Colon Tumours Colon Tumours Cengiz Pata, M.D Gastroenterology Department, Yeditepe University...
-
Upload
rebecca-pitts -
Category
Documents
-
view
223 -
download
0
Transcript of Colon Tumours Colon Tumours Cengiz Pata, M.D Gastroenterology Department, Yeditepe University...
Colon TumoursColon Tumours
Cengiz Pata, M.DCengiz Pata, M.D
Gastroenterology Department, Yeditepe Gastroenterology Department, Yeditepe UniversityUniversity
IstanbulIstanbul
“ “ Colon TumoursColon Tumours””
Benign%.....Benign%.....MalignMalign
Pathogenesis of ProgressionPathogenesis of Progression from Adenoma to Carcinoma from Adenoma to Carcinoma
AdenomaAdenoma Neoplastic transformationNeoplastic transformationof one cell !of one cell !
MutationMutation APC, DCC, k, RASAPC, DCC, k, RAS
DeletionDeletion 5q, 17b5q, 17b
ActivationActivation c, mycc, myc MILD MILD MODERATE MODERATE SEVERE DYSPLASIA SEVERE DYSPLASIA
> > 2 cm – Villous components 2 cm – Villous components MalignancyMalignancy
Road of carcinomaRoad of carcinoma
Benign Benign TumoursTumours
= POLYPS (mostly) = POLYPS (mostly)
but may be malign !but may be malign !
Mucosal protrusions (= projections) Mucosal protrusions (= projections)
into the lumen of the GI – tract.into the lumen of the GI – tract.
Premalign disease of Premalign disease of the colonthe colon
PolypsPolyps Hereditary and nonhereditary Hereditary and nonhereditary
polyposis syndromepolyposis syndrome Hereditary nonpolyposis Hereditary nonpolyposis
syndromesyndrome İnflamatuar bowel diseaseİnflamatuar bowel disease
The Polyposis Syndrom’sThe Polyposis Syndrom’s
Rarely singleRarely single
Often multipleOften multiple
> 100 Polyps = Polyposis> 100 Polyps = Polyposis
ClassificationClassification“ There is no unique classification ““ There is no unique classification “
A.A. FORMFORM
B.B. SIZESIZE
C.C. HISTOLOGYHISTOLOGY
D.D. DYSPLASIA (Degree !)DYSPLASIA (Degree !)
E.E. Hereditary X Non-hereditaryHereditary X Non-hereditary
F.F. NEOPLASTIC X NON-NEOPLASTICNEOPLASTIC X NON-NEOPLASTIC
FORMFORM
Sessile (broad based)Sessile (broad based)
Pedunculated (stalk)Pedunculated (stalk)
Semi-pedunculatedSemi-pedunculated
SIZE SIZE + (correlation to Ca-Risk)+ (correlation to Ca-Risk)
<< 1 cm1 cm (( 1 - 2 %) 1 - 2 %)
1-2 cm1-2 cm (( 10 %) 10 %)
>> 2 cm2 cm (( 40 - 50 %) 40 - 50 %)
HISTOLOGYHISTOLOGY
Tubular Tubular : inf. > 75 % in Histology : inf. > 75 % in Histology
is from a complex is from a complex
network of branching network of branching
adenomatous adenomatous architecturearchitecture VillousVillous : > 75 % : > 75 % in Histology in Histology
ffront like surfaceront like surface Tubulo-villousTubulo-villous : : 50 : 5050 : 50 % %
(not easy to distinguish)(not easy to distinguish)
Tubulo-adenomaTubulo-adenoma
DYSPLASIA (= DEGREE)DYSPLASIA (= DEGREE)
Mild:Mild: 5 % 5 %
Moderate: Moderate: 20 20%%
Severe: > 30 %Severe: > 30 %
Polyposis SyndromePolyposis Syndrome
HereditaryHereditary FAPFAP
Gardner SyndromeGardner Syndrome
Turcot SyndromeTurcot Syndrome PEUTZ-JEGHERS PEUTZ-JEGHERS
SyndromeSyndrome JUVENILE (Fam) JUVENILE (Fam)
POLYPOSİSPOLYPOSİS COWDEN SyndromeCOWDEN Syndrome
Non-hereditaryNon-hereditary
CRONKHITE – CRONKHITE –
CANADA SyndromeCANADA Syndrome
HYPERPLASTIC (= HYPERPLASTIC (=
METAPLASTIC)METAPLASTIC)
INFLAMMATORYINFLAMMATORY
EASY – SIMPLIFIED EASY – SIMPLIFIED CLASSIFICATIONCLASSIFICATION
NEOPLASTICNEOPLASTIC
AdenomasAdenomas
CarcinomasCarcinomas
