colo rectal cancer by prof shamsul alam

7/28/2019 Colo Rectal Cancer by Prof Shamsul Alam

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Colo-rectal Cancer

Prof.A.H.M.Shamsul Alam


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Introduction

Colo-rectal cancer is a major health burden worldwide andthe third most common cause of cancer-related mortality in2008.

A multitude of risk factors have been linked to colorectal

cancer, including heredity, environmental exposures,modern lifestyle and inflammatory syndromes affectinggastrointestinal tract.

Surgery remains the best hope for the cure of early colo-rectal cancer, although newer anticancer drugs areefficient in improving survival of advanced cases.


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Aetiology

Factors that increase the risk of developing colon cancer Age: advanced age increase the risk, incidence peaks in

sixth decade Genetic: Higher tendency to run in families and races Diet: less common in people taking high fiber and less

chemical content in diet Lifestyle: Obesity, lack of exercise, smoking, high alcohol

consumption are associated with increased incidence Pre-cancerous conditions:

o Polyposis coli: familial multiple polyps in colon

o Villus and tubular adenoma of rectumo Long standing Ulcerative colitis


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Pathology

Colon cancer is mostly adenocarcinoma. Lymphoma, Carcinoid

tumour, sarcoma and melanoma are rare tumours.Site of colon most frequently affected are in the following

order

Morphological types of adenocarcinoma

Ulcerative Anular Tubular Cauliflower


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Tubular

Ulcerative Cauliflower


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Spread of colon cancer


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Clinical features

Symptoms Altered bowel habit: Alternate constipation/diarrhoea Weight loss and loss of energy Loss of appetite Rectal bleeding

Abdominal painSigns Anaemia Poor nutrition Abdominal mass Ascites Enlargement of liver Rectal ulcer/mass on DRE with finger blood show


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Differential diagnosis

Several diseases closly mimic colonic cancer clinically Tuberculosis of ileo-caecum Crohn's disease Ulcerative colitis

Colo-rectal polyp Colonic arterio-venous malformation Gastro-intestinal stromal tumour Diverticular disease of colon


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Investigations

Blood

CBC: anaemia CEA (Carcino embryonic antigen): Tumour marker

Stool Occult blood test

Imaging Barium-enama double contrast radiogram for tumour Ultrasonography of abdomen: for tumour and spread

assessment CT scan of abdomen with Enema contrast: for tumour Dx

X-ray chest for pulmonary mats.Procedures Colonoscopy Colonoscopic biopsy FNAC of liver lesion Histopathology: Tomour type, grade


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Filling defect in Ba.Enema looks like an'apple core'

CT scan of colon

Liver Mmetastasis

Double contrast:

Barium and air


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Staging colon cancer


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Staging colon cancer


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Staging

Dukes classification is an older and less complicatedstaging system. It identifies the stages as:

A - Tumour confined to the intestinal wall B - Tumour invading through the intestinal wall C - With lymph node(s) involvement (this is further subdivided into C1 lymph node

involvement where the apical node is not involved and C2 where the apical lymphnode is involved)

D - With distant metastasis


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Treatment

CurativeSurgical treatmentcan be offered if the tumour is

localized. In colon cancer, tumor typically requires surgical removal of

the section of colon containing the tumor with sufficientmargins and

Radical en-bloc resection of mesentery and lymph nodes toreduce local recurrence

If possible, the remaining parts of colonare anastomosed together to create a functioning colon.

In cases when anastomosis is not possible,

a stoma (Colostomy) is created.


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Treatment

ChemotherapyChemotherapy is used to reduce the likelihood of metastasis developing,

shrink tumor size, or slow tumor growth. Chemotherapy is often appliedafter surgery (adjuvant), before surgery (neo-adjuvant), or as theprimary therapy (palliative).

Radiotherapy

Radiotherapy is not used routinely in colon cancer, as it could leadto radiation enteritis, and it is difficult to target specific portions of thecolon. It is more common for radiation to be used in rectal cancer, sincethe rectum does not move as much as the colon and is thus easier totarget.


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Radical en-block meso-vascularcolon resection for colon cancer

Tuour withadequatehealthy margin

Mesentery Blood vessels

Lymph nodes

En-Block


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Right hemicolectomy for carcinomacaecum


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Abdomino-perineal resection and terminal colostomy forcarcinoma rectum


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Follow up

Patients are followed up with the following parameters

CEA estimation: Higher value indicates recurrence ormetastasis

Faecal occult blood test Colonoscopy: yearly colonoscopy for 5 years, the 5 yearly


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Prognosis

5 years survival rate for stage I and II is more than 90%


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Prevention

Surveillance

Most colorectal cancer arise from adenomatous polyps. These lesions canbe detected and removed during colonoscopy. Studies show thisprocedure would decrease by > 80% the risk of cancer death, providedit is started by the age of 50, and repeated every 5 or 10 years

Lifestyle and nutrition High fiber diet Weight reduction and exercise Quitting smoking and moderation of alcohol consumption

Chemoprevention

Aspirin


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Conclusion

Colo-rectal cancer is preventable and curable disease.

Regular screening can detect the cancer at early stages andsurgical treatment eliminates the disease in more than 90%of cases.

Newer chemotheraputic agents are effective in controlling theadvanced cancers in addition to necessary surgicaltreatment.

Colo-rectal cancer incidence can be largely reduced bybringing about some lifestyle changes.


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colo rectal cancer by prof shamsul alam

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