Professional Documents
Culture Documents
Colorectalcancer 200612134444
Colorectalcancer 200612134444
a. Conventional Adenomas;
c. Polyposis syndromes;
FAP- familial adenomatous polyposis syndrome
• Autosomal dominant on chromosome 5q21
• It account for less than 1% of colorectal cancer
• Characterized by more than 100 polyps
• 75-100% of patients develop carcinoma of the rectum and sigmoid at a mean
age of 40 years if untreated.
• The cancer may be multiple.
• Variants; Gardner’s syndrome, Turcot’s, oldfields syndrome
Familial adenomatous polyposis
Hamartomatous polyposis syndromes
• Amsterdam criteria
• Modified Amsterdam criteria
• Bethesda criteria
Amsterdam criteria
• At least 3 relatives of common cancer
• One affected person is 1st degree relative of other two affected persons
• Two successive generations affected
• At least one case of colon cancer diagnosed before the age of 50 years
• FAP excluded
Modified Amsterdam criteria;
• Same as Amsterdam except cancer must be associated with HNPCC
(colon, endometrium, small intestine, renal pelvis and ureter) instead of
specifically colon cancer
• Tumour should be verified by pathologist
Bethesda criteria
Amsterdam criteria or one of the following;
• 2 cases of HNPCC associated cancer in one patient including
synchronous or metachronous cancer.
• Colon cancer and 1st degree relative with HNPCC associated cancer
and or colonic adenoma
• Colon or endometrial cancer diagnosed before the age of 45
• Right sided colon cancer that has an undifferentiated pattern or
signet cell type before the age of 45
• Adenoma diagnosed before 45
3. DIET;
Red meat, high intake of fat (saturated), increase the risk of colorectal
cancer.
Saturated fat increases the tumour-promoting arachidonic acid and its
metabolites on cell membrane.
Increased fat/meat content of diet enhances the activity of certain
anaerobic organisms which encourage degradation of primary bile
(cholic acid and chenodeoxycholic acids) acids into secondary bile
acids (lithocholic and deoxycholic acids) which are carcinogenic.
• Fibre- (vegetable, fruits and whole grain cereals), calcium, vitamin A,
C, E, zinc and fish are protective.
• Fruits and vegetables depresses the faecal bacterial enzyme activity
and thereby reduces the concentration of faecal bile acids (FBA).
• There is positive association between colorectal cancer and the level of
FBA. High FBA is correlated to adenoma size and severity of epithelial
dyspepsia.
• Calcium combine with bile salt and fatty in the stole to insoluble
complexes that are less likely to attack the colonic mucosa. Calcium
also acts on the colonic mucosal cell to reduce the proliferative
potential.
4. Radiation; Radiation treatment of prostates cancer moderately
increases the risk of rectal cancer in radiated sites with time. (mucinous
carcinoma).
5. Surgeries; cholecystectomy, ileal resection, ureterosigmoidostomy,
gastrectomies
Cholecystectomy, alters the enterohepatic cycle of bile acids, there is
increase bile acid pool in the large bowel. The bile acids induces
hyperproliferation of intestinal mucosa via several intracellular
mechanisms.
Ureterosigmoidostomy increase the risk by 100-500 times, after
cholecystectomy and ileal resection, there is increase bile salt which is
carcinogenic.
6. OTHERS;
• Lack of physical activity
• Diabetes
• Cigarette smoking (esp. after > 35 years of use )
• Acromegaly; increase risk of circulating insulin-like growth factors
• obesity
PATHOLOGY
• MACROSCOPICALLY; there are 4 types ; “CUTA”
• C – cauliflower
• U- ulcerative
• T- annular
• A- tubular
• Cauliflower or proliferative type is a bulky fungating tumour which
project into the lumen of the gut. As it grow it may become necrotic
and ulcerates. They are usually tumours of the right side.
• Malignant ulcers has raised, irregular, everted edges and a sloughing
floor. It grows in the transverse axis of the bowel. Commonly on the
right side
• Annular (stenosing); common on the left side. It is circumferential
≤2cm. Present with intestinal obstruction.
• Tubular or infiltrative; when annular spread longitudinally to involve
segment 5cm and above.
