Modified Dukes Staging

A : confined to the rectal wall (15%).Prognosis excellent B : Up to extrarectal tissue with no lymph node (35%).Prognosis reasonable o B1-partially penetrate muscularis propia o B2-Fully penetrate C: lymph node involved.Poor prognosis o C1:only regional lymph node o C2:Lymph node supplying blood vessel up to division point D:Metastases elsewhere: liver or lung

Staging of Colorectal Cancer

Stage Extent of tumor A C2 D B1 B2 C1 No deeper Not through Through Not through Through Distant than bowel wall: metastases bowel wall bowel wall bowel wall: submucosa lymph node lymph node metastases metastases > 90% 2545% < 5% 8085% 7075% 5065%

5-year survival

Mucosa Muscularis mucosa Submucosa

Muscularis propria

Serosa Fat Lymph nodes

TNM Staging
T describes how far the tumor has spread into the wall of the intestines, and whether it has grown into nearby areas N describes whether the lymph nodes are involved M describes if the cancer has metastasized (i.e., spread) to other organs in the body. The most common areas for metastasis are the liver and the lungs

Stage 0: The cancer has not grown beyond the inner lining of the colon or rectum. Stage I: The cancer has spread through several layers of the bowel or rectum. Stage II: The cancer has grown through the wall of the colon or rectum and may extend into nearby tissue. Stage III: The cancer has spread to the lymph nodes. Stage IV: The cancer has spread from the colon or rectum to distant organs, such as the liver, lungs, or ovaries.

Symptoms of Colorectal Cancer

Time Course
Early

Symptoms
None

Findings
None Occult blood in stool Rectal mass Blood in stool Weight loss Abdominal mass Bowel obstruction

Mid

Rectal bleeding Change in bowel habits Fatigue Anemia Abdominal pain

Late

Symptoms and Signs

Right sided iron deficiency anemia, abdominal pain, weight loss, obstruction less likely Left sided rectal bleeding, alteration in bowel habit, tenesmus, obstruction Either abdominal mass, perforation, haemorrhage, fistula Metastatic jaundice, ascites, hepatomegaly

Screening Techniques for Colorectal Cancer

Fecal occult blood test (FOBT) every year Flexible sigmoidoscopy every 5 years A fecal occult blood test every year plus flexible sigmoidoscopy every 5 years (recommended by the American Cancer Society) Double-contrast barium enema every 5 to 10 years Colonoscopy every 10 years (recommended by the American College of Gastroenterology).

Screening For Colon Cancer

Test Fecal occult blood testing Flexible sigmoidoscopy
(in portion of colon examined)

Mortality Reduction
33% 66% 43%

FOBT + flexible sigmoidoscopy

(compared to sigmoidoscopy alone)

Colonoscopy
(after initial screening and polypectomy)

~76-90%

Colorectal cancer screening First assess RISK

AVERAGE RISK INDIVIDUAL All patients age 50 years and older, the asymptomatic general population HIGH RISK Personal history polyp or cancer Family history polyp or cancer in first degree relatives

Fecal Occult Blood Testing

Examination of stool for occult (hidden) blood Can detect one teaspoon or less of blood in a bowel movement Uses chemical reaction between blood and reagent

Double-contrast Barium Enema

Double-contrast Barium Enema

Pros Examines entire colon Relatively low cost Cons Never studied as a screening test Missed 50% of polyps > 1cm in one study Detects 50-75% of cancers in those with positive FOBT

Sigmoidoscopy/Colonoscopy

Flexible sigmoidoscopy
Pros May be done in office Inexpensive, cost-effective Reduces deaths from rectal cancer Easier bowel preparation, usually done without sedation Cons Detects only half of polyps Misses 40-50% of cancers located beyond the view of the sigmoidoscope Often limited by discomfort, poor bowel preparation

Colonoscopy
Pros Examines entire colon Removal of polyps performed at time of exam Well-tolerated with sedation Easier bowel preparation, usually done without sedation Cons Expensive Risk of perforation, bleeding low but not negligible Requires high level of training to perform Miss rate of polyps < 1 cm ~25%, > 1 cm ~5%

Future techniques for colorectal cancer screening

Stool DNA testing

Capsule endoscopy (Givens capsule)

CT colonography (virtual colonoscopy)

A colonoscopy looks at the entire colon to identify problems Blood tests help to categorize your overall health a CEA test is often used to follow the presence of CRC Imaging tests will identify if cancer exists in other parts of your body CAT scan, MRI, PET scan Surgery will remove tumor(s), tissue and lymph nodes which will be tested by a pathologist to determine the type and stage of cancer present

DDx
Arteriovenous malformation (AVM) Carcinoid/Neuroendocrine Tumors and Rare Tumors of GI Tract Crohn Disease Diverticulosis Gastrointestinal Lymphoma Ileus Ischemic bowel Small Intestinal Carcinomas Ulcerative Colitis

