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COLORECTAL MALIGNANCIES

COLORECTAL MALIGNANCIES

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COLORECTAL MALIGNANCIES

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  1. COLORECTAL MALIGNANCIES • Divina B. Esteban, M.D., FPSMO • Rizal Medical Center

  2. Epidemiology: • Worldwide incidence varies from: • 3.4/100,000 - Nigeria • to • 35.8/100,000 - Connecticut, USA

  3. Philippine data: 1993-1997* • Colon Cancer: • 5th most common (males) - 11.5/100,000 • 7th among females (9.5/100,000) • 6th for both sexes (10.4/100,000) • ASR in Filipino migrants to USA > ASR in the Philippines • Intermediate incidence between Thailand & high rates in Asia, USA & Europe • *Cancer In The Phil. Volume III. 2002

  4. Philippine data 1993-1997* • Rectal cancer • 9th most common (M) - 7.9/100,000 • 11th most common (F) - 5.7/100,000 • 11th for both sexes - 6.7/100,000 • ASR in Filipino migrants > than those observed in the Philippines • Int. inc. bet. low rates in Thailand and high rates in Asia, Europe & USA • *Cancer In The Philippines Vol.. III. 2002

  5. Leading Cancer Sites , Females, 1993-1997DOH - Rizal & PCS - Manila Cancer Registries 7929 48.0 Breast 3378 19.0 Cervix 1813 Lung 13.8 11.0 1934 Ovary 1244 9.3 Colon 1639 8.5 Thyroid 925 6.7 Liver 802 5.7 Rectum 725 5.3 Stomach 1115 5.2 Leukemias 0 10 20 30 40 50 60 ASR/100,000

  6. 2005 Estimates* • 8585 new colorectal cancer cases • Males: 4737Females: 3848 • 5558 deaths from colorectal cancer • Males: 3064 Females: 2494 • *2005 Philippine Cancer Facts & Estimates. PCSI. 2004 • Females: 3

  7. Philippine Survival Data* • Colon Cancer • Overall median survival: 49 months • 5-year survival rate: 47.72% • 10-year survival rate: 32.38% • Rectal Cancer • Overall median survival: 24 months • 5-year survival rate: 19.45% • 10-year survival rate: 5.84% • *Mapua et al, Population-based Cancer Survival, PCS-MCR.

  8. RISK FACTORS • Familial adenomatous polyposis (FAP) • Adenomatous polyps in colon/ rectum • Chronic ulcerative colitis • Familial cancer syndrome • Family history • High -meat and high fat/ low fiber diet

  9. SCREENING Guidelines • Screening for >50 years old: • Annual FOBT • Flexible sigmoidoscopy or DCBE every 5 yrs • Screening for 1st degree relative w/ cancer • Flexible sigmoidoscopy, DCBE or colonoscopy every 5-10 years from age 50 years • If relative was Dx before age 55, colonoscopy should be done at age 50 or 10 years prior to index case • Screening for (+) hx of adenoma or CA • Screening for (+) ulcerative colitis • Screening for HNPCC and FAP

  10. SCREENING Guidelines cont. • Screening for pts with (+) hx of adenoma or CA : • Colonoscopy, DCBE or flexible sigmoidoscopy every 3-5 years • Repeat colonoscopy within 1 yr if fragmented polyp > 1 cm, high gr dysplasia, villous changes; multiple > 2; (+) FH; more than 60 yrs old • Flexible sigmoidoscopy or DCBE every 5 yrs

  11. SCREENING Guidelines cont. • Screening for pts. with ulcerative colitis • If more than 8 yrs duration: • FOBT every 2 yrs • Flexible sigmoidoscopy every 5 yrs from age 50 years • Screening for HNPCC and FAP • Genetic consult • Annual colonoscopy from age 25 years

  12. SCREENING Guidelines • for high risk groups & symptomatic patients: • Colon Cancer: • Fecal blood tests • Colonoscoopy +/- biopsy • Barium enema • Rectal Cancer • Digital rectal examination • Proctosigmoidoscopy

  13. Clinical Presentation • Colon Cancer - Right-sided Lesion : • (bulky, exophytic, large diameter, more fluid content) • Abdominal pain • Diarrhea • Occult gastrointestinal bleeding - anemia • Weight loss • Signs of low small bowel obstruction • Mass in the right iliac fossa

