Colonic cancer

Colonic cancer is a malignant neoplasm localized in the blind, transverse and sigmoid colon. The rectum also belongs to the colonic intestine, but its cancer has specific features of the course and therapy, therefore it is considered a separate condition.

Surgical intervention options for colonic cancer

For most malignant tumors, the main method is surgical therapy. In the absence of metastases in other organs, the most effective way to treat this cancer localization is to remove the affected area.
There are two types of interventions, radical and palliative. Radical operations are performed single-stage or in two or three stages over several months; not only the tumor-affected intestine is removed, but also the surrounding tissues and organs. Palliative interventions unload the intestine from its content, and the outlet is located on the anterior abdominal wall. Contraindication to surgery is ascites with peritoneal carcinomatosis.

The symptoms of colonic cancer are caused by the tumor overlapping a part of the intestinal tube lumen, therefore, detection of the condition at an early stage is possible only with regular preventive examinations. When cancer has manifested itself in full force through various symptoms, this is by no means the beginning of the process.

What determines the clinical characteristics of the disease?

Manifestations depend on the department where the lesion is localized, and on the node size. In half of all cases, the cancer node is localized in the sigmoid, equally often in the blind and segmented part of the intestine. In the segmented intestine, adenocarcinoma occurs more often in the left half. In 2 out of 100 patients, a cancer tumor emerges simultaneously in different parts of the large intestine.There are several classifications, but the generally accepted one is based not on the specific size of the tumor, but on the depth of its penetration into the organ wall and the number of lymph nodes affected by cancer, into which lymph flows from the large intestine.

In only the organ walls are affected without metastases in the lymph nodes, the condition corresponds to stages 1 and 2. At stage 3, the determining factor is the presence of lymph node metastases, with any tumor size. Cancer stage 4 is diagnosed with metastases in other organs, most often in the liver, lungs and bones.

What determines the rate of increase of symptoms?

Adenocarcinoma has a different degree of aggressiveness or malignancy, which is determined by the differentiation or degree of maturity of its cells. The more a cancer cell differs from a normal one, the more aggressive it is and the less functions it can perform.

Well differentiated adenocarcinoma is the least aggressive, poorly differentiated is highly malignant, while moderately differentiated lies betwixt and between. The poorer the differentiation, the more aggressive is the tumor, the faster it gives metastases, but its sensitivity to medication and radiation treatment is also higher. With a high degree of malignancy, symptoms appear earlier and their intensity is higher, as the tumor grows rapidly, involving other tissues and surrounding organs.

Initial symptoms of colonic cancer

In the early stages of development, a tumor might not manifest itself in any way. Sometimes there is rapid fatigability, decreased performance, loss of appetite, but these symptoms accompany hundreds of diseases and pathological conditions, and most rarely they are referred to signs of a malignant colonic formation.

Later, the symptoms of abdominal discomfort, flatus, non-permanent pains not related to nutrition become frequent. Abdominal distension may appear, sometimes only on one side. Most often, these symptoms are regarded as exacerbation of chronic gastrointestinal conditions.

Symptoms of advanced colonic cancer

Lesion of the right half is manifested by pain and can simulate acute appendicitis. In cancer of the left half of the intestine, diarrhea can alternate with constipation, blood and mucus in the feces. Cancer of the lower parts of the large intestine is characterized by mucous, bloody and even purulent anus discharge. Adenocarcinoma of the segmented part causes discomfort with belching, incomprehensible pains and rumbling in the abdomen, vomiting and heaviness in the navel.

At this stage, the tumor can sometimes be felt through the anterior abdominal wall. Pain syndrome is different in strength and character, a very strong pain occurs when the cancerous formation overlaps the lumen and the intestinal contents stagnate, which is referred to as intestinal obstruction. This most severe condition can be the first sign of intestinal cancer.

When the cancer tumor decays with hidden bleeding, anemia develops, and for any anemia, colonoscopy is performed.

