COLORECTALCOLORECTALCANCERCANCER

COLORECTAL CANCERCOLORECTAL CANCER IncidenceIncidence

22ndnd after after after bronhopulmonary C in males after bronhopulmonary C in males and breast in femalesand breast in females

>65 ani>65 ani MM:F=:F=1-1-1,5:11,5:1

RISK FACTORSRISK FACTORS Food habitsFood habits

Excess of animal fat Excess of animal fat and colesterol and colesterol

Lack of fibers in foodLack of fibers in food Excess of salt, spicy, Excess of salt, spicy,

smoked mea, alcohol, smoked mea, alcohol, food additivesfood additives

HeredityHeredity Some diseases with Some diseases with

heredia=tary heredia=tary component – increased component – increased risk of cancerrisk of cancer::

Ulcerative colitisUlcerative colitis;; Poliposis colli Poliposis colli Adenomatous polipsAdenomatous polips..

There are families with There are families with increased incidence of increased incidence of colorectal cancer colorectal cancer NPCCNPCC

Precancerous Precancerous statusstatus Ulcerative colitisUlcerative colitis

15 times higher risk 15 times higher risk then rest of population then rest of population

Higher risk if:Higher risk if::: Onset in childhood Onset in childhood Longer then 19 years Longer then 19 years

evolution evolution Malignant degeneration Malignant degeneration

~30-40y much earlier ~30-40y much earlier then sporadic cancer then sporadic cancer

Often multiple cancer – Often multiple cancer – synchronous synchronous

Adenomatous polypes – Adenomatous polypes – specially >2 cmspecially >2 cm

FAP – certain cancer FAP – certain cancer after 15-20 yafter 15-20 y

Crohn’s 10y of evolution Crohn’s 10y of evolution in patients with onset in patients with onset below 21ybelow 21y

Pathology Pathology

More often More often sigmoid colon – sigmoid colon – logic of logic of sigmoidoscopy sigmoidoscopy

Most often Most often single tumors, single tumors, but multiple but multiple synchronous or synchronous or metachronous metachronous tumors are not tumors are not unusualunusual

MACROSCOPYMACROSCOPY a)a) exofitic –cauliflower exofitic –cauliflower

likelike b)b) schirousschirous

Major hyperplasie of Major hyperplasie of fibroconjunctiv tissuefibroconjunctiv tissue

Circular development – Circular development – stenosis stenosis

FFmore often left sidemore often left side c)c) coloid coloidee (muci (mucinous)nous)::

PProiferation of mucinous roiferation of mucinous cellscells;;

Soft, friable, bleeding Soft, friable, bleeding Often right side, Often right side,

young patientsyoung patients d)d) ulcerat ulceration ion

Pathology Pathology MiMicroscopcroscopyy::

adenocarcinoamadenocarcinoamaa:: cylindric epithemlium cylindric epithemlium Carcinoid tumors – very unusualCarcinoid tumors – very unusual;; EEpidermoid pidermoid carcinoma carcinoma– excep– excepttional;ional; SSarcoamarcoamaa

Spread pathways Spread pathways a) direct:a) direct:

In the wall – serosa – In the wall – serosa – ajacent organ ajacent organ

In the surfaceIn the surface:: circumferencircumferentialtial;; longitudinal:longitudinal:

Along submucosal Along submucosal layerlayer

b) lb) lyymmphphatic:atic: MoMost often st often Intraperietal – local – Intraperietal – local –

regional lymph nodesregional lymph nodes c) c) VascularVascular::

Colic veins – portal Colic veins – portal system – lver MTSsystem – lver MTS

Lombar and vertebral Lombar and vertebral veins – pulmonary veins – pulmonary MTSMTS

dd) ) intralumintraluminalinal:: Neoplastic cells get Neoplastic cells get

detached and detached and reseaded (anastomotic reseaded (anastomotic recurrences) recurrences) ..

e)e) transperitonetransperitonealal:: T4a – exposure to the T4a – exposure to the

serosaserosa Douglas pouchDouglas pouch OmentumOmentum Peritoneal Peritoneal

carcinomkatosiscarcinomkatosis f) perinef) perineuralural: : ..