  14. Clinical Presentation • Colon Cancer - Left-sided Lesion: • (annular or infiltrating, small diameter, semi-solid to solid contents) • Obstruction • Bleeding or bloody stools • Perforated pericolic abscesses or peritonitis • Change in bowel habits • Abdominal discomfort

  15. Clinical Presentation • Rectal Cancer: • Rectal bleeding (bright red) • Change in bowel habits • constipation / diarrhea • Feeling of incomplete emptying after BM ; unproductive urge to defecate; tenesmus • Persistent narrowing of stools • Rectal mass • Unexplained weight loss

  16. Diagnosis • Careful history (unexplained weight loss, anemia, change in bowel habits, abdominal pain, constipation, etc) • Physical examination including digital rectal examination (DRE) • Colonoscopy, proctosigmoidoscopy +/- bx • Barium enema • Tumor markers : CEA

  17. PATHOLOGY • Histological Classification • 1. Epithelial Tumors • Adenocarcinoma • Mucinous Adenocarcinoma • Signet-ring cell carcinoma • Squamous cell carcinoma • Adenosquamous carcinoma • Small cell carcinoma • Undifferentiated carcinoma

  18. Histological Classification (cont) • 2. Carcinoid Tumors • 3. Non-epithelial tumors (Leiomyosarcoma) • 4. Hematopoietic & Lymphoid Neoplasms • 5. Unclassified Tumors

  19. TNM STAGING • Primary Tumor (T) • T0 No evidence of primary tumor • Tis CIS :inv of lamina propria or muscularis • mucosa • T1 Tumor invades the submucosa • T2 Tumor invades the muscularis propria • T3 Tumor invades thru m. propria into subserosa/to nonperitonealized pericolic or perirectal tissues • T4 Tumor directly inv. other organs/perforates the visceral peritoneum

  20. TNM STAGING (cont.) • Regional Lymph nodes (N) • Nx Regional LN cannot be assessed • N0 No regional LN metastasis • N1 Metastasis to 1-3 regional LN • N2 Metastasis in 4 or more pericolic LN • N3 Metastasis in any LN along the course • of a named vascular trunk &/or mets. • to apical node(s)

  21. TNM STAGING (cont.) • Distant Metastasis (M) • Mx distant metastasis cannot be assessed • M0 No distant metastasis • M1 Distant metastasis

  22. TNM STAGING (cont.) • Stage Groupings: TNM Astler-Coller • modified • 0 Tis N0 M0 n/a • I T1 N0 M0 Stage A • T2 N0 M0 Stage B1 • II T3 N0 M0 Stage B2 • T4 N0 M0 Stage B3 • III Any T N1 M0 Stage C1- C3 • Any T N2 M0 • IV Any T Any N M1 Stage D

  23. PROGNOSTIC FACTORS PROGNOSTIC FACTORS: • Disease extension beyond the rectal wall • for (+)LN but tumor confined to wall • (Tis-2 N1-3), loc. recurrence = 20-40% • for (-) LN but w/ extension beyond wall (T3 or T4A N0 or T4B N0), loc. recur. = 20-35% • for (+) LN & (+) ext. beyond wall (T4N1-3, T4b N1-3), loc. recur. = 40- 65% • Nodal involvement

  24. PROGNOSTIC FACTORS cont. • Lymph node involvement • Extrarectal extension • = Amount of uninvolved tissue (circumferential or radial margins) • Define the extraluminal extent of tumors • Measure the narrowest radial margin

  25. Prognostic Factors cont. • Histologic grade • Stage of tumor • Depth of invasion • Frequency of nodal involvement • Number of lymph nodes involved • Bowel obstruction 2o to tumor • Tumor perforation

  26. PATTERNS OF FAILUREafter a curative resection • Local recurrence • 30-50% in MAC B3, C2 and C3 lesions • 15-20% in many B2 and most C1 lesions • Peritoneal seedings - Least common in rectal primaries • Systemic metastasis • Rectal Cancer: Liver and Lung due to venous drainage • Colon CA: Initial mets in the liver (venous drainage via the portal system)

  27. TREATMENT SCHEMA • Colon Cancer Suspect • Rectal Cancer Suspect