Adenocarcinoma metastasizes to the lymphatic vessels, affects the liver and lungs through the venous network, and generates implantation (contact) metastases to the peritoneum, often with ascites.

At any stage, there is an opportunity to help and reduce the condition manifestations, to relieve the distressing symptoms, one just needs to want and be able to help, which implies availability of good equipment and expert staff. All of this you will find at the Clinic Medicine 24/7. Sign up for a consultation: +7 (495) 151-14-47

The cause of colonic cancer is not exactly known, if we mean the specific and only factor unconditionally leading to the malignant transformation. Most likely, the process of cancerous cell development from a normal cell starts from several points and proceeds in several ways.

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The most likely cause of colonic cancer

It is a disease of mature and elderly persons. It is known that in most cases it develops from polyps against the background of constipation and chronic inflammation of the mucous membrane. Polypous formations on the mucous membrane are considered a pretumor state, most malignant tumors of the large intestine can in principle be prevented, if polyps are detected and treated in time. Removal of polyps is recognized as the most effective cancer prevention, it is believed that this can preclude 8 out of 10 cancer nodes from developing.

A polyp is not an outgrowth of a normal mucosa, but a benign tumor consisting of a dense connective tissue base covered with a mucous membrane with altered, defective glands. Only hyperplastic polyps represent a chronically inflamed mucous membrane, therefore they do not belong to tumor structures.

Adenomatous polyps, in which genes mutate actively, giving up control of cell activity and starting the processes of too frequent and rapid cell fission, which leads to a neoplasm, can potentially result in cancer. The larger and the older is the polyp, the greater is the likelihood of its malignancy. Approximately every sixth formation may develop a malignant colonic tumor.

Adenomas are also benign tumors, but the of nastiest villous kind, and every fourth of them threatens with a malignant transformation. Tubular and tubulo-villous adenomas are more favorable, but it is impossible to guarantee that they will not cause cancer over time, therefore large adenomas should be removed.

The cause for appearance of intestinal polyps is unknown; the destructive role of genes is not excluded.

Genetic causes of colonic cancer

Genetic predisposition is included into risk factors, it is actualized only over time and in conjunction with other factors, for example, with chronic intestine conditions accompanied by constipation.

Genetic syndromes with a high probability of polyp malignization at a young age occur very infrequently, hardly in every 20th patient. These hereditary syndromes are passed on from generation to generation, and such patients are identified in childhood and treated. The bulk of colonic neoplasms arises spontaneously and is not inherited, although a certain degree of predisposition to genetic failure on this account cannot be excluded.

There is a genetic racial predisposition, thus, the condition is much more common in Mongoloids.

Nutrition as the cause of colonic cancer

A relationship of the condition with the diet has been noted. An unbalanced nutrition with the predominant consumption of meat without vegetables and plant fiber leads to a slow evacuation of fecal material, respectively, the exposure time of various carcinogens from the mucous membrane increases, and mucous inflammation is present during stagnation of feces.

Africans have a vegetable diet, so the volume of feces, though twice as large compared to Europeans, evacuates in just 8 hours, while the traditional food of northern peoples migrates through the large intestine for at least half a day. Therefore, colorectal neoplasms are quite rare among the peoples of Africa.

Additional causes factoring into malignant transformation

Obesity is also a risk factor for this condition. Often tumors develop in people who are constantly in contact with toxic substances.

Adenocarcinoma occurs against background of hormonal imbalance, and can combine with cancers of the breast and ovaries. The tumor is dependent on the level of estrogen, but unlike breast neoplasms, it is completely insensitive to hormone drugs.

When the malignant formation is already diagnosed, it is too late to look for its cause, you should look for a clinic where treatment is carried out according to Russian standards, taking into account international clinical experience and scientific recommendations, but strictly individually, perhaps even with genetic mapping to determine the sensitivity of cancer to drugs, as is the case at the Clinic Medicine 24/7. Sign up for a consultation: +7 (495) 151-14-47

Diagnostics of colonic cancer does not greatly depend on the department where the tumor is located, the entire colon is checked, because in every 2000th case cancer is multicentric, that is, several neoplasms appear in different parts of the intestinal tube.

