-          colorectal cancer is the most common malignant tumour in the Czech Republic (first in Europe)

-          risk factors are exogenous (nutrition - meat and its inappropriate preparation, lack of vegetables, fruit, fibre, vitamin D and C, smoking, alcohol) and endogenous (predisposition - adenomatosis, Lynch syndrome, ulcerative colitis and Crohn's disease, cholecystectomy, radiation)

histology

-          most often carcinoma adenomatosum (tubular or alveolar), less often carcinoma gelatinosum (seal ring type cells floating in mucus)

classification

1)  TNM

2) Dukes:

·         A – carcinoma limited only to the intestinal mucosa

·         B – carcinoma grows through the entire wall of the intestine, but has not yet metastasized

·         C – metastasis in regional lymph nodes (pericolic, perivascular)

·         D – distant (haematogenous) metastases

macroscopy

1.)    polypous (ca polyposum) – medular carcinoma

2.)    flat ulcerated with mounded edges (ca pataeneforme) 

3.)    infiltrated (diffuse sclerchus or gelatinous carcinoma)

-          localization most often in the rectum and sigmoid colon, with caecum and ascendens in 2nd place, rarely in the transverse and descendens

cancer spreading

1.)    per continuitatem (continuous) – growth through the intestinal wall and into surrounding organs

2.)    metastasizing (discontinuous)

a.)    lymphogenous

b.)    hematogenous – liver, lungs

c.)    implantation – carcinomatosis of the peritoneum

complications of the colonic cancer

1.)    bowel stenosis – obstructive ileus

2.)    bleeding from the exulecrated survace – hypochromic anaemia

3.)    bowel perforation – peritonitis stercoralis

4.)    fistulas development (rectovesical, rectovaginal)

clinical manifestation

1.) „left-sided“ carcinomas

-          the tumour usually takes the form of a diffuse infiltrating sprue, spreading circularly and causing intestinal stenosis, the intestine is narrower and filled with hard stool, symptoms are local - obstruction (sometimes the first manifestation is ileus), typical alternation of constipation and diarrhoea, blood and mucus in the stool

2.) „right-sided“ carcinomas

-          tumours usually polypoid to cauliflower-shaped, bowel is wider and stool is liquid, general symptoms - weight loss, dyspepsia, dull persistent abdominal pain, blood in stool and anaemia (tumour exulceration and bleeding), palpable resistance in the right half of the abdomen

3.) rectal carcinoma

-          more pronounced bleeding with fresh blood in the stool (dif. dg. haemorrhoids), defecation disorders later, pain is a sign of penetration into the sacral nerve plexus and thus inoperability, the basis is per rectum indagation (reveals up to 50% of tumours, in the case of rectal carcinoma cannot be excluded colonic carcinoma - the whole colon must be still examined)

diagnosis

1)  anamnesis + fysical examination (abdomen palpation, per rectum)

2)  imaging techniques:

-          recto- and coloscopy with biopsia

-          X-ray irrigograph y

-          endoUS

-          imaging of metastases (liver US, CT abdomen and pelvis, lungs X-ray, scintigraphy of the bones if the sceletal pain presented)

3)   laboratory examinations – anemiy, CEA (advisable for post-treatment follow-up)

4)   screening programs:

-          exam.per rectum (all patienst from 40 years)

-          haemocult (all patients from 50 years once in two years)

-          if hemokult positive à coloscopy

-          rizic pacients (FAP in fmily anamnesis) genetic tests

treatment

1.) surgical

a.)   curative – resection (colectomiy minimally 10 cm orally and 5 cm aborally from the tumor, resection or extirpation of rectum) with lymphadenectomy, mesocolonotomy and omentectomy, mikroskopically examined the edges of resection, resection of the liver metastases, if nonresecable à RF ablation

b.)   paliative – bypass, stomia to preserve the intestinal passage, in case of rectal tumour crystallization, laser evaporation, stent

3.)    chemotherapy – the gold standard is FUFA (5-fluorouracil + leukovorin), adjuvant or palliative

4.)    radiotherapie – palliative in inoperable tumours, neoadjuvant and adjuvant in operable rectal tumours

-          in case of acute complications (ileus in left-sided tumour), colostomy or ileocolon anastomosis is classically performed above the tumour - in case of inoperable tumour it is a definitive procedure, in case of operable tumour it is performed in the second period (1-2 weeks), radical resection is performed when the intestine is ready for surgery; more recently, subtotal colectomy with ileo-sigmoideal or ileorectal anastomosis is accepted to be performed at the same time if the tumor is operable (this allows peroperative bowel emptying and administration of effective ATB)

-          for rectal carcinoma surgery, the requirement is to remove healthy tissue at least 2 cm below the tumour - depending on the possibility of subsequent anastomosis with the anal canal:

-          anterior resection of rectum with anastomosis

-          extirpation of rectum (sec.Milese – abdomino-perineální) with permanent terminal sigmoideostomy

-          even after curative resection it is necessary to monitor patients (possibility of tumour multiplicity) - CEA, coloscopy, abdominal ultrasound and CT (liver, pelvis), chest X-ray