Introduction Second leading cause of cancer deaths Risk factors include family history IBD colorectal polyps low fiber, high fat diet (now controversial) diet low in vitamin A, E, C, and selenium Familial Adenomatous Polyposis Syndrome (FAP) 100% will develop colon cancer without resection Hereditary Nonpolyposis Colorectal Cancer (HNPCC) where a person has a single polyp that can turn to cancer Lynch Syndrome I (HNPCC I) autosomal dominant predisposition to colorectal CA right sided predominance (70% proximal to splenic flexure) Lynch Syndrome II (HNPCC II) same features of Lynch I plus extra-colonic cancers especially endometrial carcinoma carcinoma of ovary, small bowel, stomach, pancreas transitional cell CA of the ureter and renal pelvis Presentation Iron deficiency anemia in an elderly male is colon cancer until proven otherwise! Right sided lesions microcytic anemia and unrecognize blood loss postprandial discomfort fatigue Left sided lesions Change in bowel habits pencil thin stools abdominal obstruction abdominal mass gross red blood (hematochezia) tenesmus rectal mass Systemic symptoms (malaise, fatigue, weight loss) Evaluation Barium enema X-ray Colonoscopy with biopsy Lynch syndrome: every 1-2 years beginning at age 25 If a patient presents with evidence of metatasis to the liver, abominal CT is the most appropriate first step. Dukes system with 5 year survivals Classification Description 5y survival Duke A Tumor limited to mucosa or submucosa (mus. propia) 80% Duke B1 Tumor invades but not through muscle wall 60% Duke B2 Tumor penetrates entire wall but no node involvement. 55% Duke C1 Tumor into but not through wall but positive lymph nodes 30% Duke D Distant metastasis regardless of invasion <5% Differential Diverticular disease, IBD, benign polyps,infectious colitis, upper GI bleed Treatment Surgical resection following the pattern of lymphatic and vascular drainage is the primary therapy Node negative (Duke A and B) disease is resected and followed Node positive disease is resected and followed by chemotherapy or radiation Metastatic colon cancers are resected, including small to moderate liver mets Can track CEA (70% of colorectal cancers secrete) post treatment Consider prophylactic colectomy for patients with FAP Prognosis, Prevention, and Complications Regardless of stage, the overall five year survival is 35% Screening: If no strong risk factors, > 40 yo then annual digital exam and stool guiac (if positive colonoscopy) flex sigmoidoscopy or colonoscopy q 3-5 years > 50 yo if family h/o then colonoscopy at age 40 or 10 years prior to age of diagnosis, which ever is earlier Post resection follow up CEA q 3 mos. X 3 yrs Colonoscopy at 6 mos, 12 mos, yearly x 5 yrs no further treatment needed post-resection of pedunculated adenomatous polyp without evidence of invasion on histology