Colon Cancer Definition

Cancer of the colon is the disease characterized by the development of malignant cells in the lining or epithelium of the first and longest portion of the large intestine. Malignant cells have lost normal control mechanisms governing growth. These cells may invade surrounding local tissue, or they may spread throughout the body and invade other organ systems. Synonyms for the colon include the large bowel or the large intestine. The rectum is the continuation of the large intestine into the pelvis that terminates in the anus.

The colon is a tubular organ beginning in the right lower abdomen. It ascends on the right side of the abdomen, traverses from right to left in the upper abdomen, descends vertically down the left side, takes an S-shaped curve in the lower left abdomen, and then flows into the rectum as it leaves the abdomen for the pelvis. These portions of the colon are named separately though they are part of the same organ:
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cecum, the beginning of the colon ascending colon, the right vertical ascent of the colon transverse colon, the portion traversing from right to left descending colon, the left vertical descent of the colon sigmoid colon, the s-shaped segment of colon above the pelvis

These portions of the colon are recognized anatomically based on the arterial blood supply and venous and lymphatic drainage of these segments of the colon. Lymph, a protein-rich fluid that bathes the cells of the body, is transported in small channels known as lymphatics that run alongside the veins of the colon. Lymph nodes are small filters through which the lymph travels on its way back to the bloodstream. Cancer can spread elsewhere in the body by invading the lymph and vascular systems. Therefore, these anatomic considerations become very important in the treatment of colon cancer. The small intestine is the continuation of the upper gastrointestinal tract that is responsible for carrying ingested nutrients into the body. The waste left after the small intestine has finished absorbing nutrients amounts to a few liters (about the same as quart) of material per day and is directly delivered to the colon (at the cecum) for processing. The colon is responsible for the preservation of fluid and electrolytes as it propels the increasingly solid waste toward the rectum and anus for excretion. When cells lining the colon become malignant, they first grow locally and may invade partially or totally through the wall of the bowel and even into adjacent structures and organs. In the process, the tumor can penetrate and invade the lymphatics or the capillaries locally and gain access to the circulation. As the malignant cells work their way to other areas of the body, they again become locally invasive in the new area to which they have spread. These tumor deposits, originating in the colon primary tumor, are then known as metastases. If metastases are found in the regional lymph nodes from the primary, they are known as regional metastases or regional nodal metastases. If they are distant from the primary tumor, they are known as distant metastases. The patient with distant metastases has systemic disease. Thus, the cancer originating in the colon begins locally and, given time, can become systemic. By the time the primary is originally detected, it is usually larger than 0.4 in (1 cm) in size and has over one million cells. This amount of growth itself is estimated to take about three to seven years. Each time the cells double in number, the size of the tumor quadruples. Thus, like most cancers, the part that is identified clinically is later in the progression than would be desired and screening becomes a very important endeavor to aid in earlier detection of this disease. There are at least 100,000 cases of colon cancer diagnosed per year in the United States. Together, colon and rectal cancers account for 10% of cancers in men and 11% of cancers in women. It is the second most common site-specific cancer affecting both men and women. A 2003 study reported that for unknown reasons, women are more likely to have advanced colon cancer at diagnosis than men. Nearly 57,000 people died from colon and rectal cancer in the United States in 2003. In recent years the incidence of this disease has decreased slightly, as has the mortality rate. It is difficult to tell if the decrease in mortality reflects earlier diagnosis, less death related to the actual treatment of the disease, or a combination of both factors.

