1. COLORECTAL MALIGNANCIES Divina B. Esteban, M.D., FPSMO Rizal Medical Center

2. Epidemiology : Worldwide incidence varies from: 3.4/100,000 - Nigeria to 35.8/100,000 - Connecticut, USA

3. 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

4. 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

6. Leading Cancer Sites, Females, 1993-1997 DOH - Rizal & PCS - Manila Cancer Registries 0102030405060 Leukemias Stomach Rectum Liver Thyroid Colon Ovary Lung Cervix Breast ASR/100,00 0 7929 1813 725 1115 3378 1934 925 1244 1639 80 2 48.0 19.0 11.0 9.3 8.5 5.7 5.3 5.2 13.8 6.7

7. 2005 Estimates* 8585 new colorectal cancer cases Males: 4737 Females: 3848 5558 deaths from colorectal cancer Males: 3064Females: 2494 * 2005 Philippine Cancer Facts & Estimates. PCSI. 2004 Females: 3

8. 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.

9. 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

10. 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

11. 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

12. 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

13. SCREENING Guidelines for high risk groups & symptomatic patients: –Colon Cancer: Fecal blood tests Colonoscoopy +/- biopsy Barium enema –Rectal Cancer Digital rectal examination Proctosigmoidoscopy

14. 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

15. 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

16. 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

17. 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

18. PATHOLOGY Histological Classification 1. Epithelial Tumors Adenocarcinoma Mucinous Adenocarcinoma Signet-ring cell carcinoma Squamous cell carcinoma Adenosquamous carcinoma Small cell carcinoma Undifferentiated carcinoma

19. Histological Classification (cont) 2. Carcinoid Tumors 3. Non-epithelial tumors (Leiomyosarcoma) 4. Hematopoietic & Lymphoid Neoplasms 5. Unclassified Tumors

20. 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

21. 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)

22. TNM STAGING (cont.) Distant Metastasis (M) Mx distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis

23. TNM STAGING (cont.) Stage Groupings: TNM Astler-Coller modified 0 Tis N0 M0n/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 IVAny T Any N M1 Stage D

24. PROGNOSTIC FACTORS: 1Disease 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

25. PROGNOSTIC FACTORS cont. 2 Lymph node involvement 3 Extrarectal extension = Amount of uninvolved tissue (circumferential or radial margins) Define the extraluminal extent of tumors Measure the narrowest radial margin

26. Prognostic Factors cont. Histologic grade Stage of tumor Depth of invasion Frequency of nodal involvement Number of lymph nodes involved Bowel obstruction 2 o to tumor Tumor perforation

27. PATTERNS OF FAILURE after 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)

28. TREATMENT SCHEMA Colon Cancer Suspect Rectal Cancer Suspect