Staging Staging Stadiul 0Stadiul 0 Tis Tis N0 N0 M0 M0 Dukes Dukes Stadiul IStadiul I T1 T1 N0 N0 M0 M0 AA

T2 T2 N0 N0 M0 M0 Stadiul IIStadiul II T3T3 N0 N0 M0 M0 BB

T4 T4 N0N0 M0 M0 Stadiul IIIStadiul III anyany T T N1N1 M0 M0 CC

anyany T T N2, N3N2, N3 M0M0 Stadiul IVStadiul IV anyany T T anyany N N M1M1

SYMPTOMSSYMPTOMS Changes in bowel Changes in bowel

habithabit ConstipationConstipation DiarrheaDiarrhea !alternation of !alternation of

constipation with constipation with diarrhea) diarrhea)

Dependent on Dependent on location of the colonlocation of the colon

PainPain From discomfort to colicky From discomfort to colicky Aggressive peristalsis above the Aggressive peristalsis above the

tumor tumor Borborism Borborism Meteorism Meteorism Can suggest the locationCan suggest the location Location of painLocation of pain::

RLQ – distension of cecumRLQ – distension of cecum;; EEpigastric – pigastric – often in transverse often in transverse

colon cancercolon cancer;; RUIQ lombar – may creat RUIQ lombar – may creat

confusionconfusion

Bleeding Bleeding occultoccult melenar;melenar; Hematochezia Hematochezia

Other synptoms: Other synptoms: ~ gastric problems~ gastric problems ~ billiary symptoms ~ billiary symptoms ~ urinary syptoms ~ urinary syptoms

General signs General signs :: anorexia, anorexia, weight loss, low weight loss, low

feverfever

Clinical examinationClinical examinationOften negativeOften negative GENERALGENERAL;;

general:general: Palor, apathy, diminshed turgor Palor, apathy, diminshed turgor Cachexia – advanced stages Cachexia – advanced stages

LOCALLOCAL NothingNothing TumorTumor AscitAscitisis HepatomegalHepatomegalyy

Rectal/vaginal Rectal/vaginal :: Sigmoid tumors falling in the pouch of Sigmoid tumors falling in the pouch of

Douglas;Douglas; CarcinomatosisCarcinomatosis..

LABLAB Non specificNon specific

Anaemia (microcytis, hypochromic) Anaemia (microcytis, hypochromic) ;; Increased ESRIncreased ESR leucocitoleucocitosissis Abnormal liver testsAbnormal liver tests

CEACEA Not for diagnostic purposeNot for diagnostic purpose;; Only high values are significant for C colon, Only high values are significant for C colon,

stomach, pancreas. Normal value do not stomach, pancreas. Normal value do not have significance have significance

More valuable for post therapy follow upMore valuable for post therapy follow up Occult blood testOccult blood test:: screening ??? screening ??? Colic cytologyColic cytology

X-RayX-RayCorect dg in Corect dg in 90%90%

Plain X-Ray in Plain X-Ray in complications complications

Barium enemaBarium enema Wall rigidity Wall rigidity Filling defectsFilling defects.. Stenosis – golf Stenosis – golf

trouserstrousers UlcerationsUlcerations

ColonoscopyColonoscopy BiopsBiopsyy TrTreeatment atment

EchoendoscopyEchoendoscopyCTCTMRIMRIUS scan US scan

Virtual CT colonoscopy Virtual CT colonoscopy

Evolution and Evolution and complicationscomplications

1. Obstruc1. Obstructiontion:: Left colon and rectum Left colon and rectum Incomplete obstruction to acut Incomplete obstruction to acut

obstructionobstruction TTypical presentationypical presentation

2. Perfora2. Perforationtion:: a) a) extension through the wallextension through the wall;; b) diastatic:b) diastatic: c) juxtatumoral.c) juxtatumoral.

3. Septic3. Septicalal:: Abscess formationAbscess formation;; PeritonitisPeritonitis

4. Fistul4. Fistulaa:: eexterior – xterior –

piostercoralpiostercoral fistula fistula Other organOther organ;;

5. 5. VolvulusVolvulus

6. Invagination6. Invagination

7. Compression7. Compression

8. 8. Invazia Invazia organelor organelor învecinateînvecinate::

9. Anemia9. Anemia::

10. 10. MetastasisMetastasis

TREATMENTTREATMENT

SurgicalSurgical:: - - tumor, lymph nodes, regiomal tumor, lymph nodes, regiomal lymphnodes +/- invadet organslymphnodes +/- invadet organs RadicalRadical – oncologic colectomy with regional – oncologic colectomy with regional

Paliative:Paliative: 1. 1. by passby pass:: 2. 2. diverting stoma diverting stoma 3. stents 3. stents

Tratament endoscopicTratament endoscopic