In late 2003. a team of researchers identified the specific location on a human chromosome by analyzing blood samples from 53 families in which at least one member had a colon cancer or precancerous colon polyp. There also is a slight increased risk for colon cancer in the individual who smokes. red meat.) This results in anemia and chronic fatigue. Polyps. (Often. however. chronic fatigue abdominal discomfort unexplained weight loss very rarely. Exposure to agents in the environment that may induce mutation is the process of carcinogenesis and is caused by agents known as carcinogens (cancer-causing agents). or recurrent colon cancer. Twenty percent of people are thought to have genetic predisposition. In addition. this means that in 80% of cases. total calories. suggests a genetically transmitted form of the disease as opposed to the sporadic form. Patients who suffer from inflammatory diseases of the colon known as ulcerative colitis and Crohn's colitis are also at increased risk. Since malignant cells have a changed genetic makeup. so the research will continue to identify the particular gene responsible for the cancer. Two-thirds of all cases occur after age 50 and the average age for those who develop the disease is 62. Colon cancer is more common in industrialized nations. or at multiple sites. when identified. this blood is not visible. often implying substantial obstruction or the presence of systemic disease. The key is recognizing that the persistence of these types of symptoms without ready explanation should prompt the individual to seek medical evaluation. are removed for diagnosis. The symptoms are caused by the tumor blocking the opening in the colon. Polyps are benign growths of the colon lining. dietary factors seem to be involved. whereas those born with a genetic predisposition are either destined to get the cancer or less environmental exposure can induce the cancer. the patient should undergo careful surveillance for the development of more polyps or the development of colon cancer. At least 200 genes exist on the location of chromosome 9. it will begin to cause symptoms as it reaches a certain size. precancerous. Causes and symptoms Causes of colon cancer often are environmental in sporadic cases (80%) and sometimes genetic (20%). the environment spontaneously induces change. These symptoms may occur alone or in combination:           a change in bowel habit blood in the stool bloating. High-fiber diets may help lessen exposure of the colon lining to carcinogens from the environment. these are not absolutely specific to colon cancer. nausea and vomiting Most of these symptoms are caused by the physical presence of the tumor mass in the colon. Diets high in fiber seem to decrease risk. or malignant. persistent abdominal distention constipation a feeling of fullness even after having a bowel movement narrowing of the stool—so-called ribbon stools persistent. If the polyps are benign. They can be unrelated to cancer. Researchers know there is a genetic link to many cases of colon cancer. meaning their genes carry a trigger for the disease. . however. Similar symptoms can be caused by other processes. and alcohol seem to predispose people to the disease. Colon cancer causes symptoms related to its local presence in the large bowel or by its effect on other organs if it has spread. as the transit time through the bowel is faster with a high-fiber diet than it is with a low-fiber diet. If a tumor develops in the colon. those called familial cases. This is the type of colon cancer that tends to run in families. Development of colon cancer at an early age.Cancer of the colon is thought to arise sporadically in about 80% of those who develop the disease. Weight loss is a late symptom. Age plays a definite role in the predisposition to colon cancer. Diets high in fat. the tumor commonly oozes blood that is lost in the stool. Specific carcinogens have been difficult to identify. The development of polyps of the colon usually precedes the development of colon cancer by five or more years.

and the prostate. . the patient is asked to swipe a sample of stool obtained with a small stick on a card. after having a bowel movement. screening by chemical analysis for CEA has not been helpful. is the search for pre-malignant. Screening involves physical exam. shorter scopes were rigid. while it can be helpful. The examiner notes the tone of the anus and feels the walls and the edges for texture. and other irregularities. When this occurs. particularly since some patients might still require the regular colonoscopy as a follow-up to the virtual procedure if a polyp or abnormality is found that requires biopsy. for example). At home. The physician introduces the instrument through the rectum. and. it is called flexible sigmoidoscopy. To visualize the colon epithelium. abscesses. Indirect visualization of the colon may be accomplished by placing barium through the rectum and filling the colon with this compound. the procedure is known as colonoscopy A procedure called virtual colonoscopy has been developed but debate continues on whether or not it is effective as colonoscopy. not just in detecting small cancers. benign polyps. and the visualization of the lining of the colon. it is known as carcinoembryonic antigen. Proteins are sometimes produced by cancers. These studies are known as the barium enema (BE) and the double contrast barium enema (DCBE). and these may be elevated in the patient's blood. Virtual colonoscopy refers to the use of imaging. Direct visualization of the colon lining is accomplished using a scope or endoscope. After lubricating the gloved finger and anus. Screening for colorectal cancers. or CEA. or it may not be produced by a particular colon cancer. tenderness and masses as far as the examining finger can reach. it is not 100% accurate—only about 50% of cancers are FOBTpositive. CEA has been helpful when used in a follow-up role for patients treated for colon cancer if their tumor makes the protein. Older. (The stool analysis mentioned here is known as a fecal occult blood test.Diagnosis Screening In all other cancers (breast and prostate. If the left colon only is visualized. During this examination. this protein may be made by other adenocarcinomas as well. the physician examines the anus and the surrounding skin for hemorrhoids. screening tests look for small.) These exams are accomplished as an easy part of a routine yearly physical exam. Detail can be increased if the barium utilized is thinned and air also introduced. usually with computed tomography (CT) scans ormagnetic resonance imaging (MRI) to produce images of the colon. the physician checks the stool on the examining glove with a chemical to see if any occult (invisible) blood is present. the scopes are flexible and can reach much farther. simple laboratory tests. the card is then easily chemically tested for occult blood also. At the time of this exam. clinicians use x rays (indirect visualization) and endoscopy (direct visualization). However. When the entire colon is visualized. the contour of the lining of the colon may be seen. malignant lesions. There is a tumor marker for some cancers of the colon. The DRE includes manual examination of the rectum. anus. however. or FOBT. the examiner gently slides the finger into the anus and follows the contours of the rectum. The physical examination involves the performance of a digital rectal exam (DRE). Today. Barium produces a white contrast image of the lining of the colon on x ray and thus. utilizing fiberoptic technology. many physicians were unwilling to accept it as a replacement for colonoscopy. Studies in late 2003 showed that virtual colonoscopy was as effective as colonoscopy for screening purposes and it offered the advantage of being less invasive and less risky. Therefore. the protein produced is known as a tumor marker. This screening can be close to 100% effective in preventing cancer development. Unfortunately. After three such specimens are on the card.

