Pathology : Colorectal cancer

CONTENT

• Introduction• Statistics• Risk factor• Symptoms• Diagnosis & Confirmation test• Treatment• Prevention• Case study• Conclusion• References

Introduction

• Cancer that affect the colon or the rectum, the last 20-25 centimeters of the colon.

• Normal cells in the lining of the colon or rectum begin to change, grow without control, and no longer die.

• Usually begins as a noncancerous polyp that can, over time, become a cancerous tumor.

Figure 1: Anatomical position of colon and rectum (http://training.seer.cancer.gov, 2012)

Statistics • Colorectal cancer is the fourth leading cause of cancer

death worldwide (WHO, 2012). • In Malaysia, colorectal cancer now is the most common

cancer in males and the third most common in females. • One in 33 Malaysians are at risk of developing colorectal

cancer (World Health Organisation's Globocan, 2008) • Majority of patients are above 40 years old.• A cross sectional study was conducted from August 2009

till April 2010 involving average risk individuals from 44 primary care clinics in West Malaysia (Yusoff et al., 2012).

• The barrier questions domains: 1. patient factors2. test factors 3. health care provider factors

• Result:• Descriptive analysis shows of 1905 respondents,

only 13 (0.7%) had done screening due to health problems and believed to have signs and symptoms.

Stages of Colorectal cancer• Stage 0: Cancer found only in the innermost lining of the colon

or rectum• Stage I: Cancer involves more of the inner wall of the colon or

rectum• Stage II: Cancer spread outside to nearby tissue except lymph

nodes• Stage III: Cancer spread to lymph nodes but not to other parts

of the body• Stage IV: Cancer spread to other parts of the body (tends to

spread to liver and/or lungs)

Figure 2: Stages of Colorectal Cancer (www.fmh.org/, 2012)

Risk factor• Age (>40 years old)• Polyps• Family history• Personal history • Diet (high fat and low fibre)• Tobacco• Body weight and physical activity• Inflammatory Bowel Disease

Figure 3 : Colon polyp

Signs & Symptoms• A change in bowel habits

• Diarrhoea, constipation or feeling that the bowel does not empty completely

• Blood (either bright red or very dark) in the stool

• Stools that are narrower than usual

• General abdominal discomfort

• Constant tiredness

• Vomiting

Diagnosis and Confirmation Tests

1. Physical exam and history To check general signs of health

2. Digital rectal exam inserts a lubricated gloved finger

into the rectum to feel for lumps or anything else that seems

unusual.

Figure 4: Digital Rectal Exam

3. Fecal occult blood test (FOBT)

Detects small amounts of blood in the feces which would not normally see or be aware of.

4. Sigmoidoscopy The rectum and lower colon are examined using a

lighted instrument called a sigmoidoscope

Figure 5: Fecal occult blood test (FOBT) Figure 6: Sigmoidoscopy

5. Colonoscopy The rectum and entire colon are examined

using a lighted instrument called a colonoscope

Figure 7: Colonoscopy

Figure 8: Colon viewed under colonoscope

6. Double contrast barium enema (DCBE)A series of x-rays of the entire colon and rectum are

taken after the patient is given an enema with a barium solution and air is introduced into the colon

The barium and air help to outline the colon and rectum on the x-rays

Figure 9: Double contrast barium enema (DCBE)

7. Computed Tomography (CT Scan) Combines special x-ray equipment with

sophisticated computers to produce multiple images or pictures of the inside of the body

A CT scan may be used if colorectal cancer has metastasized to other organs

Figure 10: CT scan of hepatic metastatic colorectal cancer.

8. Positron emission tomography (PET) Help to determine whether an abnormal area seen

on another imaging test is a tumor or not. For patients who have already been diagnosed with

cancer, this test help the doctor to see if the cancer has spread to lymph nodes or other parts of the body.

Figure 11: Colorectal cancer showing metastatic disease to the liver on PET imaging

TREATMENT

1. Surgery • Local excision• Removing cancer without cutting through abdominal

wall• put a tube through the rectum into the colon

• Anastomosis• Part of the colon containing the cancer and nearby healthy

tissue are removed, and then the cut ends of the colon are joined.

Figure 12 : Anastomasis

• Colostomy• Part of the colon containing the cancer and nearby healthy

tissue is removed, a stoma is created, and a colostomy bag is attached to the stoma.

Figure 13 : Colostomy

2. Chemotherapy

• Use drugs to stop the growth of cancer cells• killing the cells • stopping them from dividing.

2 types :i. Systemic chemotherapy• Taken orally or intravenously

ii. Regional chemotherapy• placed directly into the spinal column, an organ,

or a body cavity

3. Radiation • Use high-energy x-rays to kill cancer cells or keep them

from growing. • local therapy - affects the cancer cells only in the treated

area.

