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Colorectal cancer
Krista Brūna, MF V
About...
• Colorectal cancer - starts in the large intestine (colon) or the
rectum. Almost all colon cancers start in glands in the lining of
the colon and rectum.[1]
• CRC is the 3rd most common cancer in men and 2nd in
women. 55% occur in more developed countries.[2]
• 5 year life expectancy depends of the stage CRC is detected.
• localized stage – 90%,
• regional -70%,
• distant metastatic disease -10%.[3]
GLOBOCAN 2012: Estimated Cancer incidence, Mortality and
Prevalence Worldwide in 2012*[2]
* Estimated numbers (thousands)
Men
GLOBOCAN 2012: Estimated Cancer incidence, Mortality and Prevalence Worldwide in 2012.
http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx
Women
Nonmodifiable risc factors[3]
• Age (likelihood increases >40 years, sharp rise >50 years)
• Personal history (adenomatous polyps)
• Inflammatory bowel disease (Crohn’s, Ulcerative colitis)
• Family history (CRC or adenomatous polyps)
• Inherited genetic risk
The adenoma-carcinoma sequence in sporadic and hereditary colorectal cancer. (From
Ivanovich JL, Read TE, Ciske DJ, et al: Am J Med 107:68-77, 1999.)
Hereditary cancer syndromes[4]
• HEREDITARY NONPOLYPOSIS COLON CANCER
• HEREDITARY ADENOMATOUS POLYPOSIS SYNDROMES
• Familial Adenomatous Polyposis/Gardner's Syndrome
• Turcot's Syndrome
• HEREDITARY HAMARTOMATOUS POLYPOSIS
SYNDROMES
•
•
•
•
Cowden's Disease
Familial Juvenile Polyposis
Peutz-Jeghers Syndrome
Ruvalcaba-Myhre-Smith Syndrome (Bannayan-Zonana
Syndrome)
Townsend:Sabiston Textbook of surgery ,18th ed. 2007, Elsevier. Chapter:50.
Environmental risc factors
• Studies of immigrants and their offspring ( from low-risk
countries to high-risk; incidence increases toward that of the
host country).[3]
• Nutritional practices
• High level of processed and /or red meat intake (20% increased
risk).[5]
•
In most publications, “red meat” gathers beef, veal, mutton, pork and offal, and
“processed meat” (equivalent: deli meat) gathers cooked, dried, smoked, or cured meat
and offals from any animal, but mostly pork.[7]
• Possible underlying mechanism – heme iron in red meat,
heterocyclic amines and polycyclic aromatic hydrocarbons (when
cooked at high t0) – possible carcinogenic properties.[3]
• Current WCFR-AICR recommendations <500 g per week red meat,
to avoid processed meat.[7]
• Physical activity and Obesity
• Regular physical activity and a healthy diet can help decrease the
risk of colorectal cancer, although the evidence is stronger for
colonic than for rectal disease.[3]
• Protective effect slightly stronger in men than women (22% for
men and 13% for women).[5]
• Sustained moderate physical activity raises the metabolic rate
and increases maximal oxygen uptake. [3]
• Several biologic correlates of being overweight or obese, notably
increased circulating estrogens and decreased insulin sensitivity,
are believed to influence cancer risk, and are particularly
associated with excess abdominal adiposity independent of
overall body adiposity.[3]
• Alcohol consumption
• For heavy drinkers risk is increased for 60% than in light or nondrinkers.[5]
• Acetaldehyde (alcohol metabolite) is a possible carcinogen.[8]
• Alcohol may also function as a solvent, enhancing penetration of
other carcinogenic molecules into mucosal cells.[8]
• Cigarette smoking
• The carcinogens found in tobacco increase cancer growth in the
colon and rectum, and increase the risk of being diagnosed with
this cancer.[3]
• Cigarette smoking is important for both formation and growth
rate of adenomatous polyps, the recognized precursor lesions of
colorectal cancer.[9]
• Mean age of patients with CRC who did not smoke or drink
being 71.3 years, while the mean age of current drinkers and
smokers was 62.6 years.[10]
Clinical presentation[11]
• Patient with CRC may present in 3 ways:
• Patients with suspicious symptoms and/or signs
• Asymptomatic individuals discovered by routine screening
• Emergency admission with intestinal obstruction, peritonitis, or
rarely, an acute gastrointestinal (GI) bleeding;
• Symptoms of CRC are typically due to growth of the tumor
into the lumen or adjacent structures, and as a result,
symptomatic presentation usually reflects relatively advanced
CRC.
Signs and symptoms
• Hematochezia or melena – hematochezia more common in
rectosigmoid location. [11]
• Change in bowel habit – passage of loose stool or increased
frequency of defaecation (60-91% in distal CRC, 40-61% in proximal
CRC); constipation not so common.[12]
• Iron deficit anemia – common, more frequent in right sided CRC
(65-80%)[12], which cause greater blood loss (9ml/day).[11]
• Weight loss - 5% of body weight in 6-12 months.[12]
• Abdominal pain – nonspecific. More common for proximal cancer
(45-90%), than distal (10-15%). Nonspecific pain and rectal bleeding
/ diarrhea / weight loss – caution necessary.[12]
• Palpable mass – rectal cancer, right iliac fossa.[12]
• Abdominal distention and/or nausea, vommiting – rarely, indicators
of possible obstruction.[11]
• Right sided tumors– exophytic mass (grows outward in
the lumen).
• Left sided tumors- endophytic mass (grows inward,
«apple core» sign).