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Colonic cancer diagnostics

The unity of origin and diagnostics made it possible to combine rectal and colonic cancer differing in treatment approach and prognosis in the single term «colorectal cancer» (CRC).

For the initial detection of a rectal tumor, a digital examination is sufficient, after which instrumental proctoscopy is performed. All the higher sections of the intestine one and a half meter long are accessible only to the endoscopic equipment in the course of a colonoscopy.

Sometimes, an ultrasound examination of the abdominal cavity and small pelvis can reveal a tumor formation originating from the large intestine, but the intestine itself cannot be seen with ultrasound imaging. On the other hand, colonoscopy combined with ultrasound enables visualization of the entire thickness of the intestinal wall and parietal arrangements in the abdominal cavity outside the intestine.

In some cases, tumor of the sigmoid colon is detected during proctoscopy, however, in all cases of CRC, a total colonoscopy is indicated with a biopsy, where a piece of pathological tissue is obtained for examination under a microscope. Currently, the resolution of endoscopic research is increased by the possibility of local magnification, spectral analysis and special staining techniques.

What specifying diagnostics will be required?

A positive result of the histological study of a piece of the tumor taken at endoscopic examination of the intestine is sufficient to establish a diagnosis of cancer.

Further clarification of the malignant process advancement will be needed, for which irrigoscopy is used, that is, fluoroscopy with intestinal filling with a contrast agent. X-ray images show the degree of narrowing of the intestinal tube lumen, the tumor spreading in the intestinal wall, and the relationship with the tissues of the abdominal cavity adjacent to the intestine.

Irrigoscopy is required when it is impossible to perform a total endoscopic examination of the intestine.

Laboratory diagnostics of colonic cancer

Laboratory methods of diagnostics include the examination of feces for concealed blood to detect bleeding, and determining the level of tumor markers CEA and CA 19.9. These markers do not increase in 100% of cases, but in the future, changes of their level allow monitoring the course of the process and evaluate the effectiveness of treatment.

In a piece of tumor tissue, mutations of the KRAS and NRAS genes are determined, which makes it possible to plan targeted drug therapy.

In all cases, blood tests are made repeatedly.

Identification of metastases

With an established colonic cancer, abdominal and retroperitoneal ultrasound examination is a method of searching for metastases, although it is inferior to CT in sensitivity and accuracy, supplemented by intravenous administration of a contrast agent for better results.

The liver is the favorite organ for the development of metastases, so a CT scan of the liver is more than relevant for CRC. Liver MRI is necessary to develop the tactics for treating metastatic liver damage.
Chest radiography can be replaced by chest CT scan showing even smaller changes, which is not at all superfluous given that colonic cancer often gives pulmonary metastases.

Laparoscopy may be required if the spread of tumor seedings in the peritoneum is suspected.

Diagnostics should be sufficient but not excessive, as each examination is associated with anxiety, of which a cancer patient has too much as it is. The experts of the Clinic Medicine 24/7 are careful with patients and are united with them with one goal, to make the life of each of them as long and as comfortable as possible. Sign up for a consultation: +7 (495) 151-14-47

Colonic cancer is a malignant neoplasm localized in the blind, transverse and sigmoid colon. The rectum also belongs to the colonic intestine, but its cancer has specific features of the course and therapy, therefore it is considered a separate condition.

Like a century ago, colonic cancer can only be cured by surgery, though modern oncology has introduced fine endosopic excisions of the tissues affected by cancer to the group of radical interventions.
Surgery is now applied for the condition much more often, while the adherence to chemotherapy somewhat diminished with the increase in the role of targeted drugs. The condition has remained aloof from the success of radiation therapy, as not a single method of irradiation has been found that would allow at least minimal control over the process.

