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THE REGISTRATION OF COLORECTAL CANCER. The anatomy of the colon rectum and anus,the pathology and treatment of colorectal cancer, and the collection of data on colorectal cancer. FIVE FACTS ABOUT COLORECTAL CANCER. Incidence:

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The registration of colorectal cancer l.jpg

THE REGISTRATION OF COLORECTAL CANCER

The anatomy of the colon rectum and anus,the pathology and treatment of colorectal cancer, and the collection of data on colorectal cancer.


Five facts about colorectal cancer l.jpg
FIVE FACTS ABOUT COLORECTAL CANCER

  • Incidence:

    1 in 14 men and 1 in 20 women in the TCR area develop colorectal cancer during their lifetime. Incidence rates increase with age.

  • Survival:

    For people in the TCR area the 5 yr survival estimates are:

    42% for colon tumours, 45% for rectal tumours. For anal tumours the figures are 47% for men and 60% for women.

  • Most common agegroup:

    75-80 yrs

  • Population most at risk:

    Colon and rectum cancers are most common in developed countries. Anal cancer is most common in patients with HIV and sexually transmitted disease, especially in homosexual men.

  • Predisposing factors:

    Western diet, hereditary factors (e.g. familial polyposis coli), inlammatory diseases (e.g. Chrohn’s)


The anatomy function of the colon rectum anus l.jpg

The large intestine is a tube of smooth muscle about 140 cm (4ft 6ins) long

joining the ileum (at the ileocaecal valve) to the external surface of the

body (at the anus).

It is lined with mucous membrane which:

Absorbs water and salts from the liquid contents of the ileum, to form faeces.

Secretes mucous to facilitate the passage of faeces.

Contains neuroendocrine cells to control the function of the intestine

The muscular tube then expels the faeces at the anus.

THE ANATOMY & FUNCTION OF THE COLON, RECTUM & ANUS



The large intestine l.jpg
THE LARGE INTESTINE INTESTINE

The hepatic flexure

The splenic flexure

Transverse colon

Descending colon

Rectosigmoid junction

Sigmoid colon

Rectum

Anus

The

ascending colon

The caecum

The appendix


The anatomy of the large intestine l.jpg

The large intestine is closely INTESTINE

packed into the abdominal and

pelvic cavities, along with the

loops of the small intestine, and

urogenital organs. It lies below the

stomach.

THE ANATOMY OF THE LARGE INTESTINE

Stomach

Large bowel

Small bowel


The registration of malignancies occuring in the large intestine l.jpg

The parts of the colon: INTESTINE

Caecum

Ascending colon

Hepatic flexure

Transverse colon

Splenic flexure

Descending colon

Sigmoid colon

Rectosigmoid junction

Rectum

Anus

Cancer registries treat each individual part of the

large intestine as a separate tumour site.

This means that a patient with tumours in:

- the caecum and

- ascending colon

will be registered for 2 malignancies irrespective of tumour type.

A patient with two separate tumours in the ascending colon will be registered for:

- a single malignancy if the tumours both

have the same morphology, and

- 2 separate malignancies if the morphologies

are different.

THE REGISTRATION OF MALIGNANCIES OCCURING IN THE LARGE INTESTINE

N.B. Many clinicians regard the colon and rectum as a single organ - the large intestine.This may lead to duplicate cancer registrations when a rectal tumour is loosely referred to as “colon cancer”.


Topography and morphology of colorectal cancer l.jpg

Most colorectal malignancies arise in INTESTINE

the membrane lining the bowel wall. As

this is glandular tissue the majority of

tumours are:

ADENOCARCINOMAS

- Mucin secreting >80%

- Mucinous 15%

- Signet ring cell 2%

CARCINOIDS (<1%)

Arising from neuroendocrine cells

MALIGNANT LYMPHOMA (<1%)

Tumours may also arise in the muscle

wall of the intestine. They may be

described as:

Gastrointestinal stromal tumours (GIST), which may be of uncertain malignancy (borderline), or invasive.

Leiomyosarcoma, a malignant tumour of smooth muscle.

TOPOGRAPHY AND MORPHOLOGY OF COLORECTAL CANCER

The subdivisions of the large intestine, showing the percentage of all intestinal tumours that occur at each site


Colorectal tumours of differeing behaviour l.jpg
COLORECTAL TUMOURS OF DIFFEREING BEHAVIOUR INTESTINE

  • Registrable epithelial tumours of the mucosal lining of the bowel may be IN-SITU, INVASIVE, or sometimes of BORDERLINE MALIGNANCY.

  • All carcinoids are regarded as INVASIVE, unless they occur in the appendix, when they are recorded as of BORDERLINE MALIGNANCY.

  • Registrable non-epithelial malignancies, which arise in the muscular wall of the bowel, may be of BORDELINE MALIGNANCY or INVASIVE.

  • Tumours in different behaviour categories that are of the same morphological type, within the same part of the colon, and diagnosed during the same treatment episode are recorded as a single malignancy. If they arise during 2 different treatment episodes they are recorded as 2 separate malignancies.


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COLORECTAL CARCINOMAS INTESTINE

Most colorectal adenocarcinomas are thought to arise in adenomatous polyps, most often villous adenomas. Villous adenomas are registered because of their capacity to turn malignant.

An adenocarcinoma of the colon - L. This is likely to have arisen in a solitary polyp which has since been destroyed by the tumour.

