1. Anorectal Cancer Symptoms And Signs


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1. Anorectal Cancer Symptoms And Signs

  1. 1. ANORECTAL CANCER – Symptoms and Signs Louise Fischer Med IV
  2. 2. But first, some basic anatomy
  3. 3. Anorectal cancer – what the? Anorectal cancer: a) Anal cancer i) Anal canal cancer ii) Anal margin cancer b) Rectal cancer
  4. 4. Definitions according to WHO and AJCC (American Joint Committee on Cancer)  Anal canal  extends from upper border to the lower border of the internal and external sphincter (ie. from the pelvic floor to the anal verge).  Anal margin tumours  occur outside the anal verge but within a 5-6cm radius to the anus.
  5. 5. Anal canal cancer  1.5% of GI malignancies, estimated 3400 new cases/yr.  Risk Factors include:  female gender  chronic anal irritation (more specifically chronic infection with HPV)  anoreceptive intercourse  HIV positive  anogenital warts  history of STDs  increased number of sexual partners  history of cervical/vulvar/vaginal cancer (personal or partner)  Immunosuppression  LT use of corticosteroids  cigarette smoking.
  6. 6. Anal Canal Cancer (cont)  Tumours of anal canal  tend to be aggressive, nonkeratinizing, and associated with HPV infection.  Epidermoid (Squamous, Basoloid, Mucoepidermoid) Carcinoma  Symptoms  Prior to diagnosis, there is generally a long history of minor perianal complaints such as bleeding / itching / perianal discomfort / palpable anal mass.  Signs  At presentation, disease may be extensive with approx ½ of lesions extending beyond the bowel wall / perianal skin. Inguinal nodal metastases are found initially in 15-20% of patients and develop in 10-15% over time.
  7. 7. Anal Margin Cancer  Men have a 4-fold increased risk of anal margin carcinoma.  Tumours of anal margin  generally well differentiated, keratinizing tumours that behave similarly to other squamous cell carcinomas of the skin and are treated accordingly.
  8. 8. Anal Margin Cancer (cont) Squamous Basal cell Bowen’s Disease Paget’s Disease Cell carcinoma Carcinoma Symptoms Mass / Bleeding / Perianal burning / Characteristically bleeding / itching / itching /pain severe intractable pain / pain pruritus. discharge / itching / tenesmus Signs Large, Lesions When grossly On physical centrally appear with apparent, lesions examination, an ulcerated raised, appear scaly, erythematous, lesions with irregular discrete, eczematoid rash rolled everted edges and erythematous, and is apparent. edges. Feels central sometimes hard and ulceration. pigmented. woody on palpation.
  9. 9. Rectal Cancer  Incidence  Approx 135 00 new cases of colorectal cancer (CRC) occur in the US each year, 2/3 of these cases occur in the colon ad 1/3 in the rectum.  Prevalence  the lifetime risk of developing colorectal malignancy is approx 5.9% in the general population (in the US).  Race  Western countries tend to have a higher incidence than Asian and African countries. Among religious denominations, CRC occurs more frequently in the Jewish population.  Sex  Incidence of colorectal malignancy is slightly higher in males than females.  Age  Incidence peaks in 70’s (some cases reported in young children).
  10. 10. Rectal cancer (cont)  Etiology  unknown but appears to be multifactorial in origin  Diet:  High meat and animal fat diet associated with CRC  High fibre diet  protective against CRC  Increased dietary intake of calcium  protective effect  Daily alcohol-drinkers  2-fold ↑risk  Beer consumption >15L/mth  ↑risk in men.
  11. 11. Rectal cancer (cont)
  12. 12. Rectal cancer (cont) Lifetime risk of CRC in 1st-degree relatives of a patient with CRC Population risk 1 in 50 1x 1st-degree relative affected (any age) 1 in 17 1x 1st-degree relative + 1x 2nd-degree 1 in 12 relative affected 1x 1st-degree relative affected (age<45) 1 in 10 2x 1st-degree relatives affected 1 in 6 Autosomal dominant pedigree 1 in 2
  13. 13. Rectal cancer (cont)  Genetic disorders  Familial adenomatous polyposis (FAP)  Autosomal dominant inherited syndrome that results in the development of more than 100 adenomatous polyps and a variety of extraintestinal manifestations.  The defect is in the APC gene, which is located on chromosome 5 at locus q21.  The disease process causes the formation of hundreds of intestinal polyps, osteomas of the bone, desmoid tumours, and, occasionally, brain tumours.  The increased number of polyps predisposes patients to a greater risk of cancer. If left untreated, colorectal cancer develops in nearly 100% of these patients by age 40years.  While the hereditary link is documented, approx 20% of FAP cases are caused by spontaneous mutation.