Symptoms of colonic cancer

The large intestine is composed of the transverse colon and sigmoid colon, the rectum also being a part of the large intestine. Rectal cancer has specific features of its course and some differences in the therapeutic strategy, therefore it is singled out as a separate disease. The clinical course of a malignant neoplasm of the segmented intestine, even with signs of high aggressiveness, is much better than morphologically equivalent lesion of the rectum.

It has been noticed that malignant processes of the upper parts of the large intestine proceed with less aggressiveness than of the lower ones, especially the rectum. Often the tumor process is detected after it has significantly advanced, when a person lands on the operating table for complete intestinal obstruction.

The late detection of cancer is due to the high extensibility of the intestinal tube and the lack of condition-specific clinical signs. The lack of clinical signs of a tumor lesion, which allows the condition to proceed covertly, is not so bad for the patient. The fact is that a process initially characterized by clinical symptoms has a worse prognosis than an asymptomatic neoplasm of the same size in a patient with similar anthropometric and age characteristics. Symptoms are usually associated with a decrease in the intestinal tube lumen and a blood loss due to vessels destruction by the tumor.

Tumor markers allow tracking the course of cancer and the effectiveness of treatment, but are useless to detect it, for example, during clinical examination, because they increase with any intestinal condition and other benign gastrointestinal processes. The only method for diagnosing cancer is colonoscopy.

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Surgical intervention options for colonic cancer

For most malignant tumors, the main method is surgical therapy. In the absence of metastases in other organs, the most effective way to treat this cancer localization is to remove the affected area.

In recent years, minimally traumatic resections of the cancer-affected mucous membrane performed during colonoscopy have been introduced into clinical practice.

Good long-term results are shown by standard resections of the affected intestine part with removal of the lymphatic apparatus, allowing restoration of the organ throughout with maintaining the adequacy of its function.

Hemicolectomy that cripples the patient is still used today for extensive intestine lesions and unfavorable prognostic cellular characteristics. After removal of a significant part of the intestinal tube affected by cancer, the terminal part of the intestine is exteriorized to the abdominal wall. Unfortunately, organ restoration is impossible in this case, but today there are many ways to improve the quality of life, often for very a long time.

If it is impossible to remove the cancer conglomerate, unloading operations are carried out to reduce the likelihood of sudden development of deadly intestinal obstruction and bleeding from the vessels of a decaying tumor, such as application of a bypass anastomosis or colostomy.

Surgical approaches to the treatment of colonic cancer at stages 1, 2, 3 and 4

  • With minimal stage 1 cancer without metastases to the lymph nodes, preference is given to endoscopic resection of the affected mucous membrane area. This sparing surgery option is not indicated with high aggressiveness of cancer cells, their deep penetration into the intestinal wall, or spreading through the vessels and neurolemmas. In case of inexpediency of an intervention limited by the mucous membrane, resection is performed, that is, removal of the circular part of the intestine containing the tumor. No additional medication is required, since the results are already very good without chemotherapy.
  • The scope of surgery depends on the size of the cancer node and its location. In case of a local lesion, resection is also possible, but the survival results with removal of a larger amount are better; therefore, preference is given to removal of the entire department with its associated lymphatic system.
  • At cancer stage 2 and 3, treatment begins with surgery, the scope of which can be significant, and the postoperative effect is complemented by preventive adjuvant chemotherapy (CT) for six months.
  • Surgery is not performed for a technically inoperable process at stage 3, but even in this situation there is a chance for radicalism, when at the first stage a unloading operation is performed that ‘swiches off’ the affected part. After several cycles of drug treatment, it is possible to reduce the cancer conglomerate, allowing thereby tumor removal.
  • The presence of distant metastases (stage 4) with the technical possibility to remove the primary tumor will not be an absolute contraindication to surgical intervention. After each treatment stage, 4 or 6 chemotherapy cycles, it is necessary to consider the issue of removing the primary tumor and all metastases, preferably at the same time.

