine. When the disease
6、spreads, it is still called colorectal cancer 9Symptoms:rectal bleedingrectal bleedingblood in the stool or toilet after a bowel movementblood in the stool or toilet after a bowel movementprolonged diarrhea or constipation prolonged diarrhea or constipation a change in the size or shape of a change
7、in the size or shape of the the stoolstoolA change in bowel movement pattern that continues over A change in bowel movement pattern that continues over time time General discomfort in the abdomen (frequent gas pains, General discomfort in the abdomen (frequent gas pains, cramping pain, feeling of bl
8、oating or fullness) cramping pain, feeling of bloating or fullness) Vomiting Vomiting Constant fatigue Constant fatigue Chronic constipationChronic constipation10Risk Factors: Age: Age: Colorectal cancer is most common in people over Colorectal cancer is most common in people over 50.50. Family hist
9、ory: Family history: Your risk is higher with a family history Your risk is higher with a family history (especially parent, sibling) of colorectal cancer, or (especially parent, sibling) of colorectal cancer, or adenomatous polyps.adenomatous polyps. Personal history: Personal history: Your risk is
10、 higher with a personal Your risk is higher with a personal history of inflammatory bowel disease (Crohns disease history of inflammatory bowel disease (Crohns disease or colitis), colon cancer, or adenomatous polyps.or colitis), colon cancer, or adenomatous polyps. Weight: Weight: Lack of physical
11、activity and obesity are risk Lack of physical activity and obesity are risk factors.factors. 11 Diet: Diet: A high-fat diet, particularly animal fats, may A high-fat diet, particularly animal fats, may Increase your risk. Diets high in fruits and Vegetables are Increase your risk. Diets high in fru
12、its and Vegetables are thought to decrease your risk. diets high in red and thought to decrease your risk. diets high in red and processed meat, as well as those low in fiber, are processed meat, as well as those low in fiber, are associated with an increased risk of colorectal cancer. associated wi
13、th an increased risk of colorectal cancer. Individuals who frequently eat fish showed a decreased Individuals who frequently eat fish showed a decreased riskrisk Cigarette smoking and alcohol: Cigarette smoking and alcohol: Your risk may be Your risk may be higher if you smoke or drink higher if you
14、 smoke or drink Physical inactivityPhysical inactivity: People who are physically active : People who are physically active are at lower risk of developing colorectal cancer.are at lower risk of developing colorectal cancer.12Risk FactorsPolyps-Most cancers arise from them.Classified as neoplastic (
15、adenomatous)which are benign or malignant, and nonneoplastic (hyperplastic, mucosal, inflammatory, hamartomaous).Adenomatous polyps found in 33% of people by age 50, 50% by age 70.Most lesions 2cm, 34% in severe dysplasia).15TreatmentEndoscopic removal, surveillance every three years.Biopsy if it ca
16、nt be removed.Surgery for those not amenable to safe polypectomy (large sessile villous lesions).16TreatmentFungation, ulceration, distortion are contraindications for polypectomy. Colectomy indicated for residual carcinoma, those at high risk for +LN despite complete polypectomy.+margin, poor diff,
17、 level 4, vascular, lymphatic invasion.Sessile polyp with invasive cancer should be considered for resection even if no high risk pathologic features.Weigh all against pts medical condition of course.17Hereditary Polyposis SyndromesAll have this in common: Multiple intestinal polyps, extraintestinal
18、 manifestations.FAP: 1-2% of colon cancer patients. A point mutation of APC gene on chromosome 5, band q21.Polyps found throughout the GI tract but most in colon. Symptoms manifest by ages 16-50.Cancer will develop in all by age 50.18Familial Adenomatous Polyposis (FAP) Familial adenomatous polyposi
19、s (FAP) is a Familial adenomatous polyposis (FAP) is a genetic condition where affected individuals will genetic condition where affected individuals will develop hundreds to thousands of polyps develop hundreds to thousands of polyps If a parent has FAP, each child has a 50% (or, 1 If a parent has