Cancer Treatment: Surgery

Foundation of curative therapy
The tumor, along with the adjacent healthy colon or rectum and lymph nodes, is typically removed to offer the best chance for cure May require temporary or (rarely) permanent colostomy (surgical opening in abdomen that provides a place for waste to exit the body)

LAC VS Open Colectomy

Large prospective randomized trials have demonstrated that there are no significant differences with regard to intraoperative or postoperative complications, perioperative mortality rates, readmission or reoperation rates, or rate of surgical wound recurrence. #except less pain and scarring, lower risk infection and fast recovery.
Depends on the doctor expertise, facilities, and staging.
[Best Evidence] Lacy AM, Delgado S, Castells A, et al. The long-term results of a randomized clinical trial of laparoscopy-assisted versus open surgery for colon cancer. Ann Surg. Jul 2008;248(1):1-7.

Cancer Treatment: Chemotherapy

Drugs used to kill cancer cells
Typical medications include fluorouracil (5-FU), oxaliplatin (Eloxatin), irinotecan (Camptosar), and capecitabine (Xeloda) A combination of medications is often used

Types of Chemotherapy
Adjuvant chemotherapy is given after surgery to maximize a patients chance for cure
Neoadjuvant chemotherapy is given before surgery Palliative chemotherapy is given to patients whose cancer cannot be removed to delay or reverse cancerrelated symptoms and substantially improve quality and length of life

Cancer Treatment: Radiation Therapy

The use of high-energy x-rays or other particles to destroy cancer cell
Used to treat rectal cancer, either before or after surgery Different methods of delivery External-beam: outside the body Intraoperative: one dose during surgery

New Therapies: Antiangiogenesis Therapy

Starves the tumor by disrupting its blood supply
This therapy is given along with chemotherapy Bevacizumab (Avastin) VEGF, was approved by the U.S. Food and Drug Administration (FDA) in 2004 for the treatment of stage IV colorectal cancer

New Therapies: Targeted Therapy

Treatment designed to target cancer cells while minimizing damage to healthy cells
Cetuximab (Erbitux) was approved by the FDA in 2004 for the treatment of advanced colorectal cancer

Chemopreventive agents
Fiber Aspirin NSAIDs (ibuprofen, etc) Vitamin E, vitamin C, beta carotene Not effective May be effective Probably effective Not effective

Folate
Calcium

Effective if obtained in diet

Effective

Estrogen

Effective, but has other problems

Colorectal Cancer Staging

Staging is a way of describing a cancer, such as the depth of the tumor and where it has spread Staging is the most important tool doctors have to determine a patients prognosis Staging is described by the TNM system: the size (the depth of penetration of the Tumor into the wall of the bowel), whether cancer has spread to nearby lymph Nodes, and whether the cancer has Metastasized (spread to organs such as the liver or lung) The type of treatment a person receives depends on the stage of the cancer

Stage 0 Colorectal Cancer

Known as cancer in situ, meaning the cancer is located in the mucosa (moist tissue lining the colon or rectum)
Removal of the polyp (polypectomy) is the usual treatment

Stage I Colorectal Cancer

The cancer has grown through the mucosa and invaded the muscularis (muscular coat)
Treatment is surgery to remove the tumor and some surrounding lymph nodes

Stage II Colorectal Cancer

The cancer has grown beyond the muscularis of the colon or rectum but has not spread to the lymph nodes Stage II colon cancer is treated with surgery and, in some cases, chemotherapy after surgery

Stage II rectal cancer is treated with surgery, radiation therapy, and chemotherapy

Stage III Colorectal Cancer

The cancer has spread to the regional lymph nodes (lymph nodes near the colon and rectum)

Stage III colon cancer is treated with surgery and chemotherapy Stage III rectal cancer is treated with surgery, radiation therapy, and chemotherapy

Stage IV Colorectal Cancer

The cancer has spread outside of the colon or rectum to other areas of the body Stage IV cancer is treated with chemotherapy. Surgery to remove the colon or rectal tumor may or may not be done Additional surgery to remove metastases may also be done in carefully selected patients

Coping With the Side Effects of Cancer and its Treatment

Side effects are treatable; talk with the doctor or nurse Fatigue is a common, treatable side effect Pain is treatable; non-narcotic pain relievers are available Antiemetic drugs can reduce or prevent nausea and vomiting Surgery side effects Scarring and adhesions, Fecal incontinence, Ostomy (a procedure to make a new path for stool)

Follow-Up Care
Doctors visits Serial carcinoembryonic antigen (CEA) measurements are recommended Colonoscopy one year after removal of colorectal cancer Surveillance colonoscopy every three to five years to identify new polyps and/or cancers

Palliative treatment
Palliative treatment helps to improve peoples quality of life by alleviating symptoms of cancer without trying to cure the disease. It is particularly important for people with advanced cancer. However, it is not just for people who are about to die and it can be used at different stages of cancer.