• 5-10 % of colon cancer are synchronous i.e multiple primary tumours
at different part of the colon at the same time.
• 10-20 % are metachronous; growth in different part at different
period.
Histological types
• Adenocarcinoma—90%.
• Mucinous adenocarcinoma—5-10%.
• Signet ring cell carcinoma.
• Small cell/oat cell carcinoma—rare—extremely poor prognosis.
• Squamous cell carcinoma.
• Undifferentiated carcinoma.
STAGING
• DUKE’S
• B- Extends across the bowel wall to the muscularis propria with no lymph
nodes involved
N1-Metastasis in 1 to 3 regional LN
Distant metastasis
0 Tis N0 M0 - -
I T1 N0 M0 A A
T2 N0 M0 A B1
IIA T3 N0 M0 B B2
IIB T4 N0 M0 B B3
IIIA T1-T2 N1 M0 C C1
IV Any T Any N M1 - D
SPREAD
• 1. Direct spread
• 2. Via lymphatic vessels
• 3. via the blood stream
• 4. Transperitoneal seedling
• Direct infiltration; In the bowel it spread transversely to encircle it.
Spread in longitudinal axis is limited. Microscopically it does not
spread beyond 5cm. It spread through all layer to involve the adjacent
structures. Invasion may lead to formation of internal fistulae.
• Growth through lymphatics spreads to paracolic nodes, intermediate and
principal group of lymph nodes.
• Groups of lymph nodes draining colon
• N1: Nodes immediately adjacent to bowel wall.
• N2: Nodes along ileocolic/right colic/middle colic/ left colic/sigmoid
arteries.
• N3: Nodes near the origin of SMA and IMA.
• Nodal spread in carcinoma colon is sequential from N1 → N2 → N3
• However, and in about 30% of cases nodal involvement can skip a tier of
glands.
• Blood spread:
• 33- 40% of carcinoma colon spreads to liver via portal veins.
• Secondaries may be either solitary or multiple, present as liver with
hard, umbilicated nodules.
• It spread to the lungs (22%), adrenals(11%), kidneys, bones (10%) and
the brain.
• Transperitoneal seedling.
• When tumour has spread to the peritoneal surface, they drop as
seedlings. Ascites may result.
CLINICAL PRESENTATION
• Occurs usually after 50 years. Usually in the 6th and 7th decades.
Familial type can present in younger age group.
• Rectal cancer is commoner in males. Colonic commoner in females.
• Presentation maybe insidious (75%) or urgent as intestinal
obstruction (18%) or perforation (7%)
• The commonest and important symptom is change in bowel habits
and abdominal pain. Change in bowel habits maybe constipation,
diarrhea or alternating constipation and diarrhea.
• Passage of blood or mucus in the faeces , noises in the abdomen
(audible borborygmi from increasing obstruction), abdominal pain,
distension and dyspepsia are other presenting symptoms.
• The patient often notices a lump in the abdomen especially in
carcinoma of the caecum
• Right sided growth commonly presents with anaemia,asthenia and
anorexia. Palpable mass in the right iliac fossa, which is not moving
with respiration, mobile, non-tender, hard, well-localized with
impaired resonant note.
• Left sided growth presents with colicky pain, altered bowel habits
(alternating constipation and diarrhea), palpable lump, distension of
abdomen due to sub acute/chronic obstruction. Later may present like
complete colonic obstruction. Tenesmus, with passage of blood and
mucus, with alternate constipation and diarrhea, is common.
• Sigmoid colon and rectum;
• most important symptoms is rectal bleeding. The blood is bright red
and either mixed with faeces and mucus or passed alone.
• Tenesmus; frequent urge to defecate which is fruitless
• Spurious diarrhea
• Haemorrhoids ; Obstruction to superior rectal veins. So any patient
above 40 years with haemorrhoid should be properly evaluated.
• Involvement of adjacent structures; sacral pain when sacral plexus is
invaded, recto-vaginal fistulae. Recto-vesical fistula presenting with
faecoluria and pneumaturia. Compression of the ureters give
hydroureters and hydronephrosis. Tumour of the transverse colon can
invade the stomach giving gastro-colic fistula.