20、FAP, each child has a 50% (or, 1 in 2) chance of inheriting FAP. Each child also in 2) chance of inheriting FAP. Each child also has a 50% chance of not inheriting FAP. FAP has a 50% chance of not inheriting FAP. FAP does not skip generations. Both males and does not skip generations. Both males and
21、 females are equally likely to be affected. females are equally likely to be affected. Therefore, if you have FAP, your children each Therefore, if you have FAP, your children each have a 1 in 2 chance of having FAP. have a 1 in 2 chance of having FAP. 19Hereditary Polyposis SyndromesGardners Syndro
22、me: Variant of FAP. Colonic and extracolonic manifestations.Periampulary lesions, duodenal lesions, gastric polyps.Ocular, cutaneous, skeletal (retinal, mandible, jaw, teeth, sebaceous cysts).Desmoids, hepatoblastoma, thyroid cancer, Turcots syndrome (brain).20Hereditary Nonpolyposis SyndromesLynch
23、I and II. Occurs five times more frequently than familial polyposis. 1-5 % of colon cancers. Lynch I just colon, Lynch II also involves endometrium, ovary, stomach, small bowel, biliary, pancreas, ureter, renal pelvis.85% lifetime risk of colon cancer, more right sided cancers (60-70%), earlier (45y
24、), lower stage, better survival, but 20% risk of metachronous, synchronous lesions.21Inflammatory Bowel DiseaseUlcerative colitis carries a risk of colorectal carcinoma 30 times greater than general population.Risk increases with duration of disease.After 30 years, risk increases to 35%Crohns diseas
25、e associated with 10-20 fold increased risk of cancer.Need to do surveillance in these population.22Previous Colon CancerA second primary colon cancer is three times more likely to develop in patients with a history of colon cancer.Metachronous lesions develop in 5-8% of patients.23History of First-
26、Degree RelativesPeople with first-degree relatives with colorectal cancer have a 1.8-8 fold increase risk of colorectal cancer.Risk is higher if more than one relative affected.Risk is higher if developed in the relative at a young age.24Pathology90% adenocarcinomas. Four morphologic variants.Ulcera
27、tive (most common), exophytic (polypoid, fungating), annular (classic applecore), submucosal infiltrative(linnitus type).Grading system 1-3. Most developed to least differentiated glandular structures.25The Layers of the Wall26Colon Wall27StagingA- to submucosa onlyB1- to muscularis only B2- thru wa
28、ll, not adjacent. B3- Adjacent organs involved.C1- B1 plus LNC2- B2 plus LNC3- B3 plus LND- Distant mets28A - 95 - 100 %B - 72 - 80 %C - 26 - 34 %D - 0 - 2 %29Staging-TNMT1 invades submucosaT2 invades muscularisT3 invades subserosaT4 invades organs outsideN1- 1-3 nodesN2- 4 or more nodesN3- central
29、nodesM0- no mets M1- distant mets303132333435Clinical PresentationBleeding, pain, bowel habit changes, weight loss, anorexia, nausea, vomiting, fatigue, anemia.Right upper quadrant pain, fevers sweats, hepatomegaly, ascites, effusions, adenopathy(METS).Obstruction(5-15%) increases risk of death 1.4
30、fold.Perforation (6-8%) increases it 3.4 fold.Stage I 15%, Stage II 30%, Stage III 20%, Stage IV 25%.Obstruction less common on right side.36Liver Mets37Colon Cancer38DIAGNOSIS: Colorectal cancer screening rates remain low. Therefore, screening for the disease is recommended in individuals who are a
31、t increased risk. There are several different tests available for this purpose.39Continue Digital rectal examDigital rectal exam (DRE): The doctor inserts a (DRE): The doctor inserts a lubricated, gloved finger into the rectum to feel lubricated, gloved finger into the rectum to feel for abnormal ar
32、eas. It only detects tumors large for abnormal areas. It only detects tumors large enough to be felt in the distal part of the rectum enough to be felt in the distal part of the rectum but is useful as an initial screening test. but is useful as an initial screening test. Fecal occult bloodFecal occ
33、ult blood test (FOBT): a test for blood test (FOBT): a test for blood in the stool. Two types of tests can be used for in the stool. Two types of tests can be used for detecting occult blood in stools i.e. guaiac based detecting occult blood in stools i.e. guaiac based (chemical test) and immunochem
34、ical. The (chemical test) and immunochemical. The sensitivity of immunochemical testing is superior sensitivity of immunochemical testing is superior to that of chemical testing without an to that of chemical testing without an unacceptable reduction in specifity.unacceptable reduction in specifity.
