Cancer of the Colon and rectum

General consideration
Colon and rectal account for more cases of cancer
in the population of Western countries than any
other anatomic site except the skin

Cancer of the colon and rectum is the most

frequent cause of death among visceral malignancies
that affect both sexes
 Cancer of the Colon and rectum

General consideration
Risk factors include:
* age
* a diet rich in fat and cholesterol
* inflammatory bowel disease and
* genetic predisposition including:
hereditary polyposis and
nonpolyposis syndromes
 Cancer of the Colon and rectum
General consideration
If detected early, colorectal cancer is curable by surgery

Adjuvant chemotherapy can prolonge survival in disease that has

reached the lymph nodes

Radiotherapy is used in cases of rectal cancer to reduce the risk of

local recurrence
 Cancer of the Colon and rectum

General consideration
The distribution of cancer of colon and rectum
Ascending colon: 22%
Transverse colon: 12%
Descending colon: 5%
Sigmoid colon: 26%
Rectum: 35%
 Cancer of the Colon and rectum

General consideration
Pathophysiology
The vast majority of colorectal cancers are adenocarcinomas,
which arise from preexisting adenomatous polyps that
develop in the normal colonic mucosa
 Cancer of the Colon and rectum

General consideration
Pathophysiology
Pioneering work by Bert Vogelstein and colleagues over
the last 20 years has identified a number of critically
important genetic alterations that contribute, through
their multiplicity over many years, to the eventual
development of colorectal cancer
 Cancer of the Colon and rectum

General consideration
Pathophysiology
■ The earliest event appears to involve the APC
(adenomatous polyposis coli) gene, which is
mutated in individuals affected by familial
adenomatous polyposis (FAP)

APC mutations are very common in sporadic

colorectal cancer, and beta-catenin mutations have
also been identified
 Cancer of the Colon and rectum

General consideration
Pathophysiology
DNA methylation changes are a relatively early event and have been detected at the
polyp stage
 Cancer of the Colon and rectum
General consideration
Pathophysiology
■ Diet
The mechanism by which diet contributes to carcinigenesis
is under active study

Population with a high incidence of colorectal

carcinoma generally consume diets containing more
animal protein and fat than populations with a low
incidence of this disease
 Cancer of the Colon and rectum

Frequency
International
According to the W H O, April 2003 report on global
cancer rates:

more than 940,000 new cases of colorectal cancer

and nearly 500,000 deaths are reported worldwide

each year
 Cancer of the Colon and rectum

Mortality/Morbidity
The overall 5-year survival rate from colon cancer is
approximately 60%

The 5-year survival rate is different for each stage

(Duke’s classification)
 Cancer of the Colon and rectum

Mortality/Morbidity

For Duke’s stage A tumors involving only the

mucosa, the 5-year survival rate exceeds 90%

Whereas for metastatic colon cancer, the 5-year

survival rate is about 5%
 Cancer of the Colon and rectum
Mortality/Morbidity
For Duke’s stage B colon cancers, the 5-year survival rate is
greater than 70%

And can be greater than 80% if the tumor does not penetrate
the muscularis layer

Once the tumor has spread to the lymph nodes (i.e. Duke’s
stage C), the 5-year survival rate usually is less than 60%
 Cancer of the Colon and rectum

Race
Recent data demonstrate a decrease in incidence
rates of colorectal carcinoma in whites, particularly
for the distal colon and rectum

Proximal colon carcinoma rates in blacks are

considerably higher than in whites
 Cancer of the Colon and rectum

Sex
The frequency of colon cancer is essentially the
same among men and women

Age
Is a well-known risk factor for colon cancer, and risk
begins to rise in people older than 40 years
 Cancer of the Colon and rectum
Clinical
History
Approximately 50% of patients present with
abdominal pain

35% with ► altered bowel habits

30% with ► occult bleeding and

15% with ► intestinal obstruction

 Cancer of the Colon and rectum

Clinical
History
Right-sided colon cancers tend to be larger and
more likely to bleed

Whereas left-sided tumors tend to be smaller and

more likely to be obstructing
 Cancer of the Colon and rectum

Clinical
History
Obtain a family history of:

colon cancer

familial polyposis or

ulcerative colitis
 Cancer of the Colon and rectum
Clinical
History
Remember:
Consider the possibility of cancer of the colon in
patients with:

