Download Colon Cancer Module - David Geffen School of Medicine at UCLA

Cancer
Colon Cancer
Epidemiology, Treatment, and Survival
David Geffen UCLA School of Medicine
2007 Cancer Survivorship Grant
Authors: Wendy Liu, James S. Tomlinson, M.D.
Goals of this Module
This is an interactive and self-directed learning
module intended to build a foundation of
knowledge around the epidemiology, diagnosis,
treatment and survival of colon cancer patients.
You will be presented with a patient case and a
series of related questions. You may continue with
the case upon correctly answering each question.
However, we encourage you to select each of the
answer choices for further explanations. Additional
hyperlinks are available throughout the case
providing access to related topics and journal
articles. Please remember that passage to
continue with the case is from the correct answer
slide.
Begin
case
Colon Cancer Module
Mr. Jackson is a 61 year old male who comes
to see you, his primary care doctor, complaining of
“feeling tired” and just wants a check-up. He saw a
doctor at the urgent care clinic last week who sent
some labs and made this follow up appointment for
him. He further states that his uncle recently passed
away secondary to metastatic colon cancer
diagnosed at age 86 and this event has made him
somewhat depressed and anxious about having
cancer. He reports that he had a colonoscopy at age
51 during which a nonmalignant small (1cm) polyp
was removed from his colon.
Next
Colon Cancer Module
Colon Cancer
Colon cancer is the second most common cause
of cancer deaths in the United States. It
constitutes approximately 10% of all new cancer
cases and has an estimated annual incidence of
150,000 new cases in the United States. The
estimated deaths from colon cancer exceeds
50,000 per year, which represents approximately
10% of all cancer deaths in the United States.
Epidemiology article
Next
Colon Cancer Module
Incidence of Colon Cancer by
Risk Category
Average risk (sporadic; no identifiable risk factor)
75%
Family history of colon cancer
15 to 20%
Hereditary non-polyposis colorectal cancer (HNPCC)
3 to 8%
Familial adenomatous polyposis (FAP)
1%
Ulcerative Colitis
1%
As you can see, the majority of colon cancer cases are
considered sporadic, i.e. no identifiable risk factor.
Hereditary colon cancer article
Question
#1
Colon Cancer Module
Question #1. Which of the following factors,
independently, has the greatest impact on Mr.
Jackson’s risk for developing colon cancer?
A. Age
B. Gender
C. Uncle diagnosed with colon cancer at age 86
D. Endoscopic polypectomy at age 51
Colon Cancer Module
Question #1. Correct!
A. Age
Age is a major, independent risk factor for developing colon
cancer. It has been well documented that the incidence of colon
cancer increases with age. SEER (Surveillance, Epidemiology, and
End Results) data indicates that less than 6% of cases develop
before age 50. After age 50, the incidence steadily increases.
Return to
Question #1
Ahnen DJ. “Epidemiology and risk factors for colorectal cancer.” June 2007. Jan. 2008.
<http://www.uptodate.com>.
Continue
case
Colon Cancer Module
Question #1. Incorrect
B. Gender
According to SEER data, male gender is
associated with a higher incidence of colon
cancer, across all racial and ethnic groups. The
incidence of colon cancer is 64.2 per 100,000 in
men compared to 46.7 per 100,000 in women.
Observed death rates for colon cancer are also
higher in males. Nevertheless, gender as a risk
factor alone, has not been incorporated into
screening guidelines.
Return to
Question #1
Colon Cancer Module
Question #1. Incorrect
C. Uncle diagnosed with colon cancer at age 86
About 15-20% of all colon cancer cases are
associated with a positive family history. Most
guidelines recommend earlier and more frequent
screening for patients with family history of colon
cancer in > 1 first-degree relative(s), especially if
diagnosed prior to age 60. Mr. Jackson’s uncle (not
considered a first degree relative) was diagnosed
with colon cancer at an older age (>60). This does
not significantly alter his risk of developing colon
cancer and he is still considered to be at “average”
risk for developing colon cancer.
Return to
Question #1
Colon Cancer Module
Question #1. Incorrect
D. Endoscopic polypectomy at age 51
Patients with adenomatous polyps have an increased
risk of developing colon cancer. Endoscopic
polypectomy and surveillance has been shown to
significantly reduce subsequent colon cancer
incidence. In fact, the subsequent risk of developing
colon cancer after polypectomy (non-sessile, small
size) does not exceed that of the general population.
Polypectomy article
Return to
Question #1
Colon Cancer Module
Colon Cancer Risk Factors
Age: Approximately 95% of colon cancer cases
occur after age 50. The risk increases steadily with
advancing age. Colon cancer screening is generally
advised for men and women > 50 years old.
Ahnen DJ. “Epidemiology and risk factors for colorectal cancer.” June 2007. Jan. 2008.
<http://www.uptodate.com>.
Next
Risk Factor
Colon Cancer Module
Colon Cancer Risk Factors
Symptoms and signs: Patients who experience
any rectal bleeding, any unexplained persistent
change in bowel habits or stool character, or found
to have iron deficient anemia should be referred
for colonoscopy.
Next
Risk Factor
Colon Cancer Module
Colon Cancer Risk Factors
Family History: 15-20% of all colon cancer cases
are associated with a positive family history. The
number of affected first-degree relatives and their
age of diagnosis affect a patient’s risk for colon
cancer. A family history of early onset colon cancer
should prompt suspicion for hereditary colon
cancer syndromes. A general rule of thumb is to
begin screening approximately 10 years earlier
than the youngest age of diagnosis in a first
degree relative.
Hereditary colon cancer article
Next
Risk Factor
Colon Cancer Module
Colon Cancer Risk Factors
Past medical history:
• Patients with a personal history of colon cancer
are at increased risk for developing a second
primary colon cancer.
• Patients with inflammatory bowel disease for > 810 years in duration are at an increased risk for
developing colon cancer.
Next
Risk Factor
Colon Cancer Module
Colon Cancer Risk Factors
Other risk factors: Male gender, obesity, current
smoking, and heavy alcohol intake are associated
with increased colon cancer risk, but are not part
of current screening guidelines.
Continue
Case
Colon Cancer Module
Colon Cancer Screening
Terminology
• Screening is the testing of an asymptomatic
population considered to be at average risk for a
disease. The goal of a screening test is to detect a
disease at a stage when intervention may significantly
improve outcome.
• People are considered to be at average risk if they are
> 50 years old and have no other risk factors
• Screening tests should not be offered to individuals
with symptoms/signs suggestive of cancer. They
should be offered prompt diagnostic evaluation.
Question
#2
Colon Cancer Module
Question #2: It appears Mr. Jackson had some
sort of colon cancer screening when he was 51
years of age. What are the current screening
recommendations for the average risk individual
in the United States?
