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COLORECTAL MALIGNANCIES. Divina B. Esteban, M.D., FPSMO Rizal Medical Center. Epidemiology :. Worldwide incidence varies from: 3.4/100,000 - Nigeria to 35.8/100,000 - Connecticut, USA. Philippine data: 1993-1997*. Colon Cancer : 5th most common (males) - 11.5/100,000
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COLORECTAL MALIGNANCIES • Divina B. Esteban, M.D., FPSMO • Rizal Medical Center
Epidemiology: • Worldwide incidence varies from: • 3.4/100,000 - Nigeria • to • 35.8/100,000 - Connecticut, USA
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
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
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
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
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.
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
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
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
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
SCREENING Guidelines • for high risk groups & symptomatic patients: • Colon Cancer: • Fecal blood tests • Colonoscoopy +/- biopsy • Barium enema • Rectal Cancer • Digital rectal examination • Proctosigmoidoscopy
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
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
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
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
PATHOLOGY • Histological Classification • 1. Epithelial Tumors • Adenocarcinoma • Mucinous Adenocarcinoma • Signet-ring cell carcinoma • Squamous cell carcinoma • Adenosquamous carcinoma • Small cell carcinoma • Undifferentiated carcinoma
Histological Classification (cont) • 2. Carcinoid Tumors • 3. Non-epithelial tumors (Leiomyosarcoma) • 4. Hematopoietic & Lymphoid Neoplasms • 5. Unclassified Tumors
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
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)
TNM STAGING (cont.) • Distant Metastasis (M) • Mx distant metastasis cannot be assessed • M0 No distant metastasis • M1 Distant metastasis
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
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
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
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
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)
TREATMENT SCHEMA • Colon Cancer Suspect • Rectal Cancer Suspect