and the opportunity to obtain a biopsy of any abnormality visualized. Blood studies include a complete blood count. Such biopsies are usually obtained using a special needle under local anesthesia. such as annual sigmoidoscopy. and each type of endoscopy. liver function tests. for technical reasons. Colon cancer is assigned stages I through IV based on the following general criteria: . the entire colon is not visualized endoscopically. and the presence or absence of regional or distant metastases. Colonoscopy allows direct visualization. it could be either a benign polyp (or lesion) or a cancer. Those with a first-degree relative diagnosed with colon cancer after age 60 or two second-degree relative with colon or rectal cancer should begin screening at age 40 with one of the methods listed above. If the patient has neurological symptoms. the stage of the cancer is derived. the depth of penetration through the bowel or the presence of regional lymph nodes cannot be assigned before surgery. but the preferred evaluation of the entire colon and rectum is a complete colonoscopy. and the CAT scan will evaluate potential spread to the liver as well as any local spread of the primary tumor.Unlike the indirect visualizations of the colon (the BE and the DCBE). the entire colon will be examined. and a CEA. a DCBE should complement the colonoscopy. (A biopsy is a removal of tissue for examination by a pathologist. The chest x ray will determine if the cancer has is spread to the lung. areas where the tumor has spread (such as the liver) may be amenable to biopsy. and if the patient is experiencing bone pain. The combination of a flexible sigmoidoscopy and DCBE may be performed. in addition to the physical exam. Treatment Once the diagnosis has been confirmed by biopsy. the BE. The diagnosis of colon cancer is actually made by the performance of a biopsy of any abnormal lesion in the colon. its depth of penetration through the bowel.) For this reason. studies will be performed to assess the extent of the disease. Imaging studies will include a chest x ray and a CAT scan (computed tomography scan) of the abdomen. Using the characteristics of the primary tumor. the biopsy resolves the issue. The endoscopist may take many samples to exclude any sampling errors. When a tumor growth is identified. All of the visualizations. a CAT scan of the brain will be performed. many physicians prefer endoscopic screening. DCBE. The American Cancer Society has recommended the following screening protocol for those at normal risk over 50 years of age:      yearly fecal occult blood test flexible sigmoidoscopy at age 50 flexible sigmoidoscopy repeated every five years double contrast barium enema every five years colonoscopy every 10 years The American Gastroenterologial Association revised its screening guidelines in 2003 to recommend that people with two or more first-degree relatives with colorectal cancer or a firstdegree relative with colon or rectal cancer before age 60 should have a screening colonoscopy beginning at age 40 or beginning 10 years prior to the age of the earlier colon cancer diagnosis in their family (whichever is earliest). require preprocedure preparation (evacuation) of the colon. a bone scan also will be performed. If. the endoscopic screenings allow the physician to remove polyps and biopsy suspicious tissue. Often. Once a diagnosis of colon cancer has been established by biopsy. If the patient has advanced disease at the time of diagnosis. photography. Evaluation of patients with symptoms If patients have symptoms that could possibly be related to colon cancer. the clinical stage of the cancer is assigned.