35、40EndoscopeEndoscope: : SigmoidoscopySigmoidoscopy: A lighted probe (sigmoidoscope) is : A lighted probe (sigmoidoscope) is inserted into the rectum and lower colon to check for inserted into the rectum and lower colon to check for polyps and other abnormalities. polyps and other abnormalities. Colo
36、noscopyColonoscopy: A lighted probe called a colonoscope is : A lighted probe called a colonoscope is inserted into the rectum and the entire colon to look inserted into the rectum and the entire colon to look for for polypspolyps and other abnormalities that may be and other abnormalities that may
37、be caused by cancer. A colonoscopy has the advantage caused by cancer. A colonoscopy has the advantage that if that if polypspolyps are found during the procedure they can are found during the procedure they can be immediately removed. Tissue can also be taken for be immediately removed. Tissue can
38、also be taken for biopsybiopsy. . 41DiagnosisScope, Chest X-ray, Complete blood count, CEA, Localized Fibrous TumorsPreop CT scan? Some get it for abnormal LFTs only (but only 15% of liver mets have abnormal LFTs). Others will get it if large bulky tumors to see about adjacent organs, LN.10% of mets
39、 are missed with preoperative and operative evaluations, IOUS best for this.42Diagnosis15-20% liver mets not palpable.Preop CEA reflects prognosis, disease extent (over 10-20 poor)CEA may not be elevated in poorly differentiated or rectal cancers.CEA really only good for follow up.43Rectal CancerIn
40、addition to History&Physical, CXR, CBC, LFTs, EUS, Proctoscopic exam, full colonoscopy, CT scan should be done for rectal cancer.Accurate preoperative staging critical because stage may influence treatment decisions such as trans anal excision, preop chemoradiation.44Rectal CancerEUS is most accurat
41、e tool in determining tumor stage with all layers identified with 67-93% accuracy.Differentiating T1 from T3 easy but T2 from T3 harder.Limitations of EUS: operator experience, differentiating LN vs.blood vessels, post radiation changes, stenotic lesions, overstaging (10-15%), understaging (1-2%).Su
42、perior to CT or MRI for depth of tumor.45Rectal CancerLymph node staging more difficult. EUS 62-83% accurate, CT scan 35-73% accurate.All these tests pick up size of LN only.50-75% of involved LN are normal in size, so may not be picked up. Similarly, enlarged LN may be inflammatory, so false negati
43、ve.LN 3mm and hypoechoic are likely to have malignancy, also FNA might help under EUS guidance.46Rectal CancerCT scanning of abdomen and pelvis is important for other organ involvement, and distant spread.CT is better than EUS for contiguous organ involvement.47Pathology:The pathology of the tumor i
44、s usually reported from the analysis of tissue taken from a biopsy or surgery. A pathology report will usually contain a description of cell type and grade. The most common colon cancer cell type is adenocarcinoma which accounts for 95% of cases. Other, rarer types include lymphoma and squamous cell
45、 carcinoma.48Cancers on the right side (ascending colon and cecum) tend to be exophytic, that is, the tumour grows outwards from one location in the bowel wall. This very rarely causes obstruction of feces, and presents with symptoms such as anemia. Left-sided tumours tend to be circumferential, and
46、 can obstruct the bowel much like a napkin ring.49501-Surgery and treatment:Colectomy with Ileorectostomy Colectomy with Ileorectostomy (Ileorectal Anastomasis)(Ileorectal Anastomasis) In this procedure, the colon is In this procedure, the colon is removed, but all or most of the removed, but all or
47、 most of the rectum is left in place. The small rectum is left in place. The small intestine is attached to the upper intestine is attached to the upper portion of the rectum. portion of the rectum. Most patients maintain very good Most patients maintain very good bowel function, though anti-bowel f
48、unction, though anti-diarrhea medications are diarrhea medications are sometimes needed. This sometimes needed. This procedure is typically procedure is typically recommended when there are recommended when there are very few polyps in the rectum.very few polyps in the rectum. . . 51Restorative Proc
49、tocolectomy (Ileal Pouch Anal Anastomosis)This operation involves removing the entire This operation involves removing the entire colon and most of the rectum. A new rectum, colon and most of the rectum. A new rectum, or reservoir for stool, called a pouch, is made or reservoir for stool, called a p
50、ouch, is made out of the lower end of the small intestine out of the lower end of the small intestine (ileum).(ileum). The pouch is joined to the anus so bowel The pouch is joined to the anus so bowel movements can flow in the normal way. A movements can flow in the normal way. A temporary ileostomy
