JOURNAL OF EVIDENCE BASED MEDICINE AND HEALTHCARE

Table of Contents

2014 Month : November Volume : 1 Issue : 11 Page : 1387-1396

COLORECTAL CARCINOMA IN WESTERN RAJASTHAN: A COMPREHENSIVE STUDY AND MANAGEMENT OF 245 CASES

Ram Ratan Yadav1, Pankaj Saxena2, P. K. Bhatnagar3, Rita Saxena4, Shivcharan Navariya5, Pankaj Porwal6

1. Assistant Professor, Department of Surgery, Dr. S.N. Medical College, Jodhpur, Rajasthan.
2. Professor, Department of Surgery, Dr. S.N. Medical College, Jodhpur, Rajasthan.
3. Assistant Professor, Department of OBG, Dr. S.N. Medical College, Jodhpur, Rajasthan.
4. Assistant Professor, Department of Gynaecology, Dr. S.N. Medical College, Jodhpur, Rajasthan.
5. Assistant Professor, Department of Surgery, Dr. S.N. Medical College, Jodhpur, Rajasthan.
6. Assistant Professor, Department of Surgery, Dr. S.N. Medical College, Jodhpur, Rajasthan.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. P. K. Bhatnagar,
# 14/81,
Chopasani Housing Board Colony,
Jodhpur.
E-mail: pk.bhatnagar@yahoo.com
  pradeep.bhatnagar51@gmail.com

ABSTRACT: Colorectal Carcinoma is most common malignancy in GIT, 3rd most common after lung and Breast.(1) These patients commonly present with altered bowel habits, bleeding PR, pain, lump abdomen.(2) In the present study 245 cases from west Rajasthan over a period of 26 months were studied for Age, Sex, Clinical presentation, Investigation, Subsequent management, Complication and Follow-up. Peak incidence of disease is in 6th decade of life with M/F ratio 1.8:1. Most common presentation was altered bowel habits. Most patients presented in advanced Duke’s C with moderately differentiated Adenocarcinoma. CEA levels were <5 ng/mL. Preoperative surgical feasibility for curative resection was present in 64.44% pts. CEA level is good indicator to monitor recurrence of the disease. Surgery is the mainstay of the treatment. There is a role of adjuvant chemotherapy in all cases of colorectal cancer. Follow-up study is mandatory in all patients for early management of recurrent disease.
KEYWORDS: COLORECTAL CARCINOMAGIT MALIGNANCYCOLON CARCINOMAADENOCARCI- NOMAOCCULT BLOODCOLONOSCOPYSIGMOIDOSCOPY.

How to cite this article

Ram Ratan Yadav, Pankaj Saxena, P. K. Bhatnagar, Rita Saxena, Shivcharan Navariya, Pankaj Porwal. Colorectal Carcinoma in Western Rajasthan: A Comprehensive Study and Management of 245 Cases. Journal of Evidence based Medicine and Healthcare; Volume 1, Issue 11, November 17, 2014; Page: 1387-1396.

INTRODUCTION: Colorectal cancer (CRC) is one of the most common forms of gastrointestinal malignancies in the world.(3) Compared to the Western world, the incidence rates of colorectal cancer are low in India; for colon cancer they vary from 0.7 to 3.7/100,000 among men and 0.4 to 3/100,000 among women, and for rectal cancer from 1.6 to 5.5/100,000 among men and 0 to 2.8/100,000 among women.(4) The vast majority of patients with CRC are above the age of 65 years.(5) CRC occurring before age of forty years accounts for less than 10% of the total CRC. It has been reported that CRC in the Asia-Pacific region and Africa occur a decade or more earlier compared to the USA.

The most common location of CRC is the left side of the colon including the rectum.(6) However, reports from the West suggest that the tumor location of CRC is moving proximal to the splenic flexure. Prevention and early detection are key factors in controlling and curing colorectal cancer.(7) When the cancer is found early, initial treatment can often lead to an excellent outcome The extent to which a cancer penetrates the various tissue layers determines the stage of the disease.(8) Most colorectal cancers grow slowly over a period of several years, often beginning as small benign growths called polyps. Removing these polyps early, before they become malignant, is an effective means of preventing colorectal cancer.(9)

 

