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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 • • • • • • 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 • • • • • • • 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. • • • • • • • 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