  14. 14. Rectal cancer (cont)  Hereditary nonpolyposis colorectal cancer (HNPCC)  Autosomal dominant inherited syndrome that occurs because of defective mismatch repair genes located on chromosomes 2, 3, and 7.  Patients have the same number of polyps as the general population, but their polyps are more likely to become malignant. These patients also have a higher incidence of endometrial, gastric, thyroid, and brain cancers.  Amsterdam Criteria for HNPCC:  3+ cases of CRC in minimum of 2 generations  1 affected individual must be a 1st-degree relative of the other 2+ cases  1 case must be diagnosed at age <50  CRC can be replaced by endometrial or small bowel cancer.  FAP should be excluded
  15. 15. Rectal cancer (cont)  Inflammatory Bowel Disease  Ulcerative colitis  The incidence of malignancy increases with duration. After 10yrs, the incidence of CRC in ulcerative colitis is approximately 1% per year.  Crohn’s disease  The incidence of CRC in patients with CD is 4-20 times greater than that of the general population. Cancer occurs in patients with disease of at least 10years’ duration. The average age at diagnosis (ie. 46-55) is younger than that of the general population.  Cancers often develop in areas of strictures and in defunctionalized segments of intestine. In patients with perianal Crohn’s Disease, malignancy often present in fistulous tracts.  Patients with Crohn colitis undergo the same surveillance regimen as those with UC.
  16. 16. Rectal cancer - symptoms  It is very important to take a compete history from the patient, including a family history and assessment of Risk Factors for developing rectal cancer.  Many rectal cancers produce no symptoms and are discovered during digital / proctoscopic screening examinations.
  17. 17. Rectal cancer - symptoms Bleeding 60% Change in bowel habits 43% Occult bleeding 26% Abdominal pain 20% Other: Malaise 9% Bowel obstruction 9% Pelvic pain 5% Peritonitis from perforation 3% Liver metastasis 1%
  18. 18. Rectal cancer - symptoms  Bleeding  Often attributed to other causes (eg haemorrhoids), especially if the patient has a history.  Profuse bleeding and anaemia are rare.  May be accompanied by the passage of mucus and warrant further investigation.
  19. 19. Rectal cancer - symptoms  Change in bowel habit  Often occurs in form of diarrhoea, particularly if the tumour has a large villous component.  Some patients experience a change in caliber of the stool.  Large tumours can cause obstructive symptoms.  Tumours located low in the rectum can cause a feeling of incomplete evacuation and tenesmus.
  20. 20. Rectal cancer - symptoms  Abdominal pain  Partial large bowel obstruction may cause colicky abdominal pain and bloating.  Back pain usually is a late sign caused by a tumour invading / compressing nerve trunks.  Urinary symptoms may occur if the tumour is invading or compressing the bladder / prostate.
  21. 21. Rectal cancer - signs  Physical examination is performed with specific attention to possible metastatic lesions, including enlarged lymph nodes or hepatomegaly.  Digital Rectal Examination  The average finger can reach approx 8cm above the dentate line.  Tumours can be assessed for size, ulceration, and presence of any pararectal lymph nodes. Fixation of the tumour to surrounding structures (eg sphincters, prostate, vagina) also can be assessed.  DRE also permits cursory evaluation of he patients’ sphincter function. This information is necessary when determining whether a patient is a candidate for a sphincter-sparing procedure.
  22. 22. List of resources  Burkett HG, Quick CRG, Deakin PJ. Essential Surgery: Problems, Diagnosis and Management. 3rd ed. Churchill Livingstone. 2004.  Cirincione E, Cagir B. “Rectal cancer.” eMedicine. Retrieved 23 April 2005 http://www.emdedcine.com/med/topic1994.htm.  Friedman SL, Mcquaid KR, Grendall JH. “Anorectal Diseases.” Current Diagnosis & Treatment in Gastroenterology. 2nd ed. McGraw-Hill. 2003. p452-479.  Kumar P, Clark M. Clinical Medicine. 5th ed. WB Saunders. 2002  Yamada T, Alpers DH, Kaplowitz N, et al. “Anorectal Diseases.” Textbook of Gastroenterology. 4th ed. Lippincott Williams & Wilkins. 2003. p1990-1991