NON-NEOPLASTICNON-NEOPLASTIC
HamartomatousHamartomatous HyperplasticHyperplastic JuvenileJuvenile InflammatoryInflammatory
MMoreore Simplified Simplified ClassificationClassification
Four main typesFour main types
A ) AdenomasA ) Adenomas
B ) HamartomatousB ) Hamartomatous
C ) HyperplasticC ) Hyperplastic
D ) InflammatoryD ) Inflammatory
Rare TypesRare Types
LipomaLipoma
FibromaFibroma
NeurofibromaNeurofibroma
LeiomyomaLeiomyoma
Nodular Lymphoid Nodular Lymphoid
HyperplasiaHyperplasia
SymptomsSymptoms
Most cases are asymptomaticMost cases are asymptomatic
Bleeding (increases with increased Bleeding (increases with increased
polyp size)polyp size) Abdominal discomfort (rare)Abdominal discomfort (rare)
ObstructionObstruction
DiagnosisDiagnosis
Barium-studiesBarium-studies
Endoscopically (Endoscopy is Endoscopically (Endoscopy is
preferredpreferred
polypectomypolypectomy
histologic examinationhistologic examination
Hereditary Polyposis Hereditary Polyposis SyndromesSyndromes
TYP LOCATION GENETICS
HISTO ASSOC.FINDINGS
Ca-Risk
Familial Juvenile Polyposis
Colonrectum AD Ham. ( - )
8-10 %
Peutz-Jeghers Syndrome
Stomach, small bowel
AD Ham. Pigmentation
2-3%
Colon
FamilialAdenoma-tous Polyposis
Stomach Colonrectum
AD Adenoma CHRP> 90 %
TYPES OF FAPTYPES OF FAP
GARDNER S.GARDNER S. + Osteoma, Fibroma, + Osteoma, Fibroma,
Lipoma +Epidermoid-cystsLipoma +Epidermoid-cysts
TURCOT S.TURCOT S. + Glio-, and Medulloblastoma+ Glio-, and Medulloblastoma
AAPLAAPL (= before hereditary flat (= before hereditary flat
Adenomas) = Adenomas) =
(Attenuated Adenomatous P.)(Attenuated Adenomatous P.)
High Grade Dysplasia High Grade Dysplasia 5. Deka 5. Deka
Ca Risk > 100% !Ca Risk > 100% !
FAP ve Gardner SFAP ve Gardner S
Peutz-Jeghers SyndromePeutz-Jeghers Syndrome
Recent findingsRecent findings
GITGIT ++PigmentationPigmentation MouthMouth
HandsHands
FeetFeet
Tumours :Tumours : ovarianovarian
testistestis
Peutz Jeghers S.Peutz Jeghers S.
Peutz Jeghers S.Peutz Jeghers S.
CCronkhite-ronkhite-CCanada anada SyndromeSyndrome
Acquired, nonfamilialAcquired, nonfamilial Middle aged adultsMiddle aged adults Hamartomas + AdenomasHamartomas + Adenomas Stomach, small bowel, colonStomach, small bowel, colon Associated findings :Associated findings : Alopecia Alopecia
cutaneous pigmentation cutaneous pigmentation dystrophic nails dystrophic nails
DiarrhoeaDiarrhoea Weight lossWeight loss Abdominal painAbdominal pain
Ca-RiskCa-Risk 5%5%
MANAGEMENTMANAGEMENT
Colorectal polypColorectal polyp
Tubular orTubular or VillousVillous OtherOther
TubulovillousTubulovillous < 1 cm< 1 cm > 1 cm> 1 cm no no
investigationinvestigation
< 5 polyps < 5 polyps > 5 polyps> 5 polyps
in totalin total Repeat in 1 yearRepeat in 1 year
Repeat in 3 yearsRepeat in 3 years
All clearAll clear Repeat in 5 yearsRepeat in 5 years
PolypectomyPolypectomy
SizeSize < 1 cm< 1 cm
< 2-3 cm< 2-3 cm
Total < 5 polypsTotal < 5 polyps
OperationOperationSize >3-5 cmSize >3-5 cm
FAP :FAP : Prophylactic Colectomy !Prophylactic Colectomy !
Colorectal CancerColorectal Cancer
POLYP POLYP DYSPLASIA DYSPLASIA CANCER CANCER
sequencesequence
is now generally acceptedis now generally accepted
Colorectal CancerColorectal Cancer
– Second most common Second most common cancer in USA , Germany, cancer in USA , Germany, UK, France !UK, France !
– After age 40 to age 80 the After age 40 to age 80 the incidence doubles !!!incidence doubles !!!