51、, or a stoma where the temporary ileostomy, or a stoma where the waste empties into a bag through the abdominal waste empties into a bag through the abdominal wall, is usually needed to help heal this delicate wall, is usually needed to help heal this delicate connection. connection. 52Restorative P
52、roctocolectomy (Ileal Pouch Anal Anastomosis)53Chemotherapy ChemotherapyChemotherapy is used to reduce the likelihood of is used to reduce the likelihood of metastasis developing, shrink tumor size, or slow metastasis developing, shrink tumor size, or slow tumor growth. Chemotherapy is often applied
53、 after tumor growth. Chemotherapy is often applied after surgery (adjuvant), before surgery (neo-adjuvant), surgery (adjuvant), before surgery (neo-adjuvant), or as the primary therapy (palliative). The or as the primary therapy (palliative). The treatments is to improve survival and/or reduce treat
54、ments is to improve survival and/or reduce mortality rate, In colon cancer, chemotherapy after mortality rate, In colon cancer, chemotherapy after surgery is usually only given if the cancer has surgery is usually only given if the cancer has spread to the lymph nodes (Stage III)spread to the lymph
55、nodes (Stage III)54Life Style and NutritionThe comparison of colorectal cancer incidence The comparison of colorectal cancer incidence in various countries strongly suggests that in various countries strongly suggests that sedentarily, overeating (i.e., high caloric intake), sedentarily, overeating
56、(i.e., high caloric intake), and perhaps a diet high in meat (red or and perhaps a diet high in meat (red or processed) could increase the risk of colorectal processed) could increase the risk of colorectal cancer cancer In contrast, a healthy body weight, physical In contrast, a healthy body weight
57、, physical fitness, and good nutrition decreases cancer risk fitness, and good nutrition decreases cancer risk in general. in general. 55 Accordingly, lifestyle changes could decrease the risk of Accordingly, lifestyle changes could decrease the risk of colorectal cancer as much as 60-80%. colorecta
58、l cancer as much as 60-80%. A high intake of dietary fiber (from eating fruits, A high intake of dietary fiber (from eating fruits, vegetables, cereals, and other high fiber food products) vegetables, cereals, and other high fiber food products) has, until recently, been thought to reduce the risk o
59、f has, until recently, been thought to reduce the risk of colorectal cancer colorectal cancer Calcium or folic acid (a B vitamin), aspirin are able to Calcium or folic acid (a B vitamin), aspirin are able to decrease carcinogenesis in decrease carcinogenesis in pre-clinical developmentpre-clinical d
60、evelopment models: Some studies show full inhibition of carcinogen-models: Some studies show full inhibition of carcinogen-induced tumors in the colon of rats.induced tumors in the colon of rats. 56ScreeningFOBT, DCBE, endoscopy most useful screening methods.FOBT detects cancer at an earlier stage,
61、with reduction in cancer deaths.Flexible sigmoidoscopy and polyp clearance has resulted in decreased colon cancer.Value of full colonoscopy is noted since 40% of colon cancers occur proximal to splenic flexure.DCBE used if pt refuses scope, or poor scope, etc.57Barium Enema Sigmoid Cancer58Screening
62、 CEA has no role in in screening for primary lesions. False positives occur in benign disease(lung, liver, bowel) as well as malignancies of pancreas, breast ovaries, prostate, head and neck, bladder, kidney.CEA increased in smokers.60% of tumors will be missed by CEA alone.59RecommendationsAge50 as
63、ymptomatic, average risk.FOBT yearly, scope if positiveFlex sigmoidoscopy every 5y (full colon if +)Increased risk: Same but start age 40.60RecommendationsHx of HNPCC: Full colon every 1-2y (20-30y) then full colon yearly after 40y.Hx Aden Polyps: repeat in 3y, second exam normal repeat 5y.Hx Colon
64、cancer: Full colon within 1y, if second normal repeat 3y, if next normal every 5y.FAP: Counseling, Flex Sigmoid every 12 months.61Benefits of ScreeningCancer PreventionRemoval of pre-cancerous polyps prevent cancer (unique aspect of colon cancer screening)Improved SurvivalEarly detection markedly im
65、proves chances of long term survival62Colorectal Screening RatesJust 40% of colorectal cancers are detected at the earliest stageA little more than half of Americans over age 50 report having had a recent colorectal cancer screening testSlow but steady improvement in these numbers over the past decade (but all are not benefiting to the same degree)63