A. Annual Fecal Occult Blood Test (FOBT) starting at age 40
B. Biennial FOBT starting at age 40
C. Annual FOBT starting at age 50
D. Colonoscopy every 3 years starting at age 50
E. CT colonography every 5 years starting at age 50
Colon Cancer Module
Question #2. Incorrect
A. Annual Fecal Occult Blood Test (FOBT) starting at
age 40
For average risk patients, screening for colon
cancer should start at age 50.
Return to
Question #2
Colon Cancer Module
Question #2. Incorrect
B. Biennial FOBT starting at age 40
For average risk patients, screening using FOBT
should be once a year, starting at age 50.
Return to
Question #2
Colon Cancer Module
Question #2. Correct!
C. Annual FOBT starting at age 50
For average risk patients, screening using FOBT
should be once a year, starting at age 50. Any
positive FOBT should be promptly followed by
further diagnostic evaluation such as a
colonoscopy.
Return to
Question #2
Continue
case
Colon Cancer Module
Question #2. Incorrect
D. Colonoscopy every 3 years starting at age 50
Colonoscopy is considered the gold standard in
colon cancer screening because it is the only test
that is both diagnostic and therapeutic. It can
simultaneously examine the entire colon
accurately, remove any polyps, and biopsy any
suspicious lesions. As a screening test,
colonoscopy is recommended every 10 years
starting at age 50.
More frequent colonoscopy exams, such as every
3 years, increases the associated exam risks,
such as bowel perforation without a proven
Return to
screening benefit.
Question #2
Colon Cancer Module
Question #2. Incorrect
E. CT colonography
CT colonography is currently not recommended as a
screening test for colon cancer. A recent study
compared the efficacy of CT colonography as a
colon cancer screening tool in average risk adults
against colonoscopy. The study found that the two
tests had similar detection rates for advanced
adenomas and invasive cancers, but the
colonoscopy cohort had significantly more polyps
removed than the CT colonography cohort who
subsequently were referred for polypectomy. More
studies are needed to better define the role of CT
colonography in colon cancer screening.
CT colonography article
Return to
Question #2
Colon Cancer Module
Colon Cancer Screening
Average Risk
Beginning at age 50, men and women at average risk for developing colon cancer
should be offered one of the following screening options. These options differ in
regard to evidence of effectiveness, cost, risk, and availability. As a result, presenting
patients with multiple screening options allows individualized care and may increase
the likelihood that screening will occur.
• Fecal occult blood testing (FOBT) every year (Follow up any positive with colonoscopy)
• Flexible sigmoidoscopy every 5 years
• FOBT every year plus flexible sigmoidoscopy every 5 years
• Colonoscopy every 10 years
• Double contrast barium enema every 5 years
Screening article
Next
Colon Cancer Module
Colon Cancer Screening
Positive Family History
Average Risk
Individuals with only one
first-degree relative with
colon cancer diagnosed
at age 60 or later are
still considered to be at
average risk for
developing colon cancer
and should be offered
the same screening
options as the average
risk patient.
Increased Risk
Individuals with a first-degree relative
diagnosed with early onset colon
cancer (prior to age 60) or with
multiple first-degree relatives (> 2)
with colon cancer at any age are
considered as increased risk
individuals. They should be advised
to have screening colonoscopy,
beginning at age 40, or 10 years
earlier than the youngest diagnosis
in the family, whichever comes first.
Screening colonoscopy should be
performed at 5-10 year intervals
Next
Colon Cancer Module
Color Cancer Screening
Increased Risk: Hereditary Syndromes
HNPCC
Patients with a diagnosis of
Hereditary Nonpolyposis
Colorectal Cancer syndrome
are at increased risk for colon
cancer and should receive
colonoscopy, every 1-2 years,
beginning at age 20-25 or 10
years younger than the earliest
colon cancer diagnosis in the
family, whichever comes first.
Hereditary colon cancer article
FAP
Patients with a diagnosis of
Familial Adenomatous
Polyposis are at increased
risk for developing colon
cancer and should receive
endoscopic surveillance
annually, beginning at age
10-12.
Question
#3
Colon Cancer Module
Question #3: What is the level of evidence to
support the use of FOBT as an initial screening test
for colon cancer?
A. Level 1 evidence: supported by Randomized Controlled Trials (RCT)
B. Level 2 evidence: supported by case-control or cohort studies
C. Level 3 evidence: supported by non-analytic studies, including
case reports, case series
D. Level 4 evidence: supported by expert opinions
Colon Cancer Module
Question #3. Correct!
A. Level 1 evidence: supported by Randomized
Controlled Trials (RCT)
FOBT has been shown in 3 RCTs to reduce risk of
death from colon cancer.
Return to
Question #3
Continue
case
Colon Cancer Module
Question #3. Incorrect
B. Level 2 evidence: supported by case-control or
cohort studies
FOBT has been shown in 3 RCTs to reduce risk of
death from colon cancer.
Return to
Question #3
Colon Cancer Module
Question #3. Incorrect
C. Level 3 evidence: supported by non-analytic
studies, including case reports, case series
FOBT has been shown in 3 RCTs to reduce risk of
death from colon cancer.
Return to
Question #3
Colon Cancer Module
Question #3. Incorrect
D. Level 4 evidence: supported by expert opinion
FOBT has been shown in 3 RCTs to reduce risk of
death from colon cancer.
Return to
Question #3
Colon Cancer Module
Physical Exam
On exam Mr. Jackson is noted to be overweight
(221lbs, 5 ft 10inches). Abdominal exam
demonstrated a nontender, nondistended
abdomen with no obvious masses. On digital
rectal exam the sphincter tone is normal and no
masses are noted. The prostate margins are
distinct and it appears to be normal in size. His
labs demonstrate a mild anemia (hematocrit =
32%) On further questioning, he admits that his
stools have been slender in size and lately have
been very dark in color.
Question
#4
Colon Cancer Module
Question #4: Given Mr. Jackson’s anemia coupled
with a change in his stool character, you are highly
suspicious of a diagnosis of colon cancer. What is
the next test you would like to order for Mr. Jackson
to help “rule in” or “rule out” a diagnosis of colon
cancer?
A. CEA level
B. Fecal Occult Blood Test
C. Flexible sigmoidoscopy
D. Colonoscopy
Colon Cancer Module
Question #4. Incorrect
A. CEA level
Although serum CEA is often elevated in patients
with colon cancer, it can also be elevated in other
types of adenocarcinomas and benign disorders.
Additionally, some patients with colon cancer do
not have elevated CEA level. As a result, serum
CEA level is not used in the screening or
diagnosis of colon cancer. Rather, CEA is a tool
used in the surveillance for colon cancer
recurrence after surgical resection of the primary
tumor. Its power lies in the ability to monitor
efficacy of therapy and to detect cancer
Return to
recurrence.
