Outline • Introduction • Risk factors • Presentation • Evaluation • Treatment • Case studies

Colon Cancer Interesting Cases June 15, 2004

Saeed Awan

Relative significance of Colorectal Carcinoma • Tumor

Incidence

• Lung

173,770

• CRC 146,940 • Breast 217,440 • Prostate 230,110

Cause specific Case mortality Mort 160,440 93% M:F =54%:46% 56,730 39% 40,580 19% 29,900 13%

Jemal A, Tiwari RC, Murry T, Ghafoor A Samuels A,, Ward E, Thun M,: Cancer Statistics, 2004. CA: Cancer J. for Clin 2004; 54(1): 8-29

• 15/100,000 in 40-50 yr. Old • >400/100,000 in >70 yr. Old • Caucasians and Ashkenazi Jews have the highest risk • Asians and Africans have the lowest risk • Young patient have more aggressive disease • Environmental causes include diet low in fiber and higher in fat • 95% of carcinomas arise from adenomas (villous adenoma has higher malignant potential)

Symptoms associated with CRC weight loss

rectal bleeding

loss of appetite

change in bowel habits

night sweats

obstruction

fever

abdominal pain & mass iron-deficiency anemia

Evaluation • H&P, Chest XR • Ck for evidence of tumor fixation; if present, ck for hepatomegaly, • Rectal, pelvic (as applic) necessary • Ultrasound, C.T scan, CEA & LFTs • Colonoscopy & contrast enema

Therapy 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

Treatment • Surgery – goal is to remove primary tumor along with lymphatics with draining involved bowel • Chemotherapy – 5-FU with leucovorin (stage 3 & stage 2 with high risk patients like perforation or obstruction, high CEA). – Stage 4 combination of irinotecan with 5-FU/leuco. & oxaplatin with 5FU/leuco. High response rate than 5-FU/leuco. Alone – Avastin & erbitux

• Radiation (T4 with perforation, abscess, fistula & recurrent) Depending on the stage of the cancer, two or even three types of treatment may be used at the same time or one after the other.

COLORECTAL CANCER SURVIVAL (Dukes Stages, 5 y): • Stage A: limited to mucosa and submucosa 90% • Stage B: extends into muscularis or serosa 6075% • Stage C: one positive node - 69% six or more positive nodes, 27% • Stage D: mets. to liver, bone, lung 5%

Current Screening Guidelines Normal risk men and women age 50 or older: • Fecal Occult Blood Test (FOBT) every year, or • Flexible sigmoidoscopy every five years, or • Annual FOBT and flexible sigmoidoscopy every five years, or • Double-contrast barium enema every five years, or • Colonoscopy every 10 years • High risk population starts screening at 40 years of age

COX and CRC COX-2 not detectable in normal colon but in 90% of CRCs and 40% of adenomas Animal models: COX-inhibition results in 50% reduction of carcinomas and >90% reduction of adenomas Epidemiological studies: patients regularly taking aspirin showed 40-50% reduced risk of CRC But: minimal effective dose and duration of treatment have not yet been determined

Case 1 • 65 year – female • Vomiting & Diarrhea – 4/7 • Slight abdominal distention • CBC & LFTs normal

Case 1(cont..) • Subtotal colectomy • Histopathology – moderately differentiating carcinoma invading through muscularis propria into subserosa • LN – two positive/20

Case 2 • 53 years – male • Two months hx of intermittent constipation • One day hx of crampy abdominal pain • O/E – abdominal distention • Past hx – colonoscopy 2001- hyperplastic polyps

Case 2 (cont..) • Subtotal colectomy No liver metastasis

• Histopathology – moderately diff. adenocarcinoma infiltrating through serosa 3/13 LN +ve

Case 2 (cont..) • Right hepatic lobectomy with wedge resection x 2 (left lobe) • Histopathology – Cavernous haemangomia – Metastasis x1

Case 3 • 64 year old male • Increasing weakness, weight loss, night sweats • Limping right leg • Increasing ESR & Hb-94 (low MCV) • Past hx – polypectomy 2 years ago • Suspicious mass RLQ

Case 3 (cont..) • Laprotomy – right hemicloectomy for perforated cecal cancer and drainage of abscess • Histopathology • T 3 + N2

Case 4 • • • • • •

71 years male Diffuse lower abdominal pain Nausea & vomiting – two weeks Abdominal distention LFTs – increased ALP & LDH CEA – 1142

Case 4 (cont..) • Laprotomy – Cecal plus mid-descending colon mass – Liver multiple metastasis – Peritoneal metastasis

• Procedure – Ileosigmoid bypass anastomosis

Case 5 • • • • • •

46 years old female Pain RUQ – several weeks Family hx – mother had a colon cancer Anemia (Hb 79) – 1 year ago Tender RUQ LFTs – increased ALP & LDH

Case 6 • • • • • • •

62 year old female Pseudomembranous colitis Anemia Sigmoidoscopy – stricture at sigmiod colon Contrast enema C.T. scan – normal Presented with abdominal pain and diarrhea

Case 6 (cont..) • Laprotomy - Large mass in pelvis fixed to uterus, f. tubes, ovaries – enlarged LN • Hartman’s procedure – hysterectomy + salpingo – oophorectomy • Histopathology - T3 N0

Case 7 • 59 year old male • Abdominal pain & distention • Normal LFT and CBC

Case 7 (cont..) • Contrast enema – mid-descending colon lesion • Hartman’s procedure

Summary •CRC is a leading cause of death •Early stages are detectable •Screening can prevent CRC