• Obstructive symptoms more common in tumors that
constrict the lumen circulary.[11]
http://library.med.utah.edu/WebPath/GIHTML/GI116.html
Differential diagnosis
•
•
•
•
•
Inflammatory bowel disease
Irritable bowel syndrome
Diverticulosis
Gastrointestinal lymphoma
Haemorrhoids
[13]
Diagnostic
• Patients with suspicous symptoms or signs[1]
•
•
•
•
•
Anamnesis
Physical evaluation (sometimes a palpable mass)
Occult blood test
Colonoscopy (material for histology)
Additional blood tests:
• Full blood count
• Liver enzymes
• Emergency admission[4]
•
•
•
•
Double contrast barium enema
CT / MRI
Blood tests
Surgical intervention (material for histology)
• Screening for asymptomatic patients age >50 [14]
Screening
[14][15]
• Aim: detect CRC in early stage, when no symptoms are present.
• For people age >50 years, once a year.
• Test: fecal occult blood test
• For positive result – additional
colonoscopy
• Increased risc for colorectal cancer:
• Family history of CRC (at 40 yrs or 10
years younger than earliest diagnosis in
family)
• Inflammatory bowel disease
• Anoscopy – anus, anal canal and lower rectum.
• Sigmoidoscopy – rectum, sigmoid colon.
• Colonoscopy – rectum, large intestine.
4 basic tests for colon cancer:
• a stool test (to check for blood);
• sigmoidoscopy (inspection of the lower colon;
• colonoscopy (inspection of the entire colon);
• double contrast barium enema.
All 4 are effective in catching cancers in the early stages, when
treatment is most beneficial.[18]
Colonoscopy
• Most accurate and versatile
diagnostic test for CRC.[11]
• Can localise and biopsy lesions,
detect synchronous neoplasms
and remove polyps.[11]
• Synchronous colorectal
neoplasias - 2 or more primary
tumors identified in the same
patient and at the same time.[19]
Before procedure[20]
• Intestine need to be completely cleansed.
• Bowel preparation:
• Polyethylene glycol (PEG)
• PEG - isotonic solution.
• Safe and efficiant
• Large volumes
• Contraindications for PEG:
•
•
•
•
•
•
Severe general condition
Decompensated cardiac failure
Suspected intestine wall tear or inflammation
Ileus
Non-compliant patient
Dysphagia for fluids (in emergency cases nasogastric tube)
• Newer preparations:
• Eziclen (sulphate-based forumulation; 1L +2L water)
• Moviprep PEG with electrolyte ( 3L)
• Standard scheme for bowel preparation with PEG:[20]
• Preparation begins 1 day prior to examination
• Eating not recommended 3-4 hours before PEG administration.
• Process can take at least 12 hours.
• Last PEG portion 4 hours prior to exam.
• Standard PEG is 4 l.
• One hour prior to PEG administration all medicine per os must be
discontinued.
• Additional to PEG – only non coloured, clear solutions.
• 10% of water is absorbed (400ml).
• Complete colonoscopy – visualisation of the caecum, confirmed by
identification of the ileo-caecal valve and triradiate fold or by
performing terminal ileoscopy. [21]
• Still images of the cecum is the preferred modality for documenting
colonoscopy completion.[22]
• Photographs that depict recognizable landmarks, such as the
ileocecal valve (ICV), triradiate fold, and appendiceal orifice (AO),
are favored.[22]
• terminal ileal images are superior to cecal images and are
comparable to terminal ileal biopsy.[22]
A still image of the cecum
depicting an ilcocecal valve
(ICV).[22]
A still image of the terminal ileum
showing villi.[22]
A still image of the appendicel orifice.
Unless surrounding structures, such as the
ileocecal valve or the triradiate fold, are
clearly visible in the same static image,
some reviewers are unconvinced, that the
image truly depicts the cecum.[22]
• Common causes of incomplete colonoscopy:[21]
•
•
•
•
Poor bowel preparation
Obstructing disease or colitis
Excess looping/ patient intolerance
Diverticular disease
• Failure in women most often tends to occur in the sigmoid
colon as opposed to the ascending colon in males. [21]
Polypectomy during colonoscopy
• In general, a colonic polyp should be removed if:[24]
• it is causing clinical problems (namely, hemorrhage or
obstruction)
• is thought to be malignant or premalignant
• its etiology is uncertain (requiring histopatho-logic evaluation for
diagnosis).
• Research has shown that by interrupting the adenomacarcinoma sequence, endoscopic polypectomy can prevent
the development of CRC.[24]
• If possible, the method of resection should be endoscopic, as
opposed to surgical, to decrease morbidity and cost.[24]
Anatomic landmarks of pedunculated and sessile adenomas. (From Haggitt RC, Glotzbach RE, Soffer EE,
et al: Prognostic factors in colorectal carcinoma arising in adenomas: Implications for lesions removed by
endoscopic polypectomy. Gastroenterology 89:328-336, 1985.)
• Malignant polyp – macroscopically benign appearing
adenoma, in which invasive carcinoma is detected
histologically in the resected specimen.[23]
• The management of malignant polyps includes colonoscopic
and surgical approaches.[23]
• Patients treated with polypectomy were presumably higher
risk for surgery, as reflected in age and comorbidity scores,
and were more likely to have tumor characteristics that were
favorable, including well differentiated cancers.[23]
• Management with polypectomy is a safe and effective
strategy.[23]
Thank you
for your
time!
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