Download Colorectal Cancer

RADIOLOGY INTERACTIVE
CASE
Evangelista, E.; Evangelista, K.; Facton, R.;
Fajardo, R.; Fang, M.; Florendo, G.; Fontano, M.;
Francisco, T.; Gabuat, H.; Gaffud, P.
PATIENT PROFILE
PATIENT HISTORY
Weight loss, weakness
No headache
No chest pain, no shortness of breathe
No abdominal pain, (+) abdominal
discomfort
No edema
No previous medical illness
No previous surgeries
No allergies
(+) Cancer, both sides
(+) hypertension
(-) asthma, No allergies
Smoker – 30 pack years
Heavy alcoholic beverage drinker
VITAL SIGNS: 120/90, T: 37.6, HR:
80BPM
Palpebral conjunctiva, anicteric sclera
Symmetric chest expansion, no
retractions, clear breath sounds
Distended abdomen, tensed, hyperactive
bowel sounds, tympanitic on percussion
No cyanosis, no edema, full pulses
SALIENT FEATURES
 65 years old
 Male
 (+) abdominal discomfort
 (+) changes in bowel habits (4-5x/day)
 (+) constipation not relieved by laxatives
 (+) blood streaked stools
 (+) weight loss
 (+) weakness
 FH: (+) cancer in both sides
 Smoker – 30 pack years
 Heavy alcoholic beverage drinker
 PE findings: Distended abdomen, tensed, hyperactive
bowel sounds
Clinical Impression
Intestinal obstruction;
to consider malignancy
Differential Diagnosis
Causes of Constipation
Obstruction
Benign
Benign
Polyp
Diverticular
disease
Malignant
Irritable
Bowel
Syndrome
Colorectal
Malignancy
(Large) Benign Colonic Polyp
 Abnormal growth of tissue in the mucosa
 If it is attached to the surface by a narrow elongated stalk it is
said to be pedunculated. If no stalk is present it is said to be
sessile.
 ≈ 50% of elderly people
 <1% become maligant

•
•
•
•
Signs and Symptoms
Bowel changes - obstruction
Hematochezia
Abdominal discomfort (rare)
(-) weight loss
Benign Colonic Polyp
Preserved mucosa
(-) apple core finding
Mexican hat sign
Benign Colonic Polyp
Preserved mucosa
(-) apple core finding
Mexican hat sign
Double-contrast barium enema and colonoscopy
features of polyps. Mexican hat sign. This is the
typical appearance of a pedunculated polyp seen
end-on. The outer ring represents the head of the
polyp, and the inner ring represents the stalk.
Diverticular Disease
- outpouchings of colonic mucosa through points
of weakness in the colonic wall where the blood
vessels penetrate the muscularis propria
-sigmoid  most commonly affected
- seen in hypertensive patients
- Prevalence increases with age
- May cause large bowel obstruction due to
inflamed mass associated with narrowing and
spasm
Diverticular Disease
Signs & Symptoms:
• Diarrhea
• Colon obstruction  constipation, decrease
in stool caliber, abdominal distention
• Hematochezia- results from rupture of the
small blood vessels that are stretched while
coursing over the dome of the diverticula
- 30 – 50% massive
• Anorexia  weight loss
• Abdominal pain (LLQ)
• Fever, leukocytosis
• Pelvic abscess
Diverticular Disease
scattered
diverticula throughout
the sigmoid and
descending colon
(arrows)
Irritable Bowel Syndrome
• Diagnostic Criteria for IBS
– Recurrent abdominal pain or discomfort at
least 3 days per month in the last 3 months
associated with two or more of the following:
1. Improvement with defecation
2. Onset associated with a change in frequency in
stool
3. Onset associated with a change in form of stool
Irritable Bowel Syndrome
• Spasm leads to symptoms of diarrhea and
constipation
• Usually a disorder of the young
– Agrawal et al. (2009) reported that IBS in under-recognized in
elderly
• Onset of symptoms during periods of stress or
emotional upset
• Absence of other systemic symptoms such as
fever and weight loss
• Small-volume stool without any evidence of blood
(mucus)
• No diagnostic radiological finding
Colorectal Malignancy
• INCIDENCE:
– Cancer of the large bowl is 2nd only to lung
cancer as a cause of cancer death in United
States
– The third leading cause of cancer-related
death in the Western world
– Colorectal cancer generally occurs in persons
> 50 years old.
Colorectal Malignancy
• Smoking (CASE: Smoker – 30 pack years)
 Male smokers had more than a 30% increase in risk of dying
from the disease compared to men who never had smoked.
• Alcohol (CASE: Heavy alcoholic beverage drinker)
 The WCRF panel report Food, Nutrition, Physical Activity and the
Prevention of Cancer: a Global Perspective finds the evidence
"convincing" that alcoholic drinks increase the risk of colorectal
cancer in men.