• Examination may reveal distension, ascites, lump, hepatomegaly.
• Tumours in rectum if less than 10 cm from the anal verge is felt by
rectal examination. It may be a hard tumour encircling the lumen and
narrowing it. Or a raised ulcer.
• It takes upto 6months for a tumour to occupy ¼ of the circumference
and hence 2 years to be completely circumferential
Emergency presentations
• Acute on chronic intestinal obstruction
• Perforation
• Paracolic abscess
• Acute bleeding
INVESTIGATIONS
• Double contrast Barium enema: Shows irregular filling defect and
‘apple core’ deformity (in left sided carcinoma). It also helps in finding
colonic polyps (Air-contrast barium enema). Can serve as a road map
for colonoscopy.
• Colonoscopy and biopsy confirms the diagnosis. Synchronous
tumours looked for.
• Transrectal uss; depth of invasion, lymph node. 5 year survival: 90%,
70%, and 30% for Duke A, B, C respectively.
• Abdominal uss; To see secondaries in liver, peritoneum, lymph node
status, rectovesical secondaries. Presence of hydronephrosis.
INVESTIGATIONS
• IVU ; when hydroureters and hydronephrosis is peaked by uss, ivu is
done to check the site of obstruction.
• CEA (Carcinoembryonic antigen): cell surface glycoprotein, a tumour
marker. CEA is primarily associated with colorectal cancers, however
non specific. Uses in colorectal cancers are:
• Preoperative levels >7.5 ng/ml signifies poor prognosis.
• If postoperative level does not fall, it indicates either incomplete resection, or
occult metastasis elsewhere.
• Increase CEA during follow-up indicates recurrence or secondaries.
• A slow rise indicates loco regional disease.
• A rapid rise signifies metastasis.
• Base line investigations to prepare for treatment;
• FBC, U/ECR, LFT, FBS, ECG, GXM
DIFFERENTIAL DIAGNOSIS
• Carcinoma of the caecum; appendix abscess,amoeboma,crohn’s
disease, hyperplastic ileocecal TB, actinomycosis, renal swelling,
ovarian cyst, pedunculated myoma of the uterus.
• Relatively small case series describe the safety and feasibility of TAMIS for
resection of adenomas and early rectal cancers
INTERSPHINCTERIC RESECTION
• Schiessel – 1994
• It exploits the plane between internal and external sphincters to achieve a balance between
adequate oncologic resection and continence preservation
• Proctectomy and TME are combined with resection of all or part of the internal anal
sphincter and creation of a handsewn transanal anastomosis
• Contraindications
• T4 tumors
• invasion of external anal sphincter
• fixed tumors in digital examination (indication that the tumor has broken through the
intersphincteric plane)
• poorly differentiated tumor
• poor preoperative sphincter function
• distant metastases
ABDOMINOPERINEAL
RESECTION WITH
PARMANENT
COLOSTOMY
T3 or T4 tumor in the involving the levator
ani/external sphincter muscle.
• Depends on:
• Site—left sided tumours has got better prognosis as they present early.
• Type—colloid carcinoma has got poorer prognosis.
• Size of the tumour.
• Lymph nodes status: Number of lymph nodes involved decides the prognosis.
• Liver secondaries has poor prognosis.
• Age of the patient; younger patients have poorer prognosis.
• Associated diseases like HIV.
• Stage of the tumour.
• Presence of complications, perforation, peritonitis.
• On the whole, it is a curable malignancy with proper surgery and adjuvant therapy.
PREVENTION AND SCREENING
• Screening of population at risk is recommended in asymptomatic
adults at age 50 years.
• First base-line colonoscopy is done, and if no pathology is found,
repeated every 10 years
• FOBT should be done on annual bases, positive result should
precipitate a full colonic evaluation. Every 5 years, a flexible
sigmoidoscopy is done. If a precursor lesion is found, they should be
removed and colonoscopy performed 1-3years to detected missed
(20%) or recurrent polyps.
• Individuals at increased risk, screening starts earlier. 45 years.
• Screening have shown to reduce colorectal cancer incidence by 76-
90%.