Question #4
Colon Cancer Module
Question #4. Incorrect
B. Fecal Occult Blood Test
The patient’s history of dark black stools is suggestive
of GI bleeding. Although ordering a FOBT would
confirm GI bleeding, the test result, whether positive or
negative, would not negate the need for colonoscopy.
This is an example of a test that does not alter
management and therefore is of little value in clinical
decision making. In considering any test or
intervention, a responsible healthcare provider should
assess whether the result would affect the
management and well being of the patient. This is
particularly important when dealing with tumor markers
and genetic testing.
Return to
Question #4
Colon Cancer Module
Question #4. Incorrect
C. Flexible sigmoidoscopy
Mr. Jackson’s recent change in stool character is
suspicious for colon cancer. Flexible sigmoidoscopy
refers to an endoscopic examination that is limited to
the distal colon up to approximately the splenic
flexure. This includes the rectum, sigmoid colon and
left colon. Normal findings on Flexible
sigmoidoscopy does not rule out malignancy in
proximal regions of the colon including the transverse
colon and the ascending colon or right side of the
colon. Furthermore, even when a lesion is detected
by sigmoidoscopy, a colonoscopy is still required to
search for synchronous neoplasms in the proximal
colon.
Return to
Question #4
Colon Cancer Module
Question #4. Correct!
D. Colonoscopy
Patients over the age of 50 who report visible
rectal bleeding of any type, unexplained iron
deficiency anemia, unexplained persistent change
in bowel habits or stool character should be
referred for colonoscopy. Mr. Jackson’s stool has
become slender and very dark recently. The
diagnosis of colon cancer should be suspected.
Colonoscopy allows for both visualization of the
entire colon, removal of any polyps, and biopsy of
any suspicious lesions
Return to
Question #4
Continue
case
Colon Cancer Module
Mr. Jackson states that he does not want to go
through a colonoscopy again and wants to know if
there are any other test he could do instead. You
explain to Mr. Jackson that a colonoscopy is
currently the gold standard for evaluation of the
colon. Other tests could be done but cannot
replace the need for colonoscopy. You explain that
he will have to undergo a “bowel prep” which
consists of drinking a solution that acts as a
cathartic to empty the colon of any stool. This
allows the visualization of the entire mucosal
surface of the colon during colonoscopy. In addition
he will need to remain on a liquid diet the
Continue
case
night before colonoscopy.
Colon Cancer Module
Mr. Jackson undergoes a colonoscopy and returns
to your clinic to discuss the results. The report
states that a 1 cm tubular adenoma was removed
from the transverse colon, i.e. a polypectomy.
Furthermore, a 4 cm sessile ulcerated mass was
noted in the left colon. The biopsy of this mass
revealed moderately differentiated colonic
adenocarcinoma.
Question
#5
http://www.cancer.gov/Templates/db_alpha.aspx?CdrID=45648
Colon Cancer Module
Question #5: You report the unfortunate news to Mr.
Jackson that he has colon cancer. He immediately
asks what is the next step?
A.
Surgical resection
B.
Chemotherapy
C.
Radiation therapy
D.
Clinical staging
Colon Cancer Module
Question #5. Incorrect
A. Surgical resection
Although surgery represents the primary
treatment modality for most colon cancers,
staging work up must be performed preoperatively
to determine if the patient is a surgical candidate.
For example, if the tumor has already spread to
Mr. Jackson’s liver and lungs, localized therapy
such as surgical resection of the primary tumor
does not ultimately affect survival. It would make
more sense to offer chemotherapy to treat the
systemic nature of the disease.
Return to
Question #5
Colon Cancer Module
Question #5. Incorrect
B. Chemotherapy
Extent of disease / staging work up is the most
important initial step in determining optimal
therapy for Mr. Jackson. If Mr. Jackson proves to
have metastatic disease then chemotherapy as a
first line of treatment would be indicated. In the
metastatic setting, use of chemotherapy is
referred to as “palliative chemotherapy.” Use of
chemotherapy after resection of node-positive
(Stage III) colon cancer is referred to as “adjuvant
chemotherapy” because it is given after surgical
resection of the primary tumor.
Return to
Question #5
Colon Cancer Module
Question #5. Incorrect
C. Radiation therapy
Radiation therapy (RT) alone is not recommended
in the treatment of colon cancer. RT may be
added to adjuvant chemotherapy on a case-bycase basis for patients at increased risk for
recurrence (e.g. T4 tumors) after resection of
primary tumor. Of note, RT plays an important role
in the preoperative and postoperative
management of rectal cancers.
Return to
Question #5
Colon Cancer Module
Question #5. Correct!
D. Clinical staging
Staging is the process that evaluates the local and
distant extent of cancer at time of diagnosis. Cancer
staging is the most important initial step in selecting the
optimal treatment modality and predicting outcome. For
colon cancer, the preoperative clinical stage is first
determined using information from physical exam, CT
scan of the abdomen/pelvis, and chest x-ray, in order to
look for evidence of distant metastases. Subsequently,
the postoperative pathological stage is determined
based on histologic evaluation of the resected tumor
and regional lymph nodes.
Return to
Question #5
Continue
case
Colon Cancer Module
Extent of disease or staging workup for Mr. Jackson
is completed. Physical exam is negative for ascites,
hepatomegaly, and lymphadenopathy. The CT scan
of the abdomen and pelvis is negative for any
evidence of metastases or other abnormalities. The
Chest X-Ray is also negative for abnormalities. CEA
level is noted to be 14ng/ml. You inform Mr. Jackson
that he does not have evidence of spread of his
cancer and that he will need to have surgery to
remove his colon cancer.
Question
#6
Colon Cancer Module
Question #6: Mr. Jackson first wants to know is a
CEA of 14 ng/ml good or bad?
A.
Good
B.
Bad
C.
Neither
Colon Cancer Module
Question #6. Incorrect
A. Good
Some studies have shown a correlation between
elevated preoperative CEA levels (> 5 ng/mL) and
heavier disease burden in colon cancer, while
other studies found no such association. In Mr.
Jackson’s case, although a preoperative CEA of
14ng/ml may suggest a worse prognosis, it alone
does not change the treatment plan. The TNM
staging remains the most important tool in
establishing prognosis and directing therapy.
Return to
Question #6
Colon Cancer Module
Question #6. Incorrect
B. Bad
Some studies have shown a correlation between
elevated preoperative CEA levels (> 5 ng/mL) and
heavier disease burden in colon cancer, while
other studies found no such association. In Mr.
Jackson’s case, although a preoperative CEA of
14 may suggest a worse prognosis, it alone does
not change the surgical plans. The TNM staging
remains the most important tool in establishing
prognosis and directing therapy.
Return to
Question #6
Colon Cancer Module
Question #6. Correct!
C. Neither
Elevated preoperative CEA level has been found in
several studies to correlate with worse outcome. As a
result, the Joint Committee on Cancer and the College
of American Pathologists recommend obtaining a this
information in addition to TNM staging. However, a
CEA of 14 alone would not alter surgical plans.
