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Colo rectal carcinoma
1.
2. Occurs in three form
Hereditary
Sporadic
Familial
•Family history
•Younge age at oncet
•Presence of other specific
tumors and defects
•Absence of family history
•Generally affect older
population[60-80yr age]
•Isolated colon or rectal
lesion
•Increased risk in which index
case is young[<50yr age]
•Relative is close[first degree
relative]
•20%
FAP-1%
HNPCC-5%
FCC-10-15%
•80%
3. Risk factor
• Age [m/c]
• Dietary factor
•
•
•
High animal fat diet
Low fiber diet
Alcohol
• Hereditary syndrome
•
•
FAP - germ line APC mutation –accelerated tumor
initiation, 100% risk of CRC
HNPCC-germ line mutation in MMR gene –accelerated
tumor progression,70-80% life time risk of CRC
13. HNPCC
• Autosomal Dominant
• Chromosome 2[hMSH2,hMSH6], 3[hMLH1], 7[hPMS2]
{MMR gene}
• 3-5% of all CRC
• Poorly differentiated & mucinous
• Signet ring histology
Lynch I-CRC only
Lynch 2-CRC with asso. Malignancy
•
•
•
•
Endometrial
Gastric
Ovarian
Muri-Torre synd.
Diag.
– Family history
– detection of germ line mutation in MMR
14. Clinical criteria for HNPCC
Amsterdam criteria
At least three relative with colon cancer
– One is the first degree relative of other two
– Two successive generation
– One case diagnose before 50 yr age
– FAP excluded
Modified Amsterdam criteria
–
All above with asso. Of HNPCC (other malignancy)
Bethesda criteria
Amsterdam criteria OR one of the following
– Two cases of HNPCC – asso cancer in one patient including
synchronous or metachronous cancer
– Colon cancer and a first degree relative with HNPCC asso cancer
and/or adenoma
– Colon or endometrial cancer diagnosed before age 45 yr
– Right side colon cancer that have undifferentiated pattern or signet
cell histopathology
– Adenomas diagnosed before 40 yr
15. Screening recommendation
• FAP
– Colonoscopy annually
– Beginning at age 10-12yr
• HNPCC
– Colonoscopy
– every 2 yr beginning age 20yr
– Annually after age 40yr or 10yr younger than earliest case in
family
19. Clinical feature
Right colon
Left colon
1. Fungating / cauliflower growth
1. Annular, constricting or stenosing growth
2. Ulcerative lesion leading to chronic
insidious blood loss
Melena
Fatigue
Abdominal pain
2. Symptom of obstruction
Change in bowel habbit
3. Good prognosis
3. Poor prognosis
20.
21.
22. Diagnosis
1.
2.
3.
4.
Abdominal and Per-rectal examination
Fecal occult blood testing[FOBT]
Barium enema
Water soluble contrast enema- to establish
anatomical level of obstruction
5. Colonoscopy[gold standard] and sigmoidoscopy
6. biopsy
7. Virtual colonoscopy
23. 8. MRI-better in rectal ca
9. Ultrasound- trans rectal
10. CECT abdomen and pelvis
11. FDG-PET
12. serum markers (elevated blood levels of
carcinoembryonic antigen)
13. molecular detection of APC mutations in epithelial
cells, isolated from stools
14. tests under development: detection of abnormal
patterns of methylation in DNA isolated from stool
cells
24.
25.
26.
27. Haggit classification for polyp
containing cancer
• Acc. To depth of invasion
Level o
NOT invade muscularis mucosa
Level 1
Invade but limited to head of polyp
Level 2
Level of neck of polyp
Level 3
Any part of stalk
Level 4
Invade sub mucosa but above muscularis propria
30. Staging
• TNM stagingPrimary tumor• Tx-cannot be assessed
• To-no evidence of primary tumor
• Tis-carcinoma in situ-intraepithelial or invasion of
lamina propria
• T1- tumor invade sub mucosa
• T2-muscularis propria
• T3-into peri colorectal tissue
• T4a-penetrate surface of visceral epithelium
• T4b-invade or adherent to other organ or structure
31. Regional lymph node• Nx• N0• N1-one to three
• N1a-one
• N1b-two to three
• N2-four or more
• N2a-four to six
• N2b-seven or more
32. Distant metastasis
• Mo• M1-distant metastasis
• M1a-confined to one organ or site
• M1b-more than one organ or site or
peritoneum
33. Modified Dukes classification
stage
description
A
confined to bowel wall
B1
partially penetrate the muscularis propria
B2
Fully…………………………………………………………
C1
Lymph node invasion without penetration of entire bowel wall
C2
…………………………………with……………………………………………..
D
Distant metastasis
34. Systemic Metastasis
• Incidence related to the depth of invasion
• Liver > lung
Hepatic
Extra hepatic
•5-10 % undergo curative liver
resection with upto 50% long
term survival
•Synchronous metastasis have
poor prognosis
•Recurrence is common
•CEA testing every 3mt for 2yr
after hepatic resection
•Pulmonary metastasis
•Ovarian metastasis
35. Treatment
• Surgical resection the only curative treatment
• Likelihood of cure is greater when disease is
detected at early stage
• Early detection and screening is of pivotal
importance
41. Prognosis
• Most important guide to prognosis is STAGE
of the disease i.e. depth of penetration and
number of LNs involved
ADVERSE C/F
1. Younger age < 30 yr
2. Long symptomatology
3. Obstruction/ perforation
4. Location-pelvic and splenic
flexure
43. 5 yr survival following treatment
Stage
Survival
1
90%
2
75%
3
50%
4
<5%
44. Follow up
• Stage 1– Colonoscopy 1yr after operation then every 5yr
– CEA level –every 3mt during first 2yr
• Stage 2– CEA level every 3mt for 2yr, every 6mt for a total
of 5yr
– Annual CT scan of abdo and chest for 3yr
45. • Share many genetic, biological, and
morphologic characteristic of colon ca
• Age of presentation >55yr
• Bleeding is earliest and most common
symptom
• Other sym.– Sense of incomplete defecation
– Tenesmus and spurious diarrhea
– Bloody slime
47. Treatment
Stage o [Tis, No, Mo]
Local excision
Stage 1[T1-2,No,Mo]
Polypectomy
Radical resection
Stage 2[T3-4,No,Mo]
Pre op chemo radiation + radical resection
Stage 3[Tany,NoMo]
Pre op chemo radiation + radical resection
Stage 4
[Tany,NanyM1]
Palliative procedure
48. • Low anterior resection
– >5cm above dentate line
• Abdomino perineal resection
– At or below 5cm from dentate line
• Hartmann's procedure
– For elderly or severely unstable pt