► a fever of unknown origin

► and in patients with polymyositis

 Cancer of the Colon and rectum

Clinical
Physical
The physical examination findings may be:

(1) completely normal, especially in early stage

colorectal cancer

(2) or general or specific findings due to progression of

the disease may be present
Clinical
Physical
These may include:
weight loss
cachexia
abdominal discomfort or tenderness
liver mass
abdominal distention
ascites
rectal mass
rectal bleeding on rectal examination or
occult blood by lab test
 Cancer of the Colon and rectum
Causes
A number of risk factors have been associated with
colon cancer

Colonic polyps (adenomatous)

Age
Genetic factors
*APC gene mutation
*DNA methylation
represent a risk for colon cancer development
 Cancer of the Colon and rectum

Causes
Alcohol consumption is a risk factor for
gastrointestinal cancer, including colon cancer

Diet, and in particular fat content of diet, has been

associated with increased risk of colon cancer
 Cancer of the Colon and rectum
Causes
A statistically significant association exists between:
Helicobacter exposure and
colonic polyps

Tobacco smoking is associated with a higher risk of

colon cancer, which appears to be mediated by
induction of 5-lipoxygenase–associated angiogenic
pathways
 Cancer of the Colon and rectum
DIFFERENTIALS
Crohn Disease
Diverticulitis
Diverticulosis, Small Intestinal
Fecal Incontinence
Ileus
Inflammatory Bowel Disease
Kaposi Sarcoma
Peritonitis and Abdominal Sepsis
Ulcerative Colitis
 Cancer of the Colon and rectum
Lab Studies
Carcinoembryonic antigen (CEA)
Obtaining a preoperative (CEA) level can be helpful in the clinical
management of colorectal cancer

Example
If CEA level is elevated preoperatively, it can be monitored for evidence of
recurrence
 Lab Studies
Carcinoembryonic antigen (CEA)
Remember the following 2 things:
(1)
CEA may be elevated for reasons other than colon
cancer, such as:
pancreatic or
hepatobiliary disease

And elevation does not always reflect:

cancer or
disease recurrence
Lab Studies
Carcinoembryonic antigen (CEA)
Remember the following 2 things:
(2)
Recurrence remains a possibility when CEA is not
elevated, even if CEA was elevated preoperatively

Findings of other tests, such as:

CT scans and
colonoscopy
must be incorporated in detection of recurrence
 Cancer of the Colon and rectum
Lab Studies
Other blood lab tests include:
standard complete blood cell counts (CBC) and chemistry
panels (example, electrolytes, liver test)

► Remember:
Liver function testing should be performed, but results can
be normal despite the presence of metastatic disease

► Urinalysis
 Cancer of the Colon and rectum

Imaging Studies
Chest radiography:
This is part of the routine evaluation and staging
workup. It may reveal metastatic spread to the
lungs
 Cancer of the Colon and rectum
Imaging Studies
Abdominal/pelvic CT scans
Can be useful in diagnosis of colon cancer that has
metastasized to:
lymph nodes and
liver

Multiple metastases in the liver render colon cancer

incurable by:
surgery and
chemotherapy
 Cancer of the Colon and rectum

Imaging Studies
Positron emission tomography (PET) imaging may
be useful for:
► staging colorectal cancer and
► detecting recurrent disease
TREATMENT
Medical Care
Systemic chemotherapy
5-Fluorouracil
Remains the backbone of chemotherapy regimen
for colon cancer, in both:
adjuvant and
metastatic setting

it was established that combination regimens provide

improved efficacy and prolonged progression-free
survival in patients with metastatic colon cancer
TREATMENT
Medical Care
Adjuvant (postoperative) chemotherapy

The standard therapy for:

patients with stage III and some
patients with stage II colon cancer, consisted of:
fluorouracil in combination with:
levamisole and
leucovorin
TREATMENT
Medical Care
Radiation therapy

While radiation therapy remains a standard

modality for patients with rectal cancer, the role of
radiation therapy is limited in colon cancer

it is limited to palliative therapy for selected

metastatic sites such as:
bone or
brain metastases
 Cancer of the Colon and rectum

TREATMENT
Surgery (palliative and curative)
THANKS