1. Colon Tumours Cengiz Pata, M.D
Gastroenterology Department, Yeditepe University
Istanbul

2. “ Colon Tumours”  
ß               
Benign%.....Malign

4. Pathogenesis of Progression from Adenoma to Carcinoma
Adenoma  Neoplastic transformation
of one cell !
Mutation  APC, DCC, k, RAS
Deletion  5q, 17b
Activation  c, myc
MILD  MODERATE  SEVERE DYSPLASIA
> 2 cm – Villous components 
 Malignancy 

5. Road of carcinoma

9. Benign Tumours = POLYPS (mostly) but may be malign !
Mucosal protrusions (= projections)
into the lumen of the GI – tract.

10. Premalign disease of the colon
Polyps
Hereditary and nonhereditary polyposis syndrome
Hereditary nonpolyposis syndrome
İnflamatuar bowel disease

11. The Polyposis Syndrom’s
Ú Rarely single
Ú Often multiple
Ú > 100 Polyps = Polyposis

12. Classification “ There is no unique classification “
FORM
SIZE
HISTOLOGY
DYSPLASIA (Degree !)
Hereditary X Non-hereditary
NEOPLASTIC X NON-NEOPLASTIC

13. FORM
Sessile (broad based)
Pedunculated (stalk)
Semi-pedunculated

14. SIZE + (correlation to Ca-Risk)
< 1 cm ( %)
1-2 cm ( 10 %)
> 2 cm ( %)

15. HISTOLOGY Tubular : inf. > 75 % in Histology is from a complex
network of branching
adenomatous architecture
Villous : > 75 % in Histology
front like surface
Tubulo-villous : 50 : 50 %
(not easy to distinguish)

16. Tubulo-adenoma

18. DYSPLASIA (= DEGREE)
Mild:  5 %
Moderate:  20%
Severe: > 30 %

19. Polyposis Syndrome Hereditary Non-hereditary
FAP
· Gardner Syndrome
· Turcot Syndrome
 PEUTZ-JEGHERS Syndrome
JUVENILE (Fam) POLYPOSİS
COWDEN Syndrome
Non-hereditary
 CRONKHITE – CANADA Syndrome
HYPERPLASTIC (= METAPLASTIC)
INFLAMMATORY

20. EASY – SIMPLIFIED CLASSIFICATION
NEOPLASTIC
Adenomas
Carcinomas
NON-NEOPLASTIC
Hamartomatous
Hyperplastic
Juvenile
Inflammatory

21. More Simplified Classification
·      Four main types
A ) Adenomas
B ) Hamartomatous
C ) Hyperplastic
D ) Inflammatory
·        Rare Types
Lipoma
Fibroma
Neurofibroma
Leiomyoma
Nodular Lymphoid Hyperplasia

22. Symptoms Most cases are asymptomatic
Bleeding (increases with increased
polyp size)
Abdominal discomfort (rare)
Obstruction

23. Diagnosis Barium-studies Endoscopically (Endoscopy is preferred
polypectomy
histologic examination

24. Hereditary Polyposis Syndromes

25. TYP LOCATION GENE TICS HISTO ASSOC. FINDINGS Ca-Risk Familial Juvenile
TYP
LOCATION
GENE
TICS
HISTO
ASSOC.
FINDINGS
Ca-Risk
Familial
Juvenile
Polyposis
Colon
rectum AD
Ham.
( - )
8-10 %
Peutz-Jeghers
Syndrome
Stomach,
small bowel
Pigmen
tation
2-3%
Adenoma
-tous
Stomach
CHRP
> %

26. TYPES OF FAP GARDNER S. + Osteoma, Fibroma, Lipoma +Epidermoid-cysts
TURCOT S. + Glio-, and Medulloblastoma
AAPL (= before hereditary flat Adenomas) = (Attenuated Adenomatous P.)
High Grade Dysplasia  5. Deka  Ca Risk > 100% !

