Colon Cancer 9th Sem

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Colon Cancer 9th Sem

  1. 1. COLON CANCER<br />Dr. Tanuj Paul Bhatia<br />
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  3. 3. COLON CANCEREPIDEMIOLOGY<br /> Colon cancer has 4th highest incidence after prostate , breast & lung cancers <br />Second leading cause for death after lung cancer<br />Mean age at diagnosis is 5th decade<br />
  4. 4. COLON CANCERETIOLOGY<br />Sporadic colon ca accounts for 70%<br />> Adenomas<br />> Tobacco<br />> Inflammatory bowel diseases<br />> Dietary factors<br />> Pyrolysis products – benzo (a) pyrene<br />> Micronutrients deficiency<br />
  5. 5. COLON CANCER<br />Genetics colon ca 23%<br />> Familial adenomatous polyposis – APC <br />> Hereditary nonpolyposis colorectal cancer<br /> Lynch 1( colonic syndrome)<br /> Lynch 2 (extracolonic syndrome)<br />> Harmartomatous polyposis syndrome<br />> Familial colorectal cancer<br />
  6. 6. COLON CANCER PATHOLOGY<br /><ul><li>Adenocarcinoma 90-95% - Mucinous ( colloid ) adenocarcinoma</li></ul> - Signet ring adenocarcinoma<br /><ul><li>Sirrhous tumors
  7. 7. Sarcomas
  8. 8. Neuroendocrine tumors
  9. 9. Melanomas</li></li></ul><li>Ulcerative Ca Colon<br />
  10. 10. COLON CANCERCLINICAL FEATURES<br /><ul><li>Ascending colon & caecum24 %</li></ul> - Bleeding , anemia , melena ,abdominal pain<br /> mass , obstruction , diarrhea<br /><ul><li>Transverse colon 13%</li></ul> - Abdominal pain , mass , obstruction<br />
  11. 11. Clinical features <br /><ul><li>Descending & Sigmoid colon 34%</li></ul> - Changing bowel habits / stool caliber , <br /> mucous & blood in stools ,adbominal pain <br /> mass obstruction / perforation <br /><ul><li>Metastatic disease</li></ul> - Cachexia , wt loss , jaundice , mass , ascites ,hepatomegaly, bloomer’s shelf , virchow’s nodes<br />
  12. 12. COLON CANCER INVESTIGATIONS<br />Clinical Examination<br />Double contrast barium enema<br />Colonoscopy & biopsy<br />C T scan abdomen & pelvis<br />Chest x-ray<br />Liver function test<br />Carcinoembryonic Antigen<br />PET & PET-CT - Role is emerging<br />
  13. 13. Barium studies <br />
  14. 14. Colonoscopy<br />
  15. 15. VIRTUAL ENDOSCOPY<br /> CT Colonography<br /> Highly sensitive & specific in colon ca detection <br />Polyps < 5mm sensitivity 11 – 55 %<br />Allows simultaneous staging & imaging for synchronous lesions<br />
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  17. 17. COLON CANCER STAGING<br />DUKES CLASSIFICATION<br /> A – Tumor restricted to but not through <br /> bowel wall.<br /> B – Penetration through the bowel wall<br /> C – Spread to local & regional nodes<br /> C1 – Local lymph nodes involved<br /> C2 - lymph nodes at point of ligation <br /> D – Distant metasatses<br />
  18. 18. TNM STAGING AJCC-UICC <br />T is – Carcinoma in situ<br />T1 - Tumor invades submucosa<br />T2 - Tumor invades into muscularis propria<br />T3 - Tumor invades thro muscularis propria<br />T4 – Tumor invades local structures<br />N0 – No lymph nodes<br />N1 – 1-3 Regional LNs mets<br />N2 – 4 Or more LNs mets<br />N3 – LNs identified along named vascular trunk<br />M0 – No distant mets<br />M1 – Distant metastases<br />
  19. 19. TNM<br />STAGE GROUPING<br />STAGE 0 – Tis,N0,M0<br />STAGE 1 – T1,N0,MO<br /> T2,N0,M0<br />STAGE 2A – T3,N0,M0<br /> 2B – T4,N0,M0<br />STAGE 3A – T –T2,N1,M0<br /> 3B - T3 –T4,N1,MO<br /> 3C - ANY T,N2,M0<br />STAGE 4 - ANY T,ANY N,M1<br />
