3. COLON CANCEREPIDEMIOLOGY Colon cancer has 4th highest incidence after prostate , breast & lung cancers Second leading cause for death after lung cancer Mean age at diagnosis is 5th decade
12. COLON CANCER INVESTIGATIONS Clinical Examination Double contrast barium enema Colonoscopy & biopsy C T scan abdomen & pelvis Chest x-ray Liver function test Carcinoembryonic Antigen PET & PET-CT - Role is emerging
15. VIRTUAL ENDOSCOPY CT Colonography Highly sensitive & specific in colon ca detection Polyps < 5mm sensitivity 11 – 55 % Allows simultaneous staging & imaging for synchronous lesions
16.
17. COLON CANCER STAGING DUKES CLASSIFICATION A – Tumor restricted to but not through bowel wall. B – Penetration through the bowel wall C – Spread to local & regional nodes C1 – Local lymph nodes involved C2 - lymph nodes at point of ligation D – Distant metasatses
18. TNM STAGING AJCC-UICC T is – Carcinoma in situ T1 - Tumor invades submucosa T2 - Tumor invades into muscularis propria T3 - Tumor invades thro muscularis propria T4 – Tumor invades local structures N0 – No lymph nodes N1 – 1-3 Regional LNs mets N2 – 4 Or more LNs mets N3 – LNs identified along named vascular trunk M0 – No distant mets M1 – Distant metastases
19. TNM STAGE GROUPING STAGE 0 – Tis,N0,M0 STAGE 1 – T1,N0,MO T2,N0,M0 STAGE 2A – T3,N0,M0 2B – T4,N0,M0 STAGE 3A – T –T2,N1,M0 3B - T3 –T4,N1,MO 3C - ANY T,N2,M0 STAGE 4 - ANY T,ANY N,M1
20. PROGNOSTIC FACTORS Advance stage Serosal penetration High tumor grade More than 4 LNs involved Bowel obstn or perforation CEA levels >5ng/ml
21. MANAGEMENT OF MALIGNANT COLON POLYPS 1. Pedunculated malignant polyps colon - Management by complete excision or snaring 2. Sessile malignant polyps < 2cms - Snaring via colonoscopy with 2mm free margins
22. PROPHYLACTIC SURGERY POLYPS First consider non surgical management options before surgery Endoscopic polypectomy reduces the incidence of subsequent cancer 50 – 70 %
25. MANAGEMENTSURGERY The extent of resection is determined by location of primary ,presence / absence of invasion into adjacent structures & distant mets
29. LAPAROSCOPY VS OPEN TECHNIQUES Recent studies confirmed technically feasible ,safe, yielding an equivalent no of lymph nodes and lengths of resected bowel when compared with open colectomy.
30. MANAGEMENT OF LIVER METASTASIS Appx 15 – 25 % at initial presentation Appx 25 – 50 % will develop liver mets in 3 years following primary resection Curative hepatic resection has a survival advantage 25 – 50 % at 5 years Indications . Stage 1 and 2 . Less than 4 hepatic lesions none > 5 cms without evidence of extrahepatic disease . CEA level < 5ng/ml . Disease free interval atleast 2 years
31. ALTERNATIVE MODALITIES FOR UNRESECTABLE LESION RFA -Thermal energy Cryo ablation – Rapid freezing Microwave ablation Percutaneous enthanol infiltration USG guided Adjuvant / pallivative hepatic artery infusions Interstitial radiotherapy
33. STAGE 0 COLON CANCERTREATMENT OPTIONS Local excision or simple polypectomy with clear margins Colon resection for larger lesions not amenable to local excision
34. STAGE 1 COLON CANCER Surgical resection and anastomosis Adjuvant chemotherpy is not indicated other than controlled clinical trials
35. STAGE 2 COLON CANCER Wide surgical resection and anastomosis Adjuvant therapy is not indicated other than controlled clinical trials
36. STAGE 3 COLON CANCER Wide surgical resection and anastomosis Adjuvant chemotherapy with 5-F.U and leucovorin for 6 months MOSAIC TRIAL – FOLFOX 4 Oxaliplatin , leucovorin , 5 FU demonstrated prolonged 3 yrs survival
37. STAGE 4 & RECURRENT COLON CANCER Surgical resection of locally recurrent cancer Surgical resection & anastomosis or Bypass of obstruction or bleeding primary in selected metastatic cases Resection of liver metastases in selected pt ( 5yr cure rate for solitary/ combination mets exceeds 20%) Resection of isolated pulmonary / ovarian mets in selected pt Palliative Radiotherapy Palliative chemotherapy