Colon Ca Colon Ca
RISC FACTORSRISC FACTORS
Low-fiber, high fat dietLow-fiber, high fat diet Age > 40Age > 40 Personal History : Colorectal adenomasPersonal History : Colorectal adenomas Family History : Polyps SyndromesFamily History : Polyps Syndromes Inflammatory Bowel Disease ( CD, UC)Inflammatory Bowel Disease ( CD, UC) Genital tract cancer in womenGenital tract cancer in women Lynch Syndrome : Hereditary Lynch Syndrome : Hereditary
NonpolyposeNonpolypose Colon Carcinoma (HNPCC)Colon Carcinoma (HNPCC)
Lynch Syndrome :Lynch Syndrome : Hereditary Nonpolyposis Hereditary NonpolyposisColon Carcinoma (HNPCC)Colon Carcinoma (HNPCC)
Autosomal dominantAutosomal dominant
Amsterdam criteria:3,2,1 rulesAmsterdam criteria:3,2,1 rules
(3 relative, 2 generation,1 person<50(3 relative, 2 generation,1 person<50
DNA mismatch repairDNA mismatch repair
6% of colorectal carcinoma6% of colorectal carcinoma
Typ 2:Endometrium, stomach, hepatobiliary CaTyp 2:Endometrium, stomach, hepatobiliary Ca
HMSA %60 (+)HMSA %60 (+)
SymptomsSymptoms
Bleeding (Gross or occult)Bleeding (Gross or occult)
Change in bowel habit ; constipation, Change in bowel habit ; constipation,
diarrhoea, decreased caliber of stooldiarrhoea, decreased caliber of stool
AnemiaAnemia
Weight lossWeight loss
AnorexiaAnorexia
Classification/LocalizationClassification/Localization
RectumRectum 60%60%
SigmaSigma 20%20%
Rest colonRest colon 20%20%
Most Common Most Common PresentationPresentation
Left sided :Left sided : BleedingBleeding
ObstructionObstruction
DiarrhoeaDiarrhoea
Right sided :Right sided : FatiqueFatique
WeaknessWeakness
Occult blood lossOccult blood loss
Obstruction (late)Obstruction (late)
Staging - SystemsStaging - Systems
TNM :TNM : Tumor / Nodes / MetastasisTumor / Nodes / Metastasis
UICC :UICC : Union Internationale Contra Le Union Internationale Contra Le CancerCancer
ASTLER-COLLER :ASTLER-COLLER : DEPTH OF İNVASİONDEPTH OF İNVASİON
DUKEDUKE ++
Lymph node Lymph node metastasismetastasis
00 TT1s1s N Noo M Moo Carcinoma in situ (Basal Carcinoma in situ (Basal membrane intact)membrane intact)
I aI a Dukes ADukes A TT11 N Noo M Moo Tumor involves Tumor involves mucosa+submucosamucosa+submucosa
I bI b TT22 N Noo M Moo Tumor invades to Tumor invades to muscularis muscularis propriapropria (but not true it !!!) (but not true it !!!)
IIII Dukes Dukes B1B1
TT33NNoo M Moo Tumor penetrates Tumor penetrates through the through the bowel wallbowel wall
IIII Dukes Dukes B2B2
TT44 N Noo M Moo Tumor involves Tumor involves viscerales viscerales peritoneumperitoneum
IIIIII Dukes CDukes C TTanyany N N1-21-2 M Moo + Regional positive lymph + Regional positive lymph nodesnodes
IVIV Dukes DDukes D TTanyany N Nanyany M M11 Distant metastatic spreadDistant metastatic spread
Colon Ca-SurviColon Ca-Survi
Prognosis by DUKE’s Prognosis by DUKE’s StagingStaging
5 year survival rate :5 year survival rate :A :A : 80%80%
B1 :B1 : 65%65%
B2 :B2 : 43%43%
C1 :C1 : 53%53%
C2 :C2 : 15%15%
D :D : 0% 0%
Negative Prognostic Negative Prognostic FactorsFactors
High-grade tumorHigh-grade tumor
ObstructionObstruction
PerforationPerforation
Diagnostic Procedures Diagnostic Procedures and Presurgical and Presurgical EvaluationEvaluation
Detailed History Detailed History
(including family (including family
history)history)
Physical examination Physical examination
(including (including
breast+pelvicbreast+pelvic
ovary+endometrium)ovary+endometrium)
Laboratory : Laboratory :
CEA, CA 19-9CEA, CA 19-9
TBC, Liver TBC, Liver
profileprofile
ColonoscopyColonoscopy
RadiographsRadiographs
TherapyTherapy
For cure in Duke’s For cure in Duke’s A, B, CA, B, C
For palliation in Duke’sFor palliation in Duke’s DD
SurgicalSurgical
Adjuvant Chemotherapy Adjuvant Chemotherapy ( 5-FU / Folinasid)( 5-FU / Folinasid)
Palliative ( Stenosis Palliative ( Stenosis anus-praeterminalis)anus-praeterminalis)
SURGİCALSURGİCAL
Radical tumor-resection Radical tumor-resection
+ regional lymph node extripation+ regional lymph node extripation
ColonColon HemicolectomyHemicolectomy
SigmaSigma
TransversumTransversum > > resectionresection
RectumRectum Distance “Linea ANOCUTANEA “Distance “Linea ANOCUTANEA “ cure + maintanencecure + maintanence of fecal of fecal
continencecontinence
SCREENING of PatientsSCREENING of Patients
After age 40 annual rectal examinationAfter age 40 annual rectal examination
Annual fecal occult blood testAnnual fecal occult blood test every year after every year after
age 50age 50
After age 50 Sigmoidoscopy every 5 yearsAfter age 50 Sigmoidoscopy every 5 years, ,
colonoscopy every ten yearscolonoscopy every ten years
Today: colonoscopy every 5 year after 50 Today: colonoscopy every 5 year after 50
yearsyears
Follow up in patients with Follow up in patients with positive family historypositive family history
HNPCC’ da İzlemHNPCC’ da İzlem
Ulcerative colitis Ulcerative colitis followingfollowing