Further, with complete resection, CEA level should
return to baseline, and be followed regularly for early
detection of recurrence. Thus, postoperatively, the
CEA trend is more important than the absolute value.
Return to
Question #6
Question
#7
Colon Cancer Module
Question # 7: Mr. Jackson is clinically cleared for
surgery. Keeping in mind that Mr. Jackson’s
colonoscopy revealed a 1 cm tubular adenomatous
polyp that was removed from the ascending colon
and a 4 cm colon cancer located within the left
colon. What operation will Mr. Jackson need?
A. Left Hemicolectomy
B. Right Hemicolectomy
C. Total Colectomy
D. Abdominoperineal Resection (APR)
Colon Cancer Module
Question #7. Correct!
A. Left Hemicolectomy
Two separate lesions were noted during Mr.
Jackson’s colonoscopy. The first is a single small
tubular adenomatous polyp which is virtually
always benign. Endoscopic removal is considered
curative, negating the need for surgical resection
of the portion of the colon of the proximal or right
colon. The second is a left-sided malignant lesion,
not involving the rectum (>12 cm from anal
verge). A left hemicolectomy is an appropriate
surgical option.
Return to
Question #7
See image of
Left hemicolectomy
Continue
case
Colon Cancer Module
Question #7. Incorrect
B. Right Hemicolectomy
The malignant lesion is left-sided, requiring at
minimum a left hemicolectomy. The right-sided
small tubular adenomatous polyp is virtually
always benign. Endoscopic removal is considered
curative, negating the need for a right
hemicolectomy.
See image of
Right hemicolectomy
Return to
Question #7
Colon Cancer Module
Question #7. Incorrect
C. Total Colectomy
Although a total colectomy would remove the
malignant lesion, it is overly aggressive in this
case with significantly increased morbidity and
mortality. The right-sided small tubular
adenomatous polyp is virtually always benign.
Endoscopic removal is considered curative,
negating the need for a right hemicolectomy. The
malignant lesion is left-sided, therefore a left
hemicolectomy would be sufficient.
Return to
Question #7
Colon Cancer Module
Question #7. Incorrect
D. Abdominoperineal Resection (APR)
APR is a surgical operation used for the treatment
of low rectal cancers that are invading the anal
sphincter complex. It involves the removal of the
anus, the sphincter complex, the rectum, part of
the sigmoid colon and their draining lymph nodes.
This operation necessitates the need for a
colostomy, a surgical opening made between the
large intestine and the skin, so that stool can pass
through and drain into a colostomy bag.
See image of
APR
Return to
Question #7
Colon Cancer Module
Mr. Jackson undergoes a left hemicolectomy and
you visit him on postoperative day number 2. He
is doing well recovering from his operation and
wants to know if he will need any additional
treatment. You explain to him that further
treatment decisions will depend on the pathologic
“staging” information which is based on the
pathology report. Normally it takes approximately
7 days for a pathologist to review all of the
necessary information and finalize a report.
Continue
case
Colon Cancer Module
American Joint Committee on Cancer (AJCC)
T-N-M Staging System for Colorectal Cancer
Staging provides a universal language among healthcare
providers to allow stratification of patients according to biology
and disease burden. This enables the selection of individulaized
treatment based on prognostic information associated with a
particular “stage group” of the cancer. The Stage group is
determined by the combination of pathologic factors “T-N-M”.
“T” is usually a measure of tumor size
“N” represents the status of the regional lymph nodes with
respect to whether or not they contain adenocarcinoma
“M” represents presence of metastatic disease
Next
Colon Cancer Module
AJCC Staging System for Colorectal Cancer
Primary Tumor (T)
TX
T0
Tis
T1
T2
T3
T4
Primary tumor cannot be assessed
No evidence of primary tumor
Carcinoma in situ; intraepithelial or invasion
of lamina propria
Tumor invades submucosa
Tumor invades muscularis propria
Tumor invades through the muscularis
propria into the subserosa, or into nonperitonealized pericolic or perirectal tissues
Tumor directly invades other organs or
structures, and/or perforates visceral
peritoneum
Regional Lymph Nodes (N)
NX
N0
N1
N2
Regional lymph nodes cannot be assessed
No regional lymph node metastasis
Metastasis in 1 to 3 regional lymph nodes
Metastasis in 4 or more regional lymph
nodes
Stage Grouping
Stage
0
I
IIA
IIB
IIIA
IIIB
IIIC
IV
T
Tis
T1
T2
T3
T4
T1-T2
T3-T4
Any T
Any T
N
N0
N0
N0
N0
N0
N1
N1
N2
Any N
M
M0
M0
M0
M0
M0
M0
M0
M0
M1
Distant Metastasis (M)
MX
M0
M1
Distant metastasis cannot be assessed
No distant metastasis
Distant metastasis
See pathology
report
Colon Cancer Module
Mr. Jackson continues to do well and on
postoperative day #7 the pathology report is
available:
Pathology Report
• Moderately differentiated adenocarcinoma of colonic origin
• Tumor is 4 cm x 3 cm x 3 cm. Tumor extends through
through the muscularis propria into the subserosa
• Proximal and distal colonic margins are free of tumor.
Closest margin is 10 cm.
• 2 out of 12 regional lymph nodes were positive for
metastatic adenocarcinoma
Question
#8
Colon Cancer Module
Question # 8: What is the stage of Mr. Jackson’s
colon cancer?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
See pathology
report
See AJCC
staging table
Colon Cancer Module
Question #8. Incorrect
A. Stage I
According to the TNM system, Mr. Jackson’s
cancer is T3 (tumor extends to serosa), N1 (2
positive regional lymph nodes), and M0 (no
evidence of distant metastases), corresponding to
stage IIIb.
Return to
Question #8
Colon Cancer Module
Question #8. Incorrect
B. Stage II
According to the TNM system, Mr. Jackson’s
cancer is T3 (tumor extends to serosa), N1 (2
positive regional lymph nodes), and M0 (no
evidence of distant metastases), corresponding to
stage IIIb.
Return to
Question #8
Colon Cancer Module
Question #8. Correct!
C. Stage III
According to the TNM system, Mr. Jackson’s
cancer is T3 (tumor extends to serosa), N1 (2
positive regional lymph nodes), and M0 (no
evidence of distant metastases), corresponding to
stage IIIb.
Return to
Question #8
Question
#9
Colon Cancer Module
Question #8. Incorrect
D. Stage IV
According to the TNM system, Mr. Jackson’s
cancer is T3 (tumor extends to serosa), N1 (2
positive regional lymph nodes), and M0 (no
evidence of distant metastases), corresponding to
stage IIIb.
Return to
Question #8
Colon Cancer Module
Question #9: What is Mr. Jackson’s predicted 5
year survival rate based on his stage?
