Colon Cancer

I.
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Definition/General Considerations
Colon cancer is the 2nd leading cause of cancer mortality in the US after lung CA (55,000 deaths/year)
5% lifetime risk of getting it
Risk factors
1) Age
2) Hereditary syndromes: FAP, Gardners disease, HNPCC (Lynch syndrome)
a. Lynch syndrome I: AD with right-sided predominance
b. Lynch syndrome II: Lynch syndrome I + extra-colonic CA (endometrial, ovarian, SB, stomach,
pancreas, transitional cell of the ureter and pelvis)
3) Family history
4) IBD: UC > Crohns
5) Adematous polyp: Villous > tubular
6) Past history of colorectal cancer
7) High-fat, low-fiber diet
8) Alcohol and cigarette use
Screening
A) For healthy adults, at 50:
1) Sigmoidoscopy every 3-5 years + yearly occult blood stool testing
2) Colonoscopy every 10 years
B) If 1st degree relative has, begin screening 10 years before youngest one diagnosed
Metastases may arise from:
1) Hematogenous spread: Blood-borne mets to liver, lung, bone, and brain
2) Lymphatic spread: Pelvic LN affected
3) Direct extension
4) Peritoneal spread
Dukes Staging
A: Tumor limited to mucosa and submucosa; Tx = Excise
B1: Tumor invades into muscularis propria; Tx = Excise
B2: Tumor invades through muscularis propria; Tx = Excise
C1: B1 plus nodes; Tx = Excise + 5-FU and leukovorin
C2: B2 plus nodes; Tx = Excise + 5-FU and leukovorin
D: Distant metastasis (liver>lung>bone>CNS)/unresectable local spread; Tx = Chemo or irradiation, excision of
1-3 liver mets
Leading cause of death in cancer patients: Infection > thromboembolic complications

II. Clinical Findings

* Right-sided lesions
A) Fe deficiency anemia Dyspnea
B) Constitutional symptoms: Weight loss, anorexia, weakness, vague abdominal pain
* Left-sided lesions
A) Apple-core obstructing masses
B) Changes in bowel habits: Decreasing stool caliber, constipation, obstipation
a. Blood streaked stools
b. Obstruction often present
* Rectal lesions
A) BRBPR
B) Tenesmus and/or rectal pain
III-IV. Workup/Laboratory Findings
A) CBC: Microcytic anemia
B) Stool occult blood
C) Baseline CEA to follow
D) Sigmoidoscopy/transrectal U/S to determine depth/colonoscopy to via entire colon
E) Barium enema to rule out missed lesions after complete colonoscopy
F) Abdominal CT/MRI for staging colon cancer
G) Met workup: CXR, LFTs, and an abdominal CT

V. Differential Diagnosis
A) IBD
B) Diverticulitis
C) Ischemic colitis
D) Hemorrhoids
E) PUD
F) Other intra-abdominal malignancies
VI. Treatment
* General treatment
A) Pre-op bowel prep: GoLytely and Abx
B) Colonic lesions
a. Surgical resection with 3-5 cm margin
b. Lymphatic drainage and mesentery at the origin of the arterial supply are also resected
C) Rectal lesions
a. APR: For low-lying lesions near the anal verge, remove rectum and anus and provide permanent
colostomy
b. LAR: For proximal lesions, perform a primary anastomosis of the coon to recum
c. Wide local excision: Small, low-stage, well-differentiated tumors in the lower 1/3rd of rectum
D) Ileoanal anastomosis spares patient an abdominal ileostomy
E) Adjuvant chemo in cases of colon caner with positive nodes
a. Radiation ineffective and only used in rectal cancers
F) F/U with CEA, colonoscopy, LFTs, CXR, and abdominal CT (for metastasis)
a. CEA level q3mo for 3 years, then q6mo for 2 years
b. Colonoscopy @ 6 mo, 12 mo, and yearly for 5 years