MATERIAL AND METHODS: A prospective study was carried out at Dr. S.N. Medical College & MG Hospital, Jodhpur (Raj.) 245 cases of colorectal carcinoma were taken for study between July 2011 to August 2013. All cases were carefully studied for age and sex distribution, clinical presentation, investigation and diagnostic modalities, management, complications and mortality and follow up observations

 

OBSERVATIONS: There was male preponderance with 158 males (64.44%) and 87 females (35.56%), and rural preponderance with urban 82(33.33%) and rural 163(66.66%) (Table 1) maximum number of patients 158(64.48%) belonged to age group of 45-74 (table 2). Most patients presented with altered bowel habits 229 (93.33%) (4-6 months), bleeding per rectum 142 (57.78%) (4-6 months), pain abdomen 87(35.56%) (0-1 month) intestinal obstruction 147 (60%) (0-5 days). (Table 3) clinical findings have been distention of abdomen and features of acute/sub-acute intestinal obstructions 147(60%), palpable mass per rectal examination 136 (55.55%), lump abdomen 120(48.89%), pallor 120(48.89%) ascites 60(24.24%) and hepatomegaly 33(13.33%). (Table 4) Radiological investigations revealed positive findings. (Table 5) Plain X Ray abdomen showed distension of left colon in 65(26.67%) right colon 87(35.56%) small bowel 120(48.88%) and whole bowel 33(13.33%). Ultra sonography of abdomen showed bowel mass 201(82.22%) secondaries in liver 13(11.11%) distended bowels 163(66.67%) free fluid 125(51.11%). CT SCAN of abdomen showed bowel mass 190(77.78%), secondaries in liver 13(5.56%), dilated bowel loops 163(66.67%) enlarged lymph nodes 157(64.44%) free fluid in peritoneum 125(51.11%) and local infiltration 163(66.67%). Maximum number of patients 174 (71.11%) had CEA levels in the range of 0-10 ng /ml with 0-5 ng/ml in 93(37.78%) and 6-10 ng /ml 81(33.33%), 11-15 ng/ml in 27(11.11%), 16 -20 ng in 27(11.11%) and >20 ng/ml in 16(6.67%). (Table 6) In study 123(50%) patients were histo pathologically confirmed carcinoma before surgery and 65(26.66%) were suspected by investigation as colorectal carcinoma. 55(22.22%) patients were diagnosed at the time of laparotomy or by post-operative histopathological confirmation. (Table 7) In our study most common site of colorectal carcinoma is rectum 86(35%) followed by rectosigmoid 59 (24%), caecum 37 (15%) (Table 8). In this study most cases present to us in stage 3 rd 163. Most cases present in DUKES C (66.67%) (Table 9). In our most common histopathological finding is adenocarcinoma 201(82.23%). in adenocarcinoma most common type is moderately differentiated 163(66.67%) followed by poorly differentiated 22(8.89%) (Table 10) In definite procedures most commonly LAR was done in 101 41.3.

          % followed by APR & RIGHT HEMICOLECTOMY 51(20.6%) (TABLE 11). In this study preoperative surgical feasibility for curative resection was present in 158 (64.44 &) patients and palliative surgical feasibility in 33(13.33%). 54(22.22%) cases were undecided preoperatively because these patients were diagnosed intra operatively (table 12) In this study most patients were treated by surgery followed by chemotherapy 120(75.76 %) due to post operative death 31 (20%) were treated only by surgery. (Table 13, 14) Most frequent post operative complication was wound infction 84(48.89%), followed by chest infection 56(35.55). mortality 31(20%). (Table 15) Patients were followed up for one year and It was evident that best results could be obtained by Early diagnosis and curative surgery with chemoterapy.

 

 

 

 

Sex

Rural/urban

Distribution

 

 

Urban

 

Rural

 

total

%

 

no

%

No

%

no

 

Male

49

20

109

44.44

158

64.44

Female

33

13.33

54

22.22

87

35.56

Total

82

33.33

163

66.66

245

100

Table 1: sex & rural- urban distribution

 

 

Age in years

No. of patients

%

25-34

22

8.89

35-44

27

11.11

45-54

43

17.78

55-64

71

28.89

65-74

44

17.78

>75

38

15.55

Total

 

100

Table 2: age distribution

 

 