A. 20% 5 year survival rate
B. 40% 5 yr survival rate
C. 60% 5 yr survival rate
D. 90% 5 yr survival
Colon Cancer Module
Question #9. Incorrect
A. 20% 5 year survival rate
Mr. Jackson has stage IIIb colon cancer. The 5
year survival rate is about 60%.
Stage I — 93 percent
Stage IIA — 85 percent
Stage IIB — 72 percent
Stage IIIA — 83 percent
Stage IIIB — 64 percent
Stage IIIC — 44 percent
Stage IV — 8 percent
Return to
Question #9
Colon Cancer Module
Question #9. Incorrect
B. 40% 5 year survival rate
Mr. Jackson has stage IIIb colon cancer. The 5
year survival is about 60%.
Stage I — 93 percent
Stage IIA — 85 percent
Stage IIB — 72 percent
Stage IIIA — 83 percent
Stage IIIB — 64 percent
Stage IIIC — 44 percent
Stage IV — 8 percent
Return to
Question #9
Colon Cancer Module
Question #9. Correct!
C. 60% 5 year survival rate
Mr. Jackson has stage IIIb colon cancer. The 5
year survival is about 60% (see graph).
Stage I — 93 percent
Stage IIA — 85 percent
Stage IIB — 72 percent
Stage IIIA — 83 percent
Stage IIIB — 64 percent
Stage IIIC — 44 percent
Stage IV — 8 percent
Return to
Question #9
Survival article
Question
#10
Colon Cancer Module
Question #9. Incorrect
D. 90% 5 year survival rate
Mr. Jackson has stage IIIb colon cancer. The 5
year survival is about 60%.
Stage I — 93 percent
Stage IIA — 85 percent
Stage IIB — 72 percent
Stage IIIA — 83 percent
Stage IIIB — 64 percent
Stage IIIC — 44 percent
Stage IV — 8 percent
Return to
Question #9
Colon Cancer Module
Question #10: After recovering from his operation he
presents for a consultation with a medical oncologist.
What treatment is recommended for Stage III colon
cancer?
A. Adjuvant Chemotherapy
B. Adjuvant Radiation
C. Observation and Surveillance
Colon Cancer Module
Question #10. Correct!
A. Adjuvant Chemotherapy
The 2005 colon cancer treatment guidelines from
the National Comprehensive Cancer Network
(NCCN) and American Cancer Society
recommend adjuvant chemotherapy for all Stage
III colon cancers.
Return to
Question #10
Systemic therapy article
Question
#11
Colon Cancer Module
Question #10. Incorrect
B. Adjuvant Radiation
The 2005 colon cancer treatment guidelines from
the National Comprehensive Cancer Network
(NCCN) and American Cancer Society
recommend adjuvant chemotherapy for all Stage
III colon cancers. Unlike rectal cancers, radiation
therapy is not a routine part of adjuvant treatment
for colon cancer.
Return to
Question #10
Colon Cancer Module
Question #10. Incorrect
C. Observation and Surveillance
The 2005 colon cancer treatment guidelines from
the National Comprehensive Cancer Network
(NCCN) and American Cancer Society
recommend adjuvant chemotherapy for all Stage
III colon cancers. Observation and surveillance
alone is NOT sufficient and results in poorer
survival compared with patients who had received
adjuvant chemotherapy.
Return to
Question #10
Colon Cancer Module
Question # 11: What is the risk of Mr. Jackson
developing a recurrence of his original cancer
(local/regional or distant metastasis) over the next
five years?
A. <10%
B. 15-20%
C. 40-60%
D. >80%
Colon Cancer Module
Question #11. Incorrect
A. <10%
Approximate recurrence rate by stage
Stage I
Stage II
Stage III
10%
30%
50%
Return to
Question #11
Colon Cancer Module
Question #11. Incorrect
B. 15-20%
Approximate recurrence rate by stage
Stage I
Stage II
Stage III
10%
30%
50%
Return to
Question #11
Colon Cancer Module
Question #11. Correct!
C. 40-60%
Approximate recurrence rate by stage
Stage I
Stage II
Stage III
Return to
Question #11
10%
30%
50%
Recurrence article
Question
#12
Colon Cancer Module
Question #11. Incorrect
D. >80%
Approximate recurrence rate by stage
Stage I
Stage II
Stage III
10%
30%
50%
Return to
Question #11
Colon Cancer Module
Question # 12: What is the risk of Mr.
Jackson developing a second primary colon
cancer over the next five years?
A. <1%
B. 1.5 -2.5%
C. 10-15%
D. >20%
Colon Cancer Module
Question #12. Incorrect
A. <1%
The risk of developing a second primary colon
cancer is noted to be higher than the risk of the
general population. This risk is estimated to be
approximately 0.3-0.5% per patient per year.
Thus, at five years the cumulative risk of
developing a second colon cancer is
approximately 1.5-2.5%.
Return to
Question #12
Colon Cancer Module
Question #12. Correct!
B. 1.5-2.5%
The risk of developing a second primary colon cancer
is noted to be higher than the risk of the general
population. This risk is estimated to be approximately
0.3-0.5% per patient per year. Thus, at five years the
cumulative risk of developing a second colon cancer
is approximately 1.5-2.5%. Moreover, if a patient lives
20yrs after his colon cancer diagnosis, the risk of
developing a second colon cancer primary could be
as high as 10%.
Return to
Question #12
Second primary article
Question
#13
Colon Cancer Module
Question #12. Incorrect
C. 10-15%
The risk of developing a second primary colon
cancer is noted to be higher than the risk of the
general population. This risk is estimated to be
approximately 0.3-0.5% per patient per year.
Thus, at five years the cumulative risk of
developing a second colon cancer is
approximately 1.5-2.5%.
Return to
Question #12
Colon Cancer Module
Question #12. Incorrect
D. >20%
The risk of developing a second primary colon
cancer is noted to be higher than the risk of the
general population. This risk is estimated to be
approximately 0.3-0.5% per patient per year.
Thus, at five years the cumulative risk of
developing a second colon cancer is
approximately 1.5-2.5%.
Return to
Question #12
Colon Cancer Module
Question # 13: Given these risks of recurrence
and development of a second primary, what is
the recommended follow up and cancer
surveillance for Mr. Jackson over the next two
years?
A. Office visit / CEA level every 6 months
B. Office visit / CEA level every 6 months, colonoscopy once per year
C. Office visit / CEA level every 3 months, colonoscopy once per year
Colon Cancer Module
Question #13. Incorrect
A. Office visit / CEA every 6 months
According to the National Comprehensive Cancer Network (NCCN), follow
up during the first 2 years after curative resection of stage III colon cancer
should consist of:
• A history and physical every 3 months for 2 years
• CEA level every 3 months for 2 years
• Colonoscopy once per year for 2 years
• Consider abdominal CT scan every 6 months for 2 years if there is a high
risk of recurrence
Return to
Question #13
Colon Cancer Module
Question #13. Incorrect
B. Office visit / CEA level every 6 months, colonoscopy once per year
According to the National Comprehensive Cancer Network (NCCN), follow
up during the first 2 years after curative resection of stage III colon cancer
should consist of:
• A history and physical every 3 months for 2 years
• CEA level every 3 months for 2 years
• Colonoscopy once per year for 2 years
• Consider abdominal CT scan every 6 months for 2 years if there is a high
risk of recurrence
Return to
Question #13
Colon Cancer Module
Question #13. Correct!
