Download Colorectal Malignancies

COLORECTAL
MALIGNANCIES
Divina B. Esteban, M.D., FPSMO
Rizal Medical Center
Epidemiology:
• Worldwide incidence varies from:
3.4/100,000 - Nigeria
to
35.8/100,000 - Connecticut, USA
Philippine data: 1993-1997*
• Colon Cancer:
– 5th most common (males) - 11.5/100,000
– 7th among females (9.5/100,000)
– 6th for both sexes (10.4/100,000)
– ASR in Filipino migrants to USA > ASR
in the Philippines
– Intermediate incidence between Thailand
& high rates in Asia, USA & Europe
*Cancer In The Phil. Volume III. 2002
Philippine data 1993-1997*
• Rectal cancer
– 9th most common (M) - 7.9/100,000
– 11th most common (F) - 5.7/100,000
– 11th for both sexes - 6.7/100,000
– ASR in Filipino migrants > than those
observed in the Philippines
– Int. inc. bet. low rates in Thailand and
high rates in Asia, Europe & USA
*Cancer In The Philippines Vol.. III. 2002
Leading cancer sites, Males , 1993-1997
DOH-Rizal and PCS - Manila Cancer Registries
Lung
5431
Liver
2624
51.5
20.9
Prostate
1590
Colon
1257
11.5
Stomach
993
9.2
Rectum
910
Lymphoma
956
7.8
6.6
Leukemias
1276
6.0
Nasopharynx 1276
6.0
Oral Cavity
ASR/100,000
663
0
19.3
5.7
10
20
30
40
50
60
Leading Cancer Sites , Females, 1993-1997
DOH - Rizal & PCS - Manila Cancer Registries
Breast
7929
Cervix
3378
19.0
Lung
1813
Ovary
Colon
1934
1244
13.8
11.0
Thyroid
1639
8.5
925
6.7
Liver
48.0
9.3
Rectum 80
5.7
2
Stomach 725
5.3
Leukemias 1115
ASR/100,00 0
5.2
10
20
30
40
50
60
2005 Estimates*
• 8585 new colorectal cancer cases
Males: 4737
Females: 3848
• 5558 deaths from colorectal cancer
Males: 3064
Females: 2494
*2005 Philippine Cancer Facts & Estimates. PCSI. 2004
Philippine Survival Data*
• Colon Cancer
Overall median survival: 49 months
5-year survival rate: 47.72%
10-year survival rate: 32.38%
• Rectal Cancer
Overall median survival: 24 months
5-year survival rate: 19.45%
10-year survival rate: 5.84%
*Mapua et al, Population-based Cancer Survival, PCS-MCR.
RISK FACTORS
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Familial adenomatous polyposis (FAP)
Adenomatous polyps in colon/ rectum
Chronic ulcerative colitis
Familial cancer syndrome
Family history
High -meat and high fat/ low fiber diet
SCREENING Guidelines
• Screening for >50 years old:
– Annual FOBT
– Flexible sigmoidoscopy or DCBE every 5 yrs
• Screening for 1st degree relative w/ cancer
– Flexible sigmoidoscopy, DCBE or colonoscopy
every 5-10 years from age 50 years
– If relative was Dx before age 55, colonoscopy
should be done at age 50 or 10 years prior to
index case
SCREENING Guidelines cont.
• Screening for pts with (+) hx of adenoma or
CA :
– Colonoscopy, DCBE or flexible sigmoidoscopy
every 3-5 years
– Repeat colonoscopy within 1 yr if fragmented
polyp > 1 cm, high gr dysplasia, villous
changes; multiple > 2; (+) FH; more than 60
yrs old
– Flexible sigmoidoscopy or DCBE every 5 yrs
SCREENING Guidelines cont.