  20. 20. PROGNOSTIC FACTORS<br />Advance stage<br />Serosal penetration<br />High tumor grade<br />More than 4 LNs involved<br />Bowel obstn or perforation<br />CEA levels >5ng/ml<br />
  21. 21. MANAGEMENT OF MALIGNANT COLON POLYPS<br />1. Pedunculated malignant polyps colon<br /> - Management by complete excision or<br /> snaring<br />2. Sessile malignant polyps<br /> < 2cms <br /> - Snaring via colonoscopy with 2mm<br /> free margins <br />
  22. 22. PROPHYLACTIC SURGERY POLYPS<br />First consider non surgical management options before surgery<br />Endoscopic polypectomy <br /> reduces the incidence of subsequent <br /> cancer 50 – 70 %<br />
  23. 23. HNPCC<br />Subtotal coloectomy / Total coloectomy with <br /> ileorectal anastomosis<br />
  24. 24. FAP<br />Total proctocolectomy and IPAA<br />Various designs of ileal pouchs<br />
  25. 25. MANAGEMENTSURGERY<br />The extent of resection is determined by location of primary ,presence / absence of invasion into adjacent structures & distant mets<br />
  26. 26. RIGHT HEMICOLECTOMY<br />
  27. 27. Extended right Hemicolectomy<br />
  28. 28. LEFT HEMICOLECTOMY<br />
  29. 29. LAPAROSCOPY VS OPEN TECHNIQUES<br />Recent studies confirmed technically <br /> feasible ,safe, yielding an equivalent no of lymph nodes and lengths of resected bowel when compared with open colectomy.<br />
  30. 30. MANAGEMENT OF LIVER METASTASIS<br />Appx 15 – 25 % at initial presentation <br />Appx 25 – 50 % will develop liver mets in 3 years following primary resection<br />Curative hepatic resection has a survival advantage 25 – 50 % at 5 years<br />Indications<br /> . Stage 1 and 2<br /> . Less than 4 hepatic lesions none > 5 cms without evidence of extrahepatic disease<br /> . CEA level < 5ng/ml<br /> . Disease free interval atleast 2 years<br />
  31. 31. ALTERNATIVE MODALITIES FOR UNRESECTABLE LESION<br />RFA -Thermal energy<br />Cryo ablation – Rapid freezing<br />Microwave ablation<br />Percutaneous enthanol infiltration USG guided<br />Adjuvant / pallivative hepatic artery infusions<br />Interstitial radiotherapy<br />
  32. 32. STAGEWISE TREATMENT<br />
  33. 33. STAGE 0 COLON CANCERTREATMENT OPTIONS<br />Local excision or simple polypectomy with clear margins<br />Colon resection for larger lesions not amenable to local excision<br />
  34. 34. STAGE 1 COLON CANCER<br />Surgical resection and anastomosis<br />Adjuvant chemotherpy is not indicated other than controlled clinical trials<br />
  35. 35. STAGE 2 COLON CANCER<br />Wide surgical resection and anastomosis<br />Adjuvant therapy is not indicated other than<br /> controlled clinical trials<br />
  36. 36. STAGE 3 COLON CANCER<br />Wide surgical resection and anastomosis<br />Adjuvant chemotherapy with 5-F.U and leucovorin for 6 months<br />MOSAIC TRIAL – FOLFOX 4<br />Oxaliplatin , leucovorin , 5 FU demonstrated<br /> prolonged 3 yrs survival<br />
  37. 37. STAGE 4 & RECURRENT COLON CANCER<br />Surgical resection of locally recurrent cancer<br />Surgical resection & anastomosis or Bypass of obstruction or bleeding primary in selected metastatic cases<br />Resection of liver metastases in selected pt <br /> ( 5yr cure rate for solitary/ combination mets exceeds 20%)<br />Resection of isolated pulmonary / ovarian mets in selected pt<br />Palliative Radiotherapy<br />Palliative chemotherapy<br />
  38. 38. COLON CANCERPROGNOSIS<br /> STAGE<br />STAGE 0<br />STAGE 1<br />STAGE 2<br />STAGE 3 <br />STAGE 4<br /> 5 YRS SURVIVAL<br /> 100%<br /> 80 -100%<br /> 30-70 %<br /> 30-60%<br /> 3 -30%<br />
  39. 39. THANK YOU<br />

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