2 types : • External radiation therapy • uses a machine outside the body to send radiation

toward the cancer. • Internal radiation therapy • uses a radioactive substance sealed in needles or

catheters that are placed directly into or near the cancer.

PREVENTION1. Screening• 6 out of every 10 deaths could be prevented if all

men and women aged 50 years or older were screened routinely.• Remove precancerous polyps before they turn into

cancer. 2. Reduce risk of developing colorectal cancer • increasing physical activity• eating fruits and vegetables • limiting alcohol consumption • avoiding tobacco

Case study

HISTORY OF PRESENT ILLNESS: • 70 year old white male• post resection of a stage III adenocarcinoma of the sigmoid

colon (approx. 10 days)• 2 weeks prior to surgery he had significant coronary artery

disease and had underwent a CABG

PATHOLOGY REPORT:• highly aggressive T3, N2 adenocarcinoma of the colon,

stage III with angiolymphatic invasion. • 6 of 11 lymph nodes were positive .• He underwent adjuvant 5FU leucovorin chemotherapy• Recently he experience some vague abdominal pain.

FAMILY HISTORY: • Mother died of cancer of unknown etiology • A son who died of lymphoma at age 46.

DIAGNOSIS:• A flexible sigmoidoscopy : negative. • Ultrasound of the liver showed calcifications • CT scan : negative. • PET scan : negative.

FINDINGS: • No areas of increased FDG uptake to suggest recurrent or

metastatic disease. • Sensitivity of this study is decreased due to the patient's

hyperglycemia. (Blood glucose level was 175mg/dl)

ASSESSMENT AND PLAN: • A 70 year old white male with a history of Stage III colon

cancer, now with a rising CEA level, negative CT scan and negative PET scan.

• Recheck his CEA in two months. If it continues to rise, should move forward with a PET-CT scan follow-up.

FOLLOW-UP PET-CT SCAN:• Recurrence : Focal area of intense FDG uptake

corresponding to mildly enlarged left paraaortic lymph node

• Hepatic metastasis : Additional area of intense FDG uptake identified within the right lobe of the liver.

TREATMENT• Chemotherapy.

Figure 14 : Initial and Follow up PET scan

CONCLUSION

• Early diagnosis of colorectal cancer is key to its cure. • If found early, the disease is considered curable. • If the tumor spreads to lymph nodes, a patient's chance

of living at least five years drops to 40 - 60%.• If the cancer has already spread to distant organs, the

long-term survival may be lower.• Early and accurate detection is highly importance to

improve patient outcomes.

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• Anonymous. (2012). Colon Cancer. [Online]. Available from http://health.nytimes.com/health/guides/disease/coloncancer/overview.html [Accessed: 18th January 2013].

• Anonymous. (2011). Colorectal Screening. National Cancer Institute. [Online]. Available from http://www.cancer.gov/cancertopics/factsheet/detection/colorectal-screening [Accessed: 18th January 2013].

• Anonymous. 2012. Introduction to Colorectal Cancer. National Cancer Institute [online] Available at: http://training.seer.cancer.gov/colorectal/intro/ [Assessed 29 January 2013].

• Anonymous. 2012. Colorectal cancer [ppt] Available at: www.fmh.org/workfiles/.../Cancer%20Types/.../Colorectal_Slide [Assessed 30 January 2012].

• A. G. Norsidawati. 2009. Colorectal Cancer. COEd Sevices, Universiti Putra Malaysia. Available from : http://www.care.upm.edu.my/download/colon-ca.pdf [Accessed on 20th January 2013].

• Centre for Disease Control and Prevention, CDC. 2012. Colorectal Cancer Prevention. Available from : http://www.cdc.gov/cancer/colorectal/basic_info/prevention.htm [Accessed on 21st January 2013].

• Colorectal Association of Canada. 2012. PET & Colorectal Cancer. Available from : http://www.colorectal-cancer.ca/en/screening/pet-cancer/#D1 [Assessed on 1st February 2013]

• M. Varma et al., 2012. Division of General Study, University of San Francisco. Available from : http://colorectal.surgery.ucsf.edu/conditions--procedures/colon-cancer.aspx [Accessed on 21st January 2013].

• Blodgett. T. Colorectal Case Study#1. Available from : http://www.ri-pet.org/archives/colorectal_cancer/Colorectal-Full-Case-Study-1.pdf [Assessed on 1st February 2013].

• Pillay. S. 2012. Colorectal Cancer on Rise. Available from : http://www.nst.com.my/nation/general/colorectal-cancer-on-the-rise-1.150298 [Assessed on 1st February 2013]

• Yusoff, H., Daud, N., Noor, N. and Rahim, A. 2012. Participation and Barriers to Colorectal Cancer Screening in Malaysia. Research Article; Vol.13, p:3983-3987 [online] Available at: http://www.apocpcontrol.org/paper_file/issue_abs/Volume13_No8/3983-87%207.24%20Harmy%20Mohamed%20Yusof.pdf

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