Colo Rectal Carcinoma

COLO RECTAL CARCINOMA


COLO RECTAL CARCINOMA

  • Colo rectal carcinoma is the carcinoma affecting caecum, colon & rectum.
  • It is the most common internal carcinoma in western world.
  • 1/3rd of tumour are in rectum & 2/3rd in colon.

Etiology-

  • Environmental factors
  • Diet rich in fat, meat & low in fibre.
  • Adenomatous polyps
  • Genetic factors
  • Inflammatory bowel disease
  • Surgical procedures- Ureterosigmoidostomy
  • Choleccystectomy

Pathology

  • Colo rectal carcinoma occurs- rectum (38%), sigmoid (21%), descending colon (4%), cancer of caecum (12%), ascending colon (5%)

Staging-

  • The most important prognostic factor of colorectal carcinoma is the ‘stage of disease’.

– The two most important prognostic factors-

  • Depth of invasion
  • Lymph node status

Clinical features-

Right colon tumors

  • Growth: fungative, ulcerative, polypoid or cauliflower like
  • Infiltration absent
  • Iron deficiency anemia due to chronic blood loss
  • Palpable mass in the RIF, which is not moving with respiration
  • Spurious (early morning) diarrhea

Left sided colon tumours

  • Growth: obstructive, annular lesions producing napkin ring constriction
  • Infiltration present
  • Rectal bleeding, Colicky pain
  • Altered bowel habits (alternating diarrhea and constipation)
  • Abdominal distension due to subacute/chronic obstruction
  • Tenesmus

Investigations

  • Barium enema: apple core lesion in left sided carcinoma
  • Colonoscopy and biopsy: is the investigation of choice
  • CEA: normal level <2.5ng/ml; >5ng/m1 significant
  • Low sensitivity(also ↑ in pancreatitis, hepatitis, obstructive jaundice, BPH)
  • Pre-op levels >7.5ng/ml indicates poor prognosis

Increase in CEA during follow up

  • Slow rise – loco regional disease
  • Rapid rise – metastasis

Treatment-

  • Bowel preparation is not safe for right sided colonic surgery. The method used is dietary restriction to fluids only for 48 hrs before surgery
  • Carcinoma of the caecum or ascending colon: right hemicolectomy
  • Carcinomas of the transverse colon and splenic flexure: extended right hemicolectomy
  • Carcinomas of descending and sigmoid colon: left hemicolectomy
  • Right sided tumors presenting as obstruction: right hemicolectomy
  • Left sided tumors presenting as obstruction
  • Hartmann’s procedure or resection and anastomosis

If facilities available an expanding metal stent followed by resection and anastamosis

  • The criteria for resection is < 3 lesions in one lobe of liver
  • Chemotherapy
  • 5-FU + (folinic acid)Leucovorin + Irinotecan(topoisomerase-1 inhibitor) improves survival in patients with metastatic disease(FOLFIRI regimen)
  • 5-FU + (folinic acid)Leucovorin + Oxiplatin(FOLFOX regimen) is equally effective

Exam Important

  • Colo rectal carcinoma is the carcinoma affecting caecum, colon & rectum.
  • Colo rectal carcinoma is the carcinoma affecting caecum, colon & rectum.
  • It is the most common internal carcinoma in western world.
  • 1/3rd of tumour are in rectum & 2/3rd in colon.

Etiology-

  • Environmental factors
  • Diet rich in fat, meat & low in fibre.
  • Adenomatous polyps
  • Genetic factors
  • Inflammatory bowel disease
  • Surgical procedures- Ureterosigmoidostomy
  • Choleccystectomy

Pathology

Staging-  

  • The most important prognostic factor of colorectal carcinoma is the ‘stage of disease’.

– The two most important prognostic factors-

  • Depth of invasion
  • Lymph node status

Investigations

  • Barium enema: apple core lesion in left sided carcinoma
  • Colonoscopy and biopsy: is the investigation of choice
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