COLON CANCER
Definition
• Malignant growth of tumor that begins from
the inner wall of the colon or rectum.
• Can also involve the anal canal.
EPIDEMIOLOGY
• The 3rd most common malignancy worldwide ( ≥
1.2 million new cases annually).
• The incidence is greatest among males (37.4 per
100,000 vs. 29.9 per 100,000)
• 3rd leading cause of cancer-related deaths in US.
• Highest incidence rates in economically
developed countries
• Invasive CA of rectum occurs less frequently
(<1/3 cases)
Pathophysiology
• The formation of colorectal CA is a multistep
process.
• Begins with an abnormal growth of tissue
known as a polyp (precursors to the disease)
originating from the innermost wall of the
colon.
• The process of transformation
from polyp to malignant
disease takes years.
• Once transformation occurs,
cancer begins to spread
through the wall of
colon/rectum.
• It can eventually invade blood,
L.Ns, or other organs directly.
• A stalked colon polyp
• 95% are adenocarcinoma (glandular tissue).
• The disease can be prevented by removal of
precancerous tissue.
Aetiology
• Aetiology is complex, involving:
Patient- specific factors
Environmental factor
Genetic factors
• Genetic mutations associated with colorectal cancer:
APC mutation/loss (Tumour suppressor gene).
P53 mutation
COX-2 overexpression (growth factor signalling
pathways)
K-RAS mutation 35%, BRAF mutation 5%
Risk Factors
• Increase age: Age >50 (90% of patients)
• Male sex
• Family history.
• Personal history: (history of colon polyps;
multiple adenomas or size ≥10 mm)
• IBD (Ulcerative colitis, Crohn’s disease): ↑ 5-
to 10-fold
Risk Factors
• Environmental factors/ Lifestyle:
• Physical inactivity & obesity
• Diet: (fatty food, Red meats, processed meats, low
fibers)
• Alcohol (excessive)
• SMOKING: (Rectal > colon)
Factors decreasing the risk of colorectal
CA
• Fiber (Fruit & Vegetables)
• Physical activity
• Regular consumption of milk/Calcium &
Vitamin D (May have antiproliferative effects )
Signs & Symptoms
• Subtle & nonspecific (generalised symptoms)
• Asymptomatic (early stage).
• Persistent/sudden change in bowel habits:
(*Prolong constipation *or diarrhea *pencil thin
stool)
• Bleeding from rectum or blood In stool.
• Vague Cramping or abdominal pain/discomfort,
bloating , N, V
• Secondary obstruction, perforation, bleeding.
Signs and symptoms
• Weakness and tiredness (advanced stage).
• Iron-deficiency anemia.
• Unintentional weight loss
• Increased liver enzymes (sign of liver metastasis)
(AST/ALT)
• Hepatomegaly and jaundice in advanced disease.
DIAGNOSIS
• Signs and symptoms
• Entire Large bowel evaluation:
Colonoscopy
Double-Contrast Barium Enema
CT Colonography (detect adenomas at least 6
mm).
Flexible sigmoidoscopy (FSIG) : examine lower
half of the bowel to the splenic flexure, capable
to detect 50%-60% of CA
DIAGNOSIS
• Biopsy (during colonoscopy)
• Ultrasound: Determines depth of tumor penetration,
assessing L.Ns
• CT scan: same as ultrasound + useful in assessing for
metastasis
• Blood tests: bld count, PT, PTT, Liver function test.
• CEA (carcinoembryonic antigen)
• Tumour marker
• Non-sensitive, non specific in early stage
• Usually elevated in metastatic or recurrent colon CA
• Normal 0-3 ng/mL
Biopsy (during colonoscopy)
SCREENING
• Colonoscopy/ Barium enema/ CT scan
(alternative for individuals who don’t wish to
undergo /not suitable for colonoscopy.)
• CEA level
• Fecal screening test: (Fecal occult blood
testing (FOBT)
Staging
TNM Staging System
• T – (tumor size), based on DEPTH (penetration), invasion into
mucosa
• T1 – Tumour invades the submucosa
• T2 – Invades the muscularis propria
• T3 – Invade through the muscularis propria into subserosa
• T4 – Tumors invading or adhering other local
organs/structures/segments/ surface of visceral peritoneum
• N – lymph node involvement
• N1 – 1-3 +ve L.N
• N2 – ≥ 4 or more +ve L.N
• M – distant metastasis
• M0 – no other organs involved
• M1 – distant metastases are present
Simplified Staging System
• Stage I Tumors that either invade into or
through the submucosa with NO (+) LN
• Stage II Tumors that invade through the
muscularis propria or into local organs with NO
(+) LN
• Stage III Any T with nodal involvement (+) LN
• Stage IV Tumor with nodal involvement and
with distant metastasis (usually liver, followed
by lungs, then bones)
• 25% of patients present with stage IV
Treatment
• Surgery in CA of the colon or rectum (stage, I, II, III):
• Complete surgical resection of the primary tumor mass
with regional lymphadenectomy
• At least a 5 cm margin of tumor-free bowel & regional
lymphadenectomy
• Selected patients with resectable metastases, surgical
resection may be an option.
• Rectal CA
• Total excision of the mesorectum (TME), the
surrounding tissue containing perirectal fat and draining
Treatment
• If the distal margin clear of tumor is at least 1
cm, sphincter-preserving surgery may be possible
for patients with CAs in the middle and lower
portion of the rectum.
• If not Candidate for sphincter-preserving surgery
• Abdomino-perineal resection (APR) = remove
distal sigmoid, recto-segmoid, rectum, anus.
• Colostomy (after colectomy) has become an
accepted procedure for colon and rectal cancer.
Colostomy
Treatment
• Rectal CA is more difficult to resect with wide
margins.
• Radiation (XRT) is usually reserved for rectal
cancer
• Adjuvant XRT + chemo. are standard for stage
II/III rectal CA
• Neo- Adjuvant therapy before rectal surgery
to: Shrink the tumour & make it resectable.