 "Heavy alcohol use may also increase the risk of colorectal
cancer”
 One study found that "While there was a more than twofold
increased risk of significant colorectal neoplasia in people who
drink spirits and beer, people who drank wine had a lower risk. In
our sample, people who drank more than eight servings of beer
or spirits per week had at least a one in five chance of having
significant colorectal neoplasia detected by screening
colonoscopy.”
 The NIAAA reports that: "Epidemiologic studies have
found a small but consistent dose-dependent
association between alcohol consumption and
colorectal cancer.
 "Heavy alcohol use may also increase the risk of
colorectal cancer" (NCI). One study found that
"People who drink more than 30 grams of alcohol per
day (and especially those who drink more than 45
grams per day) appear to have a slightly higher risk
for colorectal cancer.”
 "The consumption of one or more alcoholic beverages
a day at baseline was associated with approximately
a 70% greater risk of colon cancer."
PRESENTING SYMPTOMS
Constipation or diarrhea
Tenesmus
Hematochezia
Melena
Abdominal pain
Abdominal distention
Fatigue
Weakness
Pallor
Palpitations
Weight loss
Decreased appetite
In addition:
> 50 years old
Smoker – 30 pack years
Heavy alcoholic beverage
drinker
Diagnosis:
Intestinal obstruction;
Secondary to colorectal
malignancy
Colorectal Malignancy
PATHOPHYSIOLOGY
• Colorectal tumorigenesis
result from multiple acquired genetic alterations
 promote malignant transformation
• studies showed: adenoma-to-carcinoma
sequence takes ~ 10 years
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroenterology/colorectal-neoplasia/#cesec3
POLYPS
• Most arise from adenomatous polyps~30% middle-aged
~50% elderly
• Villous type adenoma- 3x likelihood into malignancy
• Probability of developing malignancy depends on polyp
size:
Polyp size
Risk of malignancy
<1.5cm
2%
1.5 – 2.5cm
2-10%
>2.5cm
10%
CARCINOMA
• Adenocarcinoma - most common colon
cancer cell type; 95% of cases
• Lymphoma & squamous cell CA –
uncommon
DIAGNOSTICS
BARIUM ENEMA
Normal Barium Enema
SCOUT FILM
SCOUT FILM
BARIUM ENEMA
BARIUM ENEMA
CT SCAN
Staging, Treatment and
Monitoring of Colon Cancer
American Cancer Society
National Cancer Institute
How is Colorectal Cancer
Staged?
• Clinical Stage VS Pathologic Stage
• AJCC (TNM) Staging System
• Survival rates for colon Ca by stage
Stage 5-year Survival Rate
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•
•
•
•
•
•
I 93%
IIA 85%
IIB 72%
IIIA 83%*
IIIB 64%
IIIC 44%
IV 8%
» National Cancer Institute's SEER database, looking
at nearly 120,000 people diagnosed with colon
cancer between 1991 and 2000
How is Colon Cancer Treated?
• Stage 0 (Carcinoma in Situ)
• Local excision or simple polypectomy
• Resection /anastomosis: tumor is too large to
remove by local excision
• Stage I Colon Cancer
• Resection /anastomosis
• Stage II Colon Cancer
• Resection /anastomosis
• Clinical trials of chemotherapy, radiation therapy,
or monoclonal antibody therapy after surgery
• Stage III Colon Cancer
• Resection /anastomosis with chemotherapy
• Clinical trials of chemotherapy, radiation therapy,
and/or monoclonal antibody therapy after surgery
• Stage IV and Recurrent Colon Cancer
• Resection /anastomosis
• Surgery to remove parts of other organs, such as
the liver, lungs, and ovaries, where the cancer may
have recurred or spread
• Radiation therapy or chemotherapy may be offered
to some patients as palliative therapy to relieve
symptoms and improve quality of life
• Clinical trials of chemotherapy and/or monoclonal
antibody therapy
• Treatment of locally recurrent colon cancer
may be local excision
• Special treatments of cancer that has
spread to or recurred in the liver may
include the following:
• Chemotherapy followed by resection
• Radiofrequency ablation or cryosurgery
• Clinical trials of hepatic chemoembolization with
radiation therapy
• Patients whose colon cancer spreads or
recurs after initial treatment with
chemotherapy may be offered further
chemotherapy with a different drug or
combination of drugs
Monitoring and Surveillance
• Physical examination every 2-3 months for 3 years
then every 6 months.
• CEA 2 weeks post-operatively if CEA was elevated
pre-op, then CBC & CEA every 2-3 months for 3 years
then every 6 months. (many studies recommended
shorter interval of doing CEA). If CEA is not elevated
preop, then CA 19-9 should be done and if elevated
can be used for follow up.
• CT of abdomen and pelvis with intravenous and oral
contrast every 6 months for 3 years then every year
for 3 years.
• Chest X-ray every year for 5 years.
• Colonoscopy, soon post-op if not done preop
otherwise every 12 months for 3 years if (-) every 3
years.
Thank You!