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Colon Cancer
Jason Ryan, MD, MPH
Colon Polyps Pedunculated Polyp
• Raised outgrowth of tissue into lumen
• Most are benign
• Some are pre-cancerous
• Removal can prevent colon cancer
• Usually removed for pathology AfraTafreeh.com Sessile Polyp
• Pedunculated: attached via stalk
• Sessile: broad base attached to colon
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Polyp Symptoms
• Almost always asymptomatic
• Screening done for detection
• Large polyps may cause bleeding
• Usually not visible in stool (“occult”)
• Basis for screening with fecal occult blood testing
Stephen Holland, MD/Wikipedia
Hyperplastic Polyp
• Benign
• Most common type of non-neoplastic polyp
• Common in rectosigmoid colon
• Normal cellular structure, no dysplasia William Crochot
• Classically have a “saw-tooth” or serrated pattern
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• Usually no special screening required after biopsy
• Exception if large number of big polyps
Jeremy T. Hetzel/Flikr
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Tubular Polyp
Adenomatous Polyps
• Most common neoplastic polyp
• Dysplastic with malignant potential
• Tubular
• Most common subtype (80%+)
• Adenomatous epithelium forming tubules
• Villous Villous Polyp
• Less common type
• Often sessile
• Long projections extending from surface
• Higher risk of development into colon cancer
• Tubulovillous
Nephron/Wikipedia
Adenomatous Polyps
High Risk Features
• Villous histology (villous = villain) Villous Polyp
• Dysplasia grade
• Determined by pathologist
• High-grade dysplasia = ↑ risk
• Size AfraTafreeh.com
• More than 10 mm in diameter = ↑ risk
• Number
• More polyps = ↑ risk
• Increased surveillance based on features
Nephron/Wikipedia
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Hamartomatous Polyps
• Hamartomas (benign tumors)
• Normal but disorganized tissue masses
• Usually in rectum
• Usually pedunculated
• Cause painless rectal bleeding
• Often “auto-amputate”
• Juvenile polyp = sporadic hamartomatous polyp
• Common in children
• No associated colorectal cancer risk
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Juvenile Polyposis Syndrome
• Multiple (usually > 10) hamartomatous polyps
• Presents by age 20 with bleeding or anemia
• Increased risk of colon cancer
• Early-onset surveillance colonoscopy
• Usually every one to three years AfraTafreeh.com
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Peutz-Jeghers Syndrome
• Autosomal dominant disorder
• Multiple hamartomas throughout GI tract
• “Peutz-Jeghers polyps”
• Pigmented spots on lips and buccal mucosa
• Often presents in childhood with spots around lips
• Risk of gastric, small intestinal, and colon CA
• Also pancreatic and breast cancer
• Early screening for malignancy
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Genetics of Colon Cancer
• Adenoma-Carcinoma sequence
• Sequence of genetic events seen in colon cancer
• Leads to colon cancer over many years
• More common in left-sided tumors
• Descending colon, sigmoid, rectum
• Involves APC, KRAS, and p53 genes AfraTafreeh.com
• Microsatellite Instability
• DNA mismatch repair defect
• More common in right-sided (proximal) tumors
William Crochot
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FAP
Familial Adenomatous Polyposis
• Autosomal dominant disorder
• Germline mutation of APC gene
• Always (100%) progresses to colon cancer
• Treatment: colectomy or proctocolectomy
• Colonoscopy every year, beginning age 10-12
• FAP variants
• Gardner’s Syndrome
• Turcot Syndrome
• All have APC gene mutation
• Polyposis plus extra-intestinal signs/symptoms
Samir/Wikipedia
HNPCC
Hereditary Non-Polyposis Colorectal Cancer/Lynch Syndrome
• Inherited mutation of DNA mismatch repair genes
• Leads to colon cancer via microsatellite instability
• About 80% lifetime risk
• Arise with out pre-existing adenoma
• Usually right-sided tumors AfraTafreeh.com
• Also increased risk endometrial cancer
• Colonoscopy every 1-2 years
• Beginning age 20 to 25
• Or at age of first cancer in other family members
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Colon Cancer
• 3rd most common cancer
• 3rd most deadly cancer
• More common after 50 years of age
• May occur anywhere in colon
• Often asymptomatic and detected by screening
• Diagnosis: colonoscopy with biopsy
• Treated with surgery +/- chemotherapy
Colon Cancer
Right-sided Left-sided
(Proximal/Ascending) (Distal/Descending)
Hematochezia
Iron-deficiency anemia
Blood-streaked stool
Weight loss
Change in stool “caliber”
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William Crochot
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Colon Cancer
Treatment
• Localized disease: partial colectomy
• With regional lymphadenectomy
• Removal of mesenteric lymph nodes
• Adjuvant chemotherapy for node-positive disease
• Metastatic disease: palliative chemotherapy
• Some patients with limited mets receive surgery
• After remission: annual CT, colonoscopy, and CEA level
CEA
Carcinoembryonic Antigen
• Tumor marker
• Elevated in colon CA and other tumors (pancreas)
• Poor sensitivity/specificity for screening
• Patients with established disease
• CEA level correlates with disease burden
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• Elevated levels should return to baseline after surgery
• Can be monitored to detect relapse
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Metastasis
• Most common site is liver
James Heilman, MD
Colon Cancer Screening
• Imaging of colon (e.g., colonoscopy)
• Fecal occult blood testing (FOBT)
• Identifies blood in stool
• Requires stool sample
• Performed annually
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• Colonoscopy if blood detected
• Fecal immunochemical test (FIT)
• Measures hemoglobin +/- DNA in the stool
• Stool sample
• Performed annually
• Colonoscopy if abnormal
James Heilman, MD
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Colon Cancer Screening
• Colonoscopy
• Standard screening test
• Requires bowel prep and sedation
• Every 10 years starting age 45 per ACS and USPSTF 2021
• Can stop at age 75 based on patient preference
• Patients with a family history of colon cancer
• First-degree relative: parent, full sibling, or child
• Start screening at age 40
• Or 10 years before age of cancer diagnosis
• Screening every 3-5 years thereafter
https://uspreventiveservicestaskforce.org/uspstf/draft-recommendation/colorectal-cancer-screening3
Inflammatory Bowel Disease
Colon cancer screening
• Ulcerative colitis or Crohn’s with colon involvement
• Pancolitis: initial colonoscopy eight years after onset of disease
• Left-sided disease only: twelve to fifteen years after onset
• Colonoscopy repeated every two to three years
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William Crochot
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Colon Cancer Screening
• Flexible sigmoidoscopy
• Bowel prep and sedation required
• Visualizes descending colon only CT Colonography
• CT Colonography
• Bowel prep required
• No sedation required
• Cannot remove polyps
• Abnormal findings → colonoscopy
Kai Sun, Ruijuan Han, Yang Han, Xuesen Shi, Jiang Hu & Bin lu
Bacteremia and Sepsis
Strep Bovis
• Strep Bovis
• Normal colonic bacteria
• Gram-positive cocci
• Four major species
• S. gallolyticus, S. lutetiensis, S. infantarius, S. pasteurianus
• Rare cause bacteremia/endocarditisAfraTafreeh.com
• Clostridium septicum
• Gram-positive cocci
• Causes gangrene/myonecrosis
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