C. Office visit / CEA level every 3 months, colonoscopy once per
year
According to the National Comprehensive Cancer Network (NCCN), follow
up during the first 2 years after curative resection of stage III colon cancer
should consist of:
• A history and physical every 3 months for 2 years
• CEA level every 3 months for 2 years
• Colonoscopy once per year for 2 years
• Consider abdominal CT scan every 6 months for 2 years if there is a high
risk of recurrence
Return to
Question #13
NCCN guidelines
Continue
case
Colon Cancer Module
During a routine follow up visit 12
months after his operation, Mr.
Jackson’s CEA level was noted to
have risen from his previous value
of 3 to 8 ng/ml. Recall that any
value >5 ng/ml is considered
abnormally elevated. You order a
CT scan of the abdomen and this
demonstrates a single 3 cm
metastatic lesion (red arrow) in the left lobe of his liver.
You also ordered a whole body PET scan which
demonstrated a single area of positivity corresponding
to the lesion in the left lobe. Mr. Jackson thus has
evidence of a single site of colon cancer
Question
recurrence in his left liver.
Personal Teaching File; James S. Tomlinson
#14
Colon Cancer Module
Question # 14: You refer Mr. Jackson to a surgical
oncologist who recommends hepatic resection of
his metastatic colon cancer and states that this is
the only potential curative therapy. Before Mr.
Jackson undergoes such a radical procedure, he
wants to know what are his chances of being cured
if he undergoes the operation?
A. 0-5%
B. 5-10%
C. 15-25%
D. 50%
Colon Cancer Module
Question #14. Incorrect
A. 0-5%
Surgical resection of colorectal liver metastasis (CLM) in
selected patients with limited disease has become the
standard of care in the past 20 years. A recently published
study looked at over 600 patients who underwent resection
of CLM with 10-year follow-up. The study found that in
well-selected patients, the overall 10 year disease free
survival is 15-25% after hepatic resection.
Back to
Question #14
Colon Cancer Module
Question #14. Incorrect
B. 5-10%
Surgical resection of colorectal liver metastasis (CLM) in
selected patients with limited disease has become the
standard of care in the past 20 years. A recently published
study looked at over 600 patients who underwent resection
of CLM with 10-year follow-up. The study found that in
well-selected patients, the overall 10 year disease free
survival is 15-25% after hepatic resection.
Back to
Question #14
Colon Cancer Module
Question #14. Correct!
C. 15-25%
Surgical resection of colorectal liver metastasis (CLM) in
selected patients with limited disease has become the
standard of care in the past 20 years. A recently published
study looked at over 600 patients who underwent resection
of CLM with 10-year follow-up. The study found that in
well-selected patients, the overall 10 year disease free
survival is 15-25% after hepatic resection.
Back to
Question #14
Hepatic resection article
Continue
Case
Colon Cancer Module
Question #14. Incorrect
D. 50%
Surgical resection of colorectal liver metastasis (CLM) in
selected patients with limited disease has become the
standard of care in the past 20 years. A recently published
study looked at over 600 patients who underwent resection
of CLM with 10-year follow-up. The study found that in
well-selected patients, the overall 10 year disease free
survival is 15-25% after hepatic resection.
Back to
Question #14
Colon Cancer Module
Mr. Jackson decides to go ahead with surgery and
underwent a left lateral hepatic segmentectomy. He
recovered well post operatively.
Continue
Case
Colon Cancer Module
Left Lateral Hepatic Segmentectomy
Question
#15
Personal Teaching File; James S. Tomlinson
Colon Cancer Module
Question # 15: If Mr. Jackson initially had multiple
sites of recurrence making surgical resection of his
disease impossible, what would be his predicted
median survival if he received current standard
palliative chemotherapy (FOLFOX with Avastin)?
A. 0-5 months
B. 5-10 months
C. 15-20 months
D. 36-72 months
Colon Cancer Module
Question #15. Incorrect
A. 0-5 months
In patients with advanced metastatic colon cancer,
treatment with FOLFOX and Avastin has been shown to
prolong median survival to approximately 15-20 months.
By contrast, patients who do not receive any form of
chemotherapy have a median survival of approxmately 6
months.
Back to
Question #15
Colon Cancer Module
Question #15. Incorrect
B. 5-10 months
In patients with advanced metastatic colon cancer,
treatment with FOLFOX and Avastin has been shown to
prolong median survival to approximately 15-20 months.
By contrast, patients who do not receive any form of
chemotherapy have a median survival of approxmately 6
months.
Back to
Question #15
Colon Cancer Module
Question #15. Correct!
C. 15-20 months
In patients with advanced metastatic colon cancer,
treatment with FOLFOX and Avastin has been shown to
prolong median survival to approximately 15-20 months.
By contrast, patients who do not receive any form of
chemotherapy have a median survival of approxmately 6
months.
Back to
Question #15
Systemic therapy article
Question
#16
Colon Cancer Module
Question #15. Incorrect
D. 36-72 months
In patients with advanced metastatic colon cancer,
treatment with FOLFOX and Avastin has been shown to
prolong median survival to approximately 15-20 months.
By contrast, patients who do not receive any form of
chemotherapy have a median survival of approxmately 6
months.
Back to
Question #15
Colon Cancer Module
Question #16: We have learned that most recurrences
after being diagnosed with colon cancer occur within 2
years of diagnosis/resection. In accordance, follow up
over the subsequent two years is considered
intensive. If Mr. Jackson did not develop a recurrence
within those two years, what would his cancer followup and surveillance plan be for the rest of his life?
A. Office visit / CEA level every 6 months until year 5 then yearly thereafter
B. Office visit / CEA level every year, colonoscopy every 10 years
C. Same level of intensive follow-up must be continued indefinitely
Colon Cancer Module
Question #16. Correct!