A segment of rectum showing polyposis coli. A carcinoma has developed just above the anal margin.


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PROGNOSTIC FACTORS FOR COLORECTAL CANCER INTESTINE

DUKES STAGE is the most widely accepted and used staging system for

colorectal cancer. It was originally introduced as a pathological grade (i.e. taken

from the surgical specimen).

  • DUKES STAGE ATumour confined to bowel wall

  • DUKES STAGE BTumour penetrated bowel wall

  • DUKES STAGE CRegional lymph nodes involved

  • DUKES STAGE Dhas been added more recently to show that metastases are present.(Not possible to tell this from a colectomy specimen)

    Stage B may be divided according to whether the tumour has just penetrated

    the outer surface of the bowel wall (B1) or the surrounding tissues are involved

    (B2), and stage C according to whether the apical nodes are involved (C2) or

    not (C1).

    The ASTLER-COLLERsystem is based on Dukes but the values:

    A, B1, B2, C1, C2, D1, D2have slightly different definitions.


Slide12 l.jpg

DUKES CLASSIFICATION OF COLORECTAL TUMOURS INTESTINE

Diagram

Regional lymph nodes

Dukes C tumour involving regional nodes

Dukes B tumour invading pericolic/

perirectal tissue

(direct extension)

Dukes A tumour confined to bowel wall

(localised)

Bowel wall


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THE CANCER REGISTRY STAGING SYSTEM INTESTINE

MODIFIED DUKES CLASSIFICATION OF COLORECTAL TUMOURS

  • Cancer registries use a simplified staging system for all tumour sites which indicates how far a tumour has spread at diagnosis:

  • LOCALISED - confined to the organ of origin.

  • DIRECT EXTENSION -spread to tissue next to the organ of origin.

  • REGIONAL LYMPH NODE

  • INVOLVEMENT – lymph nodes nearest to the organ of origin involved.

  • DISTANT METASTASES present – tumour cells have been carried to another part of the body via the blood stream, or to distant lymph nodes.

  • Duke’s B can be divided between B1, where the tumour has not penetrated beyond the bowel wall – localised disease, and B2 where it has – direct extension.

Duk

Dukes B2 tumour penetrating through bowel wall into surrounding tissue

Dukes A tumour confined to bowel wall

Dukes B1 tumour penetrating the full thickness of the bowel wall, but not invading surrounding tissue


Other prognostic factors for colorectal cancer l.jpg
OTHER PROGNOSTIC FACTORS FOR COLORECTAL CANCER INTESTINE

Other, more sophisticated staging and grading systems have been

introduced, e.g.JASS, which deals with a number of different

prognostic factors, but DUKES is the most important being the most

widely accepted and used.

  • Classical STAGE is derived from UICC TNM has the following values:

    stages 0, 1, 2A,2B,3A, 3B, 3C,4

    N.B. Cancer registries record how far the patient’s tumour has

    spread (i.e. the tumour stage) AT DIAGNOSIS.


Treatment for colorectal cancer l.jpg

SURGERY INTESTINE

Removal of all or part of the organ,

together with regional lymph nodes,

i.e. Colectomy, Hemicolectomy, Sigmoid

colectomy, Anterior resection or

Abdominoperineal resection of rectum

In all of these cases an anastomosis

and/or colostomy (temporary or

permanent) will be required.

For localised disease a local excisionof

the tumour may be sufficient. The

excision may be endoscopic for more

distal tumours.

RADIOTHERAPY

The normal colon is too sensitive to

radiation damage to allow radical

radiotherapy to be given. Smaller doses

of radiation may be given preoperatively

to make an inoperable tumour operable,

or postoperatively to increase survival.

CHEMOTHERAPY

5-Fluorouracil (5FU) is the drug most

commonly given, either to improve

survival after surgery, or palliatively.

5FU is often given in combination with

Folinic acid (FA – Calcium leucovorin)

or Levamisole.

TREATMENT FOR COLORECTAL CANCER


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CORONAL SECTION THROUGH RECTUM AND ANUS INTESTINE

anal margin

anal canal


Slide17 l.jpg

The anus may be divided into 2 INTESTINE

parts:

Anal margin

Anal canal

- Anal margin tumours are more

common in men

- Anal canal tumours are more common in women

Tumours of the anal margin are

usually well differentiated and akin

to skin tumours.

Tumours of the anal canal are more

likely to be poorly differentiated.

Types of malignancy arising in the

anus:

Squamous cell carcinoma (90%)

Cloacogenic carcinoma (basaloid tumour)(anal canal only)

Mucoepidermoid carcinomas

Malignant melanoma

Squamous cell and basal cell

carcinomas may occur in the skin

around the anal margin. They are

classified as skin tumours, not

anal ones.

ANAL CANCERMalignanciesarising in the anus have different characteristics from other colorectal tumours


The treatment of anal cancer treatment is hindered by the need to preserve continence l.jpg
THE TREATMENT OF ANAL CANCER INTESTINETreatment is hindered by the need to preserve continence

SURGERY

  • Abdominoperineal resection with permanent colostomy

    is required for tumours of the anal canal.

  • Wide local excision is sufficient for tumours of the anal margin.

    RADIOTHERAPY

    External beam or interstitial radiotherapy is used as the first line

    treatment if possible, as it preserves the function of the sphincter

    muscles.

    CHEMOTHERAPY

    Adjuvant chemotherapy may be given, but the side effects are very fierce.


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