Innovative methods for the destruction of metastases using high-frequency current, liquid nitrogen or a laser have become a good help. In our clinic, radiofrequency ablation of neoplasms (RFA) is used for several years already, which is available only in a limited number of Russian medical centers. In certain clinical cases, RFA not only complements surgery, but can also become the primary treatment method.

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Therapeutic approaches to advanced colonic cancer

With a small cancer that has no metastases but grows into pelvic bones or major abdominal vessels, which cannot be removed, a palliative unloading operation performed with formation of a colostomy when the intestinal tube is exteriorized to the abdominal wall, and subsequent long-term chemotherapy is carried out.

What is the therapy for a cancer with metastases?

With metastases to other organs and a small amount of the primary formation that can technically be removed, everything is determined by the possibility to remove these metastases. If there are few of them and it is technically possible to remove all metastases with a part of the lung or liver, then simultaneous surgical intervention is performed on the intestine and metastatic nodes. Good results are achieved with radiofrequency ablation of liver metastases. Next, the patient undergoes preventive adjuvant chemotherapy.

With a small cancer not threatening with such complications as obstruction and bleeding, a different approach is possible, when the surgical stage is performed after several chemotherapy cycles, and the affected part of the large intestine and metastatic nodes are removed then at once or at intervals. The postoperative drug therapy is brought to a total duration of six months.

Colonic cancer chemotherapy

When in presence of multiple metastases the danger of complete intestinal tube lumen overlapping remains, the problem of palliative treatment with the formation of a colostomy above the tumor conglomerate is addressed to prevent fatal intestinal obstruction. The patient is prescribed cycle chemotherapy.

When is chemotherapy for colonic cancer necessary?

Drug therapy is not carried out only for early stage 1 or 2 colonic cancer. Preventive treatment after radical surgery lasts six months, and there are several treatment regimens. If chemotherapy was carried out before radical surgery, then postoperative drug treatment is brought to a total of 6 months.

  • Adjuvant or preventive chemotherapy begins no later than 28 days after radical surgery, the standard duration of treatment being 6 months. A better combination in terms of the result-complication ratio has not yet been found, therefore, the FOLFOX and XELOX schemes are used, and targeted drugs are not used.
  • Preoperative or neoadjuvant chemotherapy using the above combinations may in fact become perioperative, that is, before and after radical surgical intervention, or become independent curative therapy, if after 2–4 cycles intestine removal does not take place. Perioperative chemotherapy consists of 2–6 cycles up to the surgical stage and the continuation of adjuvant therapy for a total of 6 months. The combination may include not only cytostatics, but also targeted drugs.
  • Independent curative chemotherapy is carried out at stage IV of the cancer, its optimal duration or the best scheme are not defined, therefore the choice is very individual.
    In some situations, the introduction of drugs into the blood vessels of the liver (chemoembolization or high-dose therapy) can help, accompanied by a mandatory symptomatic therapy and nutritional support reducing the toxicity of treatment.

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Targeted drugs in the treatment of colonic cancer

These innovative anticancer agents have found an application in palliative treatment of inoperable or metastatic colonic cancer.

At the first stage, monoclonal antibodies (MCA) are preferred, but only together with chemotherapy, since MCA practically do not produce a result if administered on their own, and together with chemotherapy it increases the patient’s life expectancy. The morphological variations of cancer promising the best result from the use of immunopreparations are still unknown, but it has been noted that with the progression of the process, a change of chemotherapy combination while MCA injections continue can give a positive result.

On the second line of colonic cancer chemotherapy, good results are obtained by using another immunodrug that alters the tumor vessels and thus disrupts its nutrition. Such drug is used in parallel with chemotherapy.

If there are no mutations in the CRAS and BRAF genes of cancer cells, it is useful to supplement chemotherapy drugs with antibodies to EGFR tumor factor that also affect the vascular system of the tumor. In this case, the targeted agents give a good result even without chemotherapy. Targeted drugs are not used for preventivec therapy, and also have unpleasant side effects.

NCCN This text is based on the materials of (National Cancer Comprehensive Network).

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