A. Office visit / CEA level every 6 months until year 5 then
yearly thereafter
According to the National Comprehensive Cancer
Network (NCCN) and American Cancer Society, follow
up after the first 2 disease-free years after curative
resection of stage III colon cancer should consist of:
• A history and physical every 6 months until year 5
• CEA level every 6 months through year 5
• Colonoscopy 2-3 years after year 2, and if no polyps,
then every 5 years thereafter
Back to
Question #16
Colonoscopy surveillance article
End Case
Colon Cancer Module
Question #16. Incorrect
B. Office visit / CEA level every year, colonoscopy every 10
years
According to the National Comprehensive Cancer
Network (NCCN) and American Cancer Society, follow
up after the first 2 disease-free years after curative
resection of stage III colon cancer should consist of:
• A history and physical every 6 months until year 5
• CEA level every 6 months through year 5
• Colonoscopy 2-3 years after year 2, and if no polyps,
then every 5 years thereafter
Back to
Question #16
Colon Cancer Module
Question #16. Incorrect
C. Same level of intensive follow-up must be continued
indefinitely
According to the National Comprehensive Cancer
Network (NCCN) and American Cancer Society, follow
up after the first 2 disease-free years after curative
resection of stage III colon cancer should consist of:
• A history and physical every 6 months until year 5
• CEA level every 6 months through year 5
• Colonoscopy 2-3 years after year 2, and if no polyps,
then every 5 years thereafter
Back to
Question #16
Colon Cancer Module
Inflammatory Bowel Disease
Ulcerative Colitis & Crohn’s Colitis
Patients with chronic colitis are at increased risk for
developing colorectal cancer. The risk is 5% after 10
years, 20% after 20 years, and 40% after 25 years of
duration of IBD. Risk of cancer may be reduced in
patients who respond well to medical therapy.
Surveillance with colonoscopy should begin 8-10 years
after diagnosis of IBD, and repeated every 1-3 years
with surveillance biopsies of the colon taken every 10
cm. Findings indicative of high grade dysplasia of the
colonic mucosa should prompt consideration of surgical
therapy (colectomy).
IBD Photos
Back
Colon Cancer Module
Inflammatory Bowel Disease
Ulcerative Colitis & Crohn’s Colitis
www.learningradiology.com
www.GI-Pathology.net
www.GI-Pathology.net
Crohn’s Colitis
endoscopic view
Ulcerative Colitis
gross specimen
Barium enema: colon with "leadpipe" appearance in ulcerative colitis
Back
Colon Cancer Module
Lynch Syndrome (HNPCC)
(Hereditary Non-Polyposis Colorectal Cancer)
HNPCC is an autosomal dominant syndrome caused by
a germline mutation in one of the DNA mismatch repair
(MMR) genes. It is associated with 2% - 3% of all colon
cancer cases. The lifetime risk of a developing colon
cancer can be as high as 70%. In recent report, median
age of colon cancer diagnosis in patients with Lynch
Syndrome (HNPCC) was 54 years in men and 70 years
in women. This syndrome is also associated with tumors
of other organs such as the uterus, ovaries, stomach,
pancreas, ureters, kidneys, small bowel, biliary tract,
and brain.
Back
Colon Cancer Module
Familial Adenomatous Polyposis
FAP is an autosomal dominant syndrome caused by germline
mutation in the APC gene. It accounts for < 1% of all colon cancer
cases. Approximately 50% of affected patients develop
adenomatous polyps by age 15 and 95% by age 35. The average
age at diagnosis of colon cancer is about 35-40 years. The lifetime
risk of developing colon cancer in a patient with FAP approaches
100%.
www.GI-Pathology.net
www.GI-Pathology.net
Back
Colon Cancer Module
Hamartomatous Polyposis Syndromes
These are a group of rare hereditary syndromes associated
with increased risk of developing colon cancer.
• Peutz Jeghers is an autosomal dominant syndrome notable
for perioral pigmentation and histologically distinct
gastrointestinal polyps (see picture). The lifetime risk for colon
cancer is 40% and for breast cancer >50%.
• Juvenile polyposis is an autosomal dominant syndrome. The
lifetime risk for colon cancer is 60% with a mean age of
presentation at age 34 (see picture).
Back
Colon Cancer Module
Peutz Jeghers
http://www.humpath.com/article.php3?id_article=2791
www.GI-Pathology.net
Back
©1999 Division of Gastroenterology, Johns Hopkins Hospital
Colon Cancer Module
Juvenile Polyposis
www.GI-Pathology.net
www.humpath.com/juvenile-polyp
Back
Colon Cancer Module
Colonic Polyps
A polyp is a macroscopic protrusion of the colonic mucosa
into the bowel lumen. Colonic polyps can be classified
according to their malignant potential. Neoplastic polyps can
become malignant while non-neoplastic polyps cannot. Within
the group of neoplastic polyps, there are malignant polyps
and benign but precancerous polyps that may evolve into
carcinoma. The table below show examples of each category.
Neoplastic
Benign
Malignant
Tubular adenoma
Carcinoma in situ
Tubulovillous adenoma Invasive carcinoma
Villous adenoma
Polypoid carcinoma
Non-neoplastic
Benign
Hyperplastic polyps
Juvenile polyps
Peutz-Jeghers polyps
Inflammatory polyps
Next
Colon Cancer Module
Colonic Polyps
Colonic adenomas are common in people over the age
of 50. Most colon cancers arise in preexisting
adenomatous polyps, but relatively few adenomas
progress to cancer. Certain characteristics are
associated with higher cancer risk. These include:
•
•
•
•
•
•
Multiple adenomas
Size > 1.0 cm
Advanced histology (villous, tubulovillous, high grade dysplasia)
Proximal location of adenoma
Older age at diagnosis of adenoma(s)
Family history of colon cancer in a parent
Next
Colon Cancer Module
Colonic Polyps
The malignant potential of a polyp based on histology is:
tubular < tubulovillous < villous. Cancer risk also rises with
increasing size of the polyp. The table below shows the
incidence of invasive carcinoma related to polyp histology and
size based on analysis of 7000 polypectomy specimens.