• Screening for pts. with ulcerative colitis
If more than 8 yrs duration:
FOBT every 2 yrs
– Flexible sigmoidoscopy every 5 yrs from age
50 years
• Screening for HNPCC and FAP
– Genetic consult
– Annual colonoscopy from age 25 years
SCREENING Guidelines
• for high risk groups & symptomatic
patients:
– Colon Cancer:
• Fecal blood tests
• Colonoscoopy +/- biopsy
• Barium enema
– Rectal Cancer
• Digital rectal examination
• Proctosigmoidoscopy
Clinical Presentation
• Colon Cancer - Right-sided Lesion :
(bulky, exophytic, large diameter, more fluid
content)
• Abdominal pain
• Diarrhea
• Occult gastrointestinal bleeding - anemia
• Weight loss
• Signs of low small bowel obstruction
• Mass in the right iliac fossa
Clinical Presentation
• Colon Cancer - Left-sided Lesion:
(annular or infiltrating, small diameter, semi-solid
to solid contents)
• Obstruction
• Bleeding or bloody stools
• Perforated pericolic abscesses or
peritonitis
• Change in bowel habits
• Abdominal discomfort
Clinical Presentation
• Rectal Cancer:
• Rectal bleeding (bright red)
• Change in bowel habits
• constipation / diarrhea
• Feeling of incomplete emptying after BM ;
unproductive urge to defecate; tenesmus
• Persistent narrowing of stools
• Rectal mass
• Unexplained weight loss
Diagnosis
• Careful history (unexplained weight loss,
anemia, change in bowel habits, abdominal pain,
constipation, etc)
• Physical examination including digital
rectal examination (DRE)
• Colonoscopy, proctosigmoidoscopy +/- bx
• Barium enema
• Tumor markers : CEA
PATHOLOGY
Histological Classification
1. Epithelial Tumors
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Adenocarcinoma
Mucinous Adenocarcinoma
Signet-ring cell carcinoma
Squamous cell carcinoma
Adenosquamous carcinoma
Small cell carcinoma
Undifferentiated carcinoma
• Histological Classification (cont)
2. Carcinoid Tumors
3. Non-epithelial tumors (Leiomyosarcoma)
4. Hematopoietic & Lymphoid Neoplasms
5. Unclassified Tumors
TNM STAGING
Primary Tumor (T)
T0 No evidence of primary tumor
Tis CIS :inv of lamina propria or muscularis
mucosa
T1 Tumor invades the submucosa
T2 Tumor invades the muscularis propria
T3 Tumor invades thru m. propria into subserosa/to
nonperitonealized pericolic or perirectal tissues
T4 Tumor directly inv. other organs/perforates the
visceral peritoneum
TNM STAGING (cont.)
Regional Lymph nodes (N)
Nx Regional LN cannot be assessed
N0 No regional LN metastasis
N1 Metastasis to 1-3 regional LN
N2 Metastasis in 4 or more pericolic LN
N3 Metastasis in any LN along the course
of a named vascular trunk &/or mets.
to apical node(s)
TNM STAGING (cont.)
Distant Metastasis (M)
Mx distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
TNM STAGING (cont.)
Stage Groupings: TNM
Astler-Coller
modified
0
I
Tis N0 M0
n/a
T1 N0 M0
T2 N0 M0
Stage A
Stage B1
II
T3 N0 M0
T4 N0 M0
Any T N1 M0
Stage B2
Stage B3
Stage C1- C3
III
Any T N2 M0
IV
Any T Any N M1
Stage D
PROGNOSTIC
PROGNOSTIC FACTORS
FACTORS:
1 Disease extension beyond the rectal wall
– for (+)LN but tumor confined to wall
(Tis-2 N1-3), loc. recurrence = 20-40%
– for (-) LN but w/ extension beyond wall (T3 or
T4A N0 or T4B N0), loc. recur. = 20-35%
– for (+) LN & (+) ext. beyond wall (T4N1-3,
T4b N1-3), loc. recur. = 40- 65%
PROGNOSTIC FACTORS cont.
2 Lymph node involvement
3 Extrarectal extension
= Amount of uninvolved tissue
(circumferential or radial margins)
Define the extraluminal extent of tumors
Measure the narrowest radial margin
Prognostic Factors cont.
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Histologic grade
Stage of tumor
Depth of invasion
Frequency of nodal involvement
Number of lymph nodes involved
Bowel obstruction 2o to tumor
Tumor perforation
PATTERNS OF FAILURE
after a curative resection
• Local recurrence
– 30-50% in MAC B3, C2 and C3 lesions
– 15-20% in many B2 and most C1 lesions
• Peritoneal seedings - Least common in
rectal primaries
• Systemic metastasis
– Rectal Cancer: Liver and Lung due to venous
drainage
– Colon CA: Initial mets in the liver (venous
drainage via the portal system)
TREATMENT SCHEMA
• Colon Cancer Suspect
• Rectal Cancer Suspect