Colon cancer Flashcards by Nayla Mansoor

What is a colon polyp

Growth on the inner surface of the colon

Can undergo malignant transformation, but not always

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What are endoscopic features of colon polyps

Pedunculated (attached by stem/stalk)

Sessile (flat)

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How can you histologically classify polyps

Hyperplastic (non-neoplastic)
Pseudopolyps (non-neoplastic)- ass. w/ IBD
Adenomas (neoplastic, pre-cancer)
Sessile serrated (pre-cancer)

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What are the types of adenomatous polyps

Tubular adenoma (MC)- may bleed if large, but not common for any polyp to bleed
Tubulovillous adenoma
Villous adenoma

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Key to surviving an adenoma in the colon is

Early detection and removal

It takes appx 10 years for a polyp to morph into adenocarcinoma

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What is an “advanced” carcinoma

> 10mm in size
Villous component (villous, tubulovillous)
High grade dysplasia
(risk of colorectal cancer is higher 2/2 size, #, and histology)

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Highlight:::

Go over the "take away" slides in this ppt to review
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What is colorectal cancer

malignant growth on the inner wall of the colon/rectum

>95% are adenocarcinomas

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Where is CRC MC found

Left colon (sigmoid) 
however right sided colon cancer rates are rising

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What are some RF for CRC

FHx of adenomas, colon cancer, FAP, HNPCC
>50
Hx of IBD x 8-10 years
African American
Smoking, excess alcohol, high fat low fiber diet, a lot of red meat, T2DM, obesity

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How does CRC present

ASx!! So watch for red flags: 
Change in bowel habits
Hematochezia/Occult blood in stool 
Iron deficiency anemia 
Anorexia, weight loss 
Abdominal pain

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On PE for CRC what may you find

Cachectic 
skin pallor 
LAD 
Abdominal distention, ascites, mass, organomegaly 
DRE: hemoccult +, rectal mass

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What diagnostics should you complete for CRC

CBC: iron deficiency anemia
LFT: Elevated Alk Phos
Carcinoembryonic antigen (CEA) a prognostic indicator and monitoring marker
Colonoscopy
Chest, Abd/pelvic CT: tumor extension, complication, regional lymphatic and distant mets

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Classic CRC finding on imaging is

Apple core lesion

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How do you stage colon cancer

Based on TNM system; Tumor, Nodes, Mets

Stage 0-4

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How do you manage colon cancer

Partial colectomy w/ wide margins and adjacent lymph node removal
Chemotherapy (if mets present)
Radiation (for rectal carcinoma)

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What does CRC surveillance include

Serial CEA q3-6 months for 3-5 years
CT chest, A&P yearly
Colonoscopy w/in 1 yr of resection. If normal, repeat in 3 years. If normal, q5 years

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How are screening and surveillance different

Screen: detecting early stage CRC and precancerous lesions in ASx people with NO prior Hx
Surveillance: follow up testing in pt w/ Hx of polyps, CA, or IBD

What tests can be used for screening

Preventive: colonoscopy, flex sig, CT colonography 
Stool test (detect but do not prevent): gFOBT, FIT, FIT-DNA

What is gold standard diagnostic AND therapeutic test

Colonoscopy
Can visualize the entire colon, remove polyps, take biopsies
Detect precancerous lesions and CRC

What does a colonoscopy require

Bowel prep (if not done correctly, can block masses)
Sedation
Chaperone
Time off from work
-Invasive and has risk of complications. Also depends on operator efficacy

What is a polypectomy

Ligation and resection of a pedunculated polyp

Do you need surveillance after a polypectomy

Yes, frequency depends on # of polyps, size, and histologic features

What is a Flex Sigmoidoscopy

limited colonoscopy that reaches distal 1/3 of colon (less protection against right sided cancer)
If you do find polyps, need to do a colonoscopy to assess proximal colon
Only need an enema prep
No sedation required
Lower cost
Lower risk of perforation

What is a CT colonography

Virtual colonoscopy created with CT scans Can easily miss flat or smaller polyps Can't remove a polyp if you find one- will need colonoscopy Still need bowel prep, but no sedation Get a lot of radiation exposure Air insufflation w/ rectal tube is not comfortable

What is a gFOBT test

Fecal occult blood test, ID hgb by a peroxidase reaction (+ if paper turns blue) Hemoccult SENSA is a take home guaiac test, more sensitive Need 2 specimens on 3 consecutive stools False + leads to colonoscopies Do special diet prior to testing; no red meat, iron, vitamin C, or NSAIDs

What is a FIT test

non-invasive test for presence of hgb less false + than FOBT Single specimen of spontaneously passed stool No diet restrictions

What stool test is preferred for CRC detection

FIT test!

What is FIT-DNA test

``` Combines FIT with testing for altered DNA markers in cells shed by CRC non-invasive Higher rate of false + No diet restrictions Requires entire bowel involvement ```

When should you start CRC screening for ASx with no RF

at age 50 (45 for black) Colonoscopy and FIT tests should be considered first (american cancer society says start in 45 for everyone)

When should you start CRC screening in high risk pt

Colonoscopy q5 years starting at 40 y/o, or 10 years prior to age of family member diagnosed -If it is one 1st degree relative dx 60+ or 2 second degree, screen at 40 and if normal, they are average risk

When should you stop colon cancer screening per MSTF

``` Up to date with screening Negative prior screening 75+ Life expectancy <10 years No prior screening at 85 y/o ```

When do you stop colon cancer screening per USPSTF

Start screening at 50, stop at 75 | Individualize need to screen 76-85 y/o (healthy never been screened more likely to benefit)

How often can you use screening tests

``` colonoscopy: 10 years CT colonography: 5 years Flex Sig: every 5-10 years gFOBT: yearly FIT: yearly FIT-DNA: q1-3 years ```

What do you have to convey well to patients when reviewing screening

That abnormal results require a colonoscopy for further visualization

What is familial adenomatous polyposis

Auto Dom disease 2/2 ACP gene mutation Causes polyps to emerge around 16 y/o, with almost 100% developing CRC by 39 y/o if not treated Increased risk of extra-colonic malignancies

How do you treat FAP

Prophylactic colectomy

What extracolonic malignancies are associated with FAP

Gastric, duodenal, ampullary carcinoma follicular or papillary thyroid cancer hepatoblastoma in kids CNS tumor

If a family member has FAP, when should you screen the kid

Sigmoidoscopy or colonoscopy annually starting at 10-12 years old Routine EGD recommended Thyroid US and other to r/o extracolonic malignancies

What is HNPCC

Auto dom syndrome (lynch syndrome) 2/2 germline mutation in 1 of several DNA mismatch repair genes Increased risk of CRC by 45-60 y/o Multiple family members are affected! Increased risk of multiple cancers

What cancer is associated with HNPCC

Endometrial (MC) | ovary, gastric, small bowel renal, ureter, brain

How do yuo diagnose HNPCC

Amsterdam criteria for lynch syndrome has "3-1-2" rule 3: need 3 consecutive relatives 2: need 2 successive generations affected 1: one fam member diagnoses before 50

What is the HNPCC screening crazy

Colonoscopy q1-2 years starting at 20-25, or 2-5 years prior to earliest stage of diagnosis of family

HNPCC screening also manages what extra-curricular activities

Pelvic exam w/ endometrial bx and transvaginal US | EGD (starting at 30-35, q2-3 years)