Size
(cm)
Tubular
Tubulovillous
Villous
0.5-0.9
0.3%
1.5%
2.5%
1.0-1.9
3.6%
6.4%
5.7%
2.0-2.9
6.5%
11.4%
17.0%
>3.0
11.0%
16.0%
20.0%
Colonic polyps article
Images from: www.endoatlas.com/atlas_co.html
Back
Colon Cancer Module
Hyperplastic Polyps
www.GI-Pathology.net
www.GI-Pathology.net
The epithelial cells at the base of the crypt
(regenerative zone) have mildly enlarged,
but uniform nuclei and brisk mitotic rate,
feature which is normally present in reactive
colonic mucosa
Endoscopic image of
hyperplastic polyps
Back
Colon Cancer Module
Tubular Adenoma
www.GI-Pathology.net
The adenomatous polyp has a smooth
outline and is composed of numerous
architecturally simple crypts with mild
irregularity in size and shape
www.endoatlas.com/atlas_co.html
Endoscopic image of a
tubular adenoma
Back
Colon Cancer Module
Villous Adenoma
www.GI-Pathology.net
Villous adenoma with glands that
extend straight down from the surface
to the base as fingerlike projections
www.endoatlas.com/atlas_co.html
Endoscopic image of a
villous adenoma
Back
Colon Cancer Module
Tubulovillous Adenoma
www.GI-Pathology.net
Tubulovillous adenoma with 80% tubular
histology and 20% villous histology
www.endoatlas.com/atlas_co.html
Endoscopic image of a
tubulovillous adenoma
Back
Colon Cancer Module
Fecal Occult Blood Test (FOBT)
Randomized Controlled Trials
1. Minnesota Colon Cancer Control Study
46,551 participants; 50-80yrs of age
18yr follow up demonstrated a 36% reduction in colon cancer mortality in
patients who underwent annual FOBT screening
2. United Kingdom-Nottingham FOBT Study
156,000 participants, 50-74yrs of age
8 yr follow up demonstrated a 15% reduction in colon cancer mortality in
patients who underwent FOBT screening
3. Danish FOBT Study
62,000 participants, 45-74yrs of age,
10yr follow up demonstrated an 18% reduction in colon cancer mortality
in patients who underwent FOBT screening
Back
Colon Cancer Module
Carcinoembryonic antigen (CEA)
CEA is a membrane-bound, surface protein expressed by fetal
enterocytes and a variety of cancers, including colon
adenocarcinoma. CEA level varies with tumor burden, grade,
site, liver involvement, tobacco smoking, and many other
factors. It is important to note that CEA levels should not be
compared among different individuals. CEA is not
used in colon cancer screening and diagnosis due to low
sensitivity and specificity. In addition, CEA levels may also be
elevated in other advanced adenocarcinomas and benign
disorders. The utility of monitoring CEA levels is in the early
detection of recurrent disease after curative resection of colon
cancer, with an average lead time of 5 months. In addition,
CEA levels can be used to follow response to treatment such
as surgery, chemotherapy, or radiation therapy. A serum level
above 5ng/ml is considered abnormal.
Return to
Question #4
Five-year survival by the American Joint Committee on Cancer sixth edition system stages I-IV
O'Connell, J. B. et al. J. Natl. Cancer Inst. 2004 96:1420-1425; doi:10.1093/jnci/djh275
Back
Colon Cancer Module
Left Hemicolectomy
hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm?pg=disease4&organ=6&disease=36&lang_id=1
Back
Colon Cancer Module
Right Hemicolectomy
hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm?pg=disease4&organ=6&disease=36&lang_id=1
Back
Colon Cancer Module
Abdominoperineal Resection
hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm?pg=disease4&organ=6&disease=36&lang_id=1
Back
Colon Cancer Module
Positron Emission Tomography in Colon Cancer
PET is a nuclear medicine imaging technique, often used in
clinical oncology, for the whole body visualization of tumors and
metastases. A glucose analog tracer such as [18F]-2-fluro-2
deoxy-D-glucose is injected into the circulation and is taken up
by glucose-using cells. Fast growing malignant cells would take
up more tracer and show up as areas of intensity (positivity).
Studies have found PET to have 80-90% accuracy in the
detection of recurrent and metastatic disease. PET can be
helpful in preoperative staging and postoperative detection of
recurrence/metastases.
See Mr. Jackson’s
PET images
Back
Mr. Jackson’s Tumor on CT and PET
PET Scan
Coronal view
Abdominal CT Scan
Liver
Tumor
Personal Teaching File; James S. Tomlinson
Personal Teaching File; James S. Tomlinson
Back
Colon Cancer Module
AJCC Staging System for Colorectal Cancer
Primary Tumor (T)
TX
T0
Tis
T1
T2
T3
T4
Primary tumor cannot be assessed
No evidence of primary tumor
Carcinoma in situ; intraepithelial or invasion
of lamina propria
Tumor invades submucosa
Tumor invades muscularis propria
Tumor invades through the muscularis
propria into the subserosa, or into nonperitonealized pericolic or perirectal tissues
Tumor directly invades other organs or
structures, and/or perforates visceral
peritoneum
Regional Lymph Nodes (N)
NX
N0
N1
N2
Regional lymph nodes cannot be assessed
No regional lymph node metastasis
Metastasis in 1 to 3 regional lymph nodes
Metastasis in 4 or more regional lymph
nodes
Stage Grouping
Stage
0
I
IIA
IIB
IIIA
IIIB
IIIC
IV
T
Tis
T1
T2
T3
T4
T1-T2
T3-T4
Any T
Any T
N
N0
N0
N0
N0
N0
N1
N1
N2
Any N
Distant Metastasis (M)
MX
M0
M1
Distant metastasis cannot be assessed
No distant metastasis
Distant metastasis
Back
M
M0
M0
M0
M0
M0
M0
M0
M0
M1
Colon Cancer Module
Pathology Report
• Moderately differentiated adenocarcinoma of colonic origin
• Tumor is 4 cm x 3 cm x 3 cm. Tumor extends through
through the muscularis propria into the subserosa
• Proximal and distal colonic margins are free of tumor.
Closest margin is 10 cm.
• 2 out of 12 regional lymph nodes were positive for
metastatic adenocarcinoma
Back
Colon Cancer Module
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Harford WV. Colorectal cancer screening and surveillance. Surg Oncol Clin N Am 2006;15:1-20.
Winawer S, et. al. Colorectal cancer screening and surveillance: clinical guidelines and rationale—update based on new evidence.
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NCCN colorectal treatment guidelines version IV 2005
Duffy MJ. Carcinoembryonic antigen as a marker for colorectal cancer: Is it clinically useful? Clinical Chemistry 2001;47(4):624-630.
Wanebo HJ et.al. The use of preoperative carcinoembryonic antigen level as a prognostic indicator to complement pathological staging. NEJM
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O’Connell JB et.al. Colon cancer survival rates with the new American Joint Committee on Cancer sixth edition staging. JNCI 2004;96(19):142025.
Galandiuk S. et.al. Patterns of recurrence after curative resection of carcinoma of the colon and rectum. Surg Gynecol Obstet 1992;174(1):2732.
Russell AH, et al. Adenocarcinoma of the proximal colon: sites of initial dissemination and patterns of recurrence following surgery alone. Cancer
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Cali RL, et al. Cumulative incidence of metachronous colorectal cancer. Dis Colon Rectum 1993;36:388-93.
Jacobson BC, et al. Surveillance after colorectal cancer resection. UpToDate 2007.
Anthony T. Colorectal cancer follow-up in 2005. Surg Oncol Clin N Am 2006;15:175-193.
Blumgart LH and Fong Y. Surgical options in the treatment of hepatic metastasis from colorectal cancer. Curr Probl Surg 1995;32(5):333-421.
Simmonds, PC. Palliative chemotherapy for advanced colorectal cancer: Systematic review and meta-analysis. Colorectal Cancer Collaborative
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Lawrence SP and Ahnen DJ. Epidemiology and risk factors for colorectal cancer. UpToDate 2007.
Mandel JS, et. al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl
J Med 1993;328:1365-1371.
Hardcastle JD, et. al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996;348(9040):1472-7.
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