28. FAP ve Gardner S

29. Peutz-Jeghers Syndrome
Recent findings
GIT +
Pigmentation Mouth
Hands
Feet
Tumours : ovarian
testis

30. Peutz Jeghers S.

31. Peutz Jeghers S.

32. Cronkhite-Canada Syndrome
Acquired, nonfamilial
Middle aged adults
Hamartomas + Adenomas
Stomach, small bowel, colon
Associated findings :  Alopecia
 cutaneous pigmentation  dystrophic nails
 Diarrhoea
 Weight loss
 Abdominal pain
Ca-Risk  5%

33. MANAGEMENT Tubular or Villous Other Colorectal polyp   
  
Tubular or Villous Other
Tubulovillous 
< 1 cm > 1 cm no investigation
< 5 polyps > 5 polyps
in total 
 Repeat in 1 year
Repeat in 3 years
 All clear  Repeat in 5 years

34. Polypectomy Operation Size < 1 cm < 2-3 cm Total < 5 polyps
FAP : Prophylactic Colectomy !

35. Colorectal Cancer POLYP  DYSPLASIA  CANCER sequence
is now generally accepted

37. Colorectal Cancer
Second most common cancer in USA , Germany, UK, France !
After age 40 to age 80 the incidence doubles !!!

39. Colon Ca

40. RISC FACTORS Low-fiber, high fat diet Age > 40
Personal History : Colorectal adenomas
Family History : Polyps Syndromes
Inflammatory Bowel Disease ( CD, UC)
Genital tract cancer in women
Lynch Syndrome : Hereditary Nonpolypose Colon Carcinoma (HNPCC)

41. Lynch Syndrome : Hereditary Nonpolyposis Colon Carcinoma (HNPCC)
Autosomal dominant
Amsterdam criteria:3,2,1 rules
(3 relative, 2 generation,1 person<50
DNA mismatch repair
6% of colorectal carcinoma
Typ 2:Endometrium, stomach, hepatobiliary Ca
HMSA %60 (+)

43. Symptoms Bleeding (Gross or occult)
Change in bowel habit ; constipation, diarrhoea, decreased caliber of stool
Anemia
Weight loss
Anorexia

44. Classification/Localization
Rectum  60%
Sigma  20%
Rest colon  20%

45. Most Common Presentation
Left sided : Bleeding
Obstruction
Diarrhoea
Right sided : Fatique
Weakness
Occult blood loss
Obstruction (late)

46. Staging - Systems TNM : Tumor / Nodes / Metastasis
UICC : Union Internationale Contra Le Cancer
ASTLER-COLLER : DEPTH OF İNVASİON
DUKE +
Lymph node metastasis

47. T1s No Mo
Carcinoma in situ (Basal membrane intact)
I a
Dukes A
T1 No Mo
Tumor involves mucosa+submucosa
I b
T2 No Mo
Tumor invades to muscularis propria (but not true it !!!) II
Dukes B1
T3No Mo
Tumor penetrates through the bowel wall
Dukes B2
T4 No Mo
Tumor involves viscerales peritoneum
III
Dukes C
Tany N1-2 Mo
+ Regional positive lymph nodes IV
Dukes D
Tany Nany M1
Distant metastatic spread

49. Colon Ca-Survi

50. Prognosis by DUKE’s Staging
5 year survival rate :
A : 80%
B1 : 65%
B2 : 43%
C1 : 53%
C2 : 15%
D : 0%

51. Negative Prognostic Factors
High-grade tumor
Obstruction
Perforation

53. Diagnostic Procedures and Presurgical Evaluation
Laboratory :
CEA, CA 19-9
TBC, Liver profile
Colonoscopy
Radiographs
Detailed History (including family history)
Physical examination (including breast+pelvic
ovary+endometrium)

54. Therapy For cure in Duke’s A, B, C For palliation in Duke’s D Surgical
Adjuvant Chemotherapy ( 5-FU / Folinasid)
Palliative ( Stenosis  anus-praeterminalis)

55. SURGİCAL Radical tumor-resection + regional lymph node extripation
Colon Hemicolectomy
Sigma
Transversum > resection
Rectum Distance “Linea ANOCUTANEA “
cure + maintanence of fecal continence

56. SCREENING of Patients After age 40 annual rectal examination
Annual fecal occult blood test every year after age 50
After age 50 Sigmoidoscopy every 5 years, colonoscopy every ten years
Today: colonoscopy every 5 year after 50 years

57. Follow up in patients with positive family history

58. HNPCC’ da İzlem

59. Ulcerative colitis following