If the primary tumor penetrates through the bowel wall. a colostomy is performed instead. are treated with surgery first before any other treatments are considered. (5FU) combined with leucovorin for a period . A colostomy is performed by bringing the end of the colon through the abdominal wall and sewing it to the skin. staging plays an important pre-treatment role to best determine treatment options. Radiation Radiation therapy is used as an adjunct to surgery if there is concern about potential for local recurrence post-operatively and the area of concern will tolerate the radiation. Stage IV: any of previous criteria associated with distant metastasis. transverse. the partial colectomies are separated into right. the hook-up is called an anastomosis. Almost all colon cancers are treated with surgery first. this circumstance is rare. Colon cancers through stage III. safer date. if the tumor invaded muscle of the abdominal wall but was not completely removed. With many cancers other than colon cancer. the anastomosis is risky and cannot be performed. It is particularly useful in shrinking metastatic colon cancer to the brain. In most cases. Surgery is used as primary therapy for stages I through III colon cancer unless there are signs that local invasion will not permit complete removal of the tumor. Most patients go on to develop completely normal bowel function. This effect usually lasts only for several weeks. and even some stage IV colon cancers. the ends of the remaining colon are reconstructed. For instance. or sigmoid sections based on the blood supply. occurring in less than 2% of all colon cancer cases. Usually. Radiation also is used in the treatment of patients with metastatic disease. Chemotherapy may also be used when the cancer is stage IV and is beyond the scope of regional therapy. emergent colostomies are not reversed and are permanent. After the resection is completed. or the colostomy may be permanent. Stage II: the tumor has penetrated through to the outer wall of the colon or has gone through it. Radiation has significant dose limits when residual bowel is exposed to it because the small and large intestine do not tolerate radiation well. this area would be considered for radiation. Once healing has occurred. any tissue adjacent to the tumor extension is also taken if feasible. there may be a slight increase in the frequency of bowel movements. possibly invading other local tissue. as may occur in advanced stage III tumors. both vessels are taken to assure complete radical resection or removal (extended radical right or left colectomy). When the cancer lies in a position such that the blood supply and lymph drainage between two of the major vessels. However. Stage III: any depth or size of tumor associated with regional lymph node involvement. left. Surgery Surgical removal of the involved segment of colon (colectomy) along with its blood supply and regional lymph nodes is the primary therapy for colon cancer. but this use is rare. Adjuvant therapy is considered in stage II disease with deep penetration or in stage III patients. The removal of the blood supply at its origin along with the regional lymph nodes that accompany it ensures an adequate margin of normal colon on either side of the primary tumor. regardless of stage. Standard therapy is treatment with 5-fluorouracil.    Stage I: the tumor is confined to the epithelium or has not penetrated through the first layer of muscle in the bowel wall. The patient will have to wear an appliance (a bag) to manage the stool. Chemotherapy Chemotherapy is useful for patients who have had all identifiable tumor removed and are at risk for recurrence (adjuvant chemotherapy). The colostomy may be temporary and the patient may undergo a hook-up at a later. Occasionally. When the anastomosis cannot be performed.

Prevention There is not an absolute method for preventing colon cancer. Avoiding cigarettes and alcohol may be helpful.of six to 12 months. (which seems to stimulate the immune system). avoiding obesity. and prolonged overall survival by a little over two months. levamisole. and all of those with a history of colon cancer in their families. fiber. The regimens do have some toxicity. Avoiding cigarettes and alcohol may be helpful. Large doses of vitamins. 5FU is an antimetabolite. added two to three months to disease-free survival. and this chemotherapy may not prolong survival or improve quality of life in Stage IV patients. Unfortunately. . Alternative treatment Alternative therapies have not been studied in a large-scale. People who turn age 50. scientific way. Irinotecan does not seem to increase toxicity but it improved response rates to 39%. should speak with their physicians about the most recent screening recommendations from physician and cancer organizations. but usually are tolerated fairly well. (A response is a temporary regression of the cancer from chemotherapy. an individual can lessen risk and to this degree prevent the disease. Before initiating any alternative therapies. the patient is wise to consult his or her physician to be sure that these therapies do not complicate or interfere with the established therapy. Similar chemotherapy may be administered for stage IV disease or if a patient progresses and develops metastases. They should watch for symptoms and attend all recommended screenings to increase the likelihood of catching colon cancer early. and green tea are among therapies tried. may be substituted for leucovorin. High-fiber diets and vitamins. these patients eventually succumb to the disease. Still. Results show response rates of about 20%. Clinical trials have now shown that the results can be improved with the addition of another agent to this regimen. there are steps an individual can take to dramatically lessen the risk or to identify the precursors of colon cancer so that it does not manifest itself. These protocols reduce rate of recurrence by about 15% and reduce mortality by about 10%. and staying active lessen the risk. and leucovorin improves the response rate.) Another agent. By controlling these environmental factors.

BSN 4 Section 2 Submitted to: Ma’am Carmencita Ragasa RN. Adrian Paulo B. MD .Submitted by: Castiva.

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