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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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