Colo-rectal Cancer

Prof.A.H.M.Shamsul Alam

Introduction
Colo-rectal cancer is a major health burden worldwide and the third most common cause of cancer-related mortality in 2008. A multitude of risk factors have been linked to colorectal cancer, including heredity, environmental exposures, modern lifestyle and inflammatory syndromes affecting gastrointestinal tract. Surgery remains the best hope for the cure of early colorectal cancer, although newer anticancer drugs are efficient in improving survival of advanced cases.

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 rectum o Long standing Ulcerative colitis

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

Tubular

Ulcerative

Cauliflower

Spread of colon cancer

Clinical features
Symptoms Altered bowel habit: Alternate constipation/diarrhoea Weight loss and loss of energy Loss of appetite Rectal bleeding Abdominal pain Signs Anaemia Poor nutrition Abdominal mass Ascites Enlargement of liver Rectal ulcer/mass on DRE with finger blood show

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

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

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

CT scan of colon

Liver Mmetastasis

Double contrast: Barium and air

Staging colon cancer

Staging colon cancer

Staging
Dukes classification is an older and less complicated staging 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 lymph node is involved) D - With distant metastasis

Treatment
Curative Surgical treatment can be offered if the tumour is
localized. In colon cancer, tumor typically requires surgical removal of the section of colon containing the tumor with sufficient margins and Radical en-bloc resection of mesentery and lymph nodes to reduce local recurrence If possible, the remaining parts of colon are anastomosed together to create a functioning colon. In cases when anastomosis is not possible, a stoma (Colostomy) is created.

Treatment
Chemotherapy
Chemotherapy is used to reduce the likelihood of metastasis developing, shrink tumor size, or slow tumor growth. Chemotherapy is often applied after surgery (adjuvant), before surgery (neo-adjuvant), or as the primary therapy (palliative). Radiotherapy Radiotherapy is not used routinely in colon cancer, as it could lead to radiation enteritis, and it is difficult to target specific portions of the colon. It is more common for radiation to be used in rectal cancer, since the rectum does not move as much as the colon and is thus easier to target.

En-Block Tuour with adequate healthy margin Mesentery Blood vessels Lymph nodes

Radical en-block meso-vascular colon resection for colon cancer

Right hemicolectomy for carcinoma caecum

Abdomino-perineal resection and terminal colostomy for carcinoma rectum

Follow up
Patients are followed up with the following parameters CEA estimation: Higher value indicates recurrence or metastasis Faecal occult blood test Colonoscopy: yearly colonoscopy for 5 years, the 5 yearly

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

Prevention
Surveillance

Most colorectal cancer arise from adenomatous polyps. These lesions can be detected and removed during colonoscopy. Studies show this procedure would decrease by > 80% the risk of cancer death, provided it 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

Conclusion
Colo-rectal cancer is preventable and curable disease. Regular screening can detect the cancer at early stages and surgical treatment eliminates the disease in more than 90% of cases. Newer chemotheraputic agents are effective in controlling the advanced cancers in addition to necessary surgical treatment. Colo-rectal cancer incidence can be largely reduced by bringing about some lifestyle changes.