Presenting symptoms

No of patients

%

Bleeding per rectum

142

57.78

Altered bowel habits

229

93.33

Pain abdomen

87

35.56

Acute/sub-acute int obst

147

60.00

Anorexia

49

20.00

Weight loss

125

51.11

Table 3: presenting symptoms

 

 

Clinical findings

No of patients

%

Distention of abdomen and

features of obstruction

147

60

Palpable rectal growth

136

55.55

Palpable lump abdomen

120

48.89

pallor

120

48.89

ascites

60

24.44

hepatomegaly

33

13.33

TABLE 4: CLINICAL FINDINGS

 

 

Investigation

 

No. of patients

%

Plain X Ray abdomen

Left colon

65

26.67

Dilated bowel loops

Right colon

87

35.56

 

Small intestine

120

48.88

 

Whole bowel

33

13.33

Ultra sonography

Bowel mass

201

82.22

 

Secondaries in liver

13

11.11

 

Dilated bowel loops

163

66.67

 

Ascites

125

51.11

CT SCAN abdomen

Bowel mass

190

77.78

 

Secondaries in liver

13

5.56

 

Dilated bowel loops

163

66.67

 

Enlarged Lymph nodes

157

64.44

 

ascites

125

51.11

 

Local infiltration

163

66.67

Table 5: Radiological findings in colorectal carcinoma

 

 

CEA LEVELS IN ng/ml

No. of patients

%

0-5

93

37.78

6-10

81

33.33

11-15

27

11.11

16-20

27

11.11

>20

16

6.67

Table 6: pre-operative levels of carcinoma embryonic antigen levels (CEA)

 

 

Pre-operative confirmation

Post op confm HPE

Histopathological confirmation

CT SCAN

SUSPECTED

Rectal biopsy (proctoscopy)

Colono scopy

Biopsy

Positive HPE

Biopsy

Positive HPE

49

49

87

76

65

55

Table 7: Histo-pathological confirmation

 

 

Site

No. of patients

%

Caecum

38

15.56

Ascending colon

11

4.44

Hepatic flexure

33

13.33

Transverse colon

0

0

Selenic flexure

5

2.22

Descending colon

0

0

Recto sigmoid

60

24.44

Sigmoid

87

35.56

Rectum

11

4.44

Total

245

100

Table 8: site distribution of colorectal carcinoma

 

 

Stage

No. of patient

%

1 st

16

6.67

2 nd

33

13.33

3 rd

163

66.67

4 th

33

13.33

Dukes

A

16

6.67

B

44

17.78

C

169

68.89

D

16

6.67

Table 9: staging at the time of presentation

 

 

HISTOPATHOLOGY TYPES

 

NO OF PATIENTS

%

ADENOCARCINOMA

WELL DIFFERENTIATED

16

6.67

MODERATELY DIFFERENTIATED

163

66.67

POORLY DIFFERENTIATED

22

8.89

TOTAL

201

82.23

MUCINOUS

 

27

11.11

COLLOID

 

16

6.67

SCIRRHOUS

 

0

0

ANAPLASTIC

 

0

0

TABLE 10: HISTOPATHOLOGY OF COLORECTAL CARCINOMA

 

 

NAME OF PROCEDURE

NO. OF PATIENTS

%

APR

33

20.6

LAR

65

41.3

RIGHT HEMICOLECTOMY

33

20.6

RIGHT EXTENDED HEMICOLECTOMY

22

13.7

SIGMOID R/A

5

3.4

TOTAL

158

 

Table 11: The various curative surgical procedures DONE IN 158 (64.44%)

 

 

Surgical feasibility

No. of patiens

%

Curative procedure

158

64.44

Palliative procedure

33

13.33

undecided

54

22.22

TABLE 12: SURGICAL FEASIBILITY STATUS FOR COLORECTAL CARCICNOMA

 

 

Palliative procedure

No. of patient

%

Hartmanns operation

21

8.89

caecostomy

6

2.22

Sigmoid colostomy

6

2.22

Ileotransverse bypass

0

0

Ileoascending byoass

0

0

Total

33

13.33

Table 13: palliative procedures in colorectal carcinoma

 

 

Treatment

No of patients

Total

%

Curative

Palliative

Surgery alone

14

17

31

20

chemotherapy

0

7

7

4.44

Surg + chemo

106

14

120

75.76

Table 14: management of colorectal carcinoma

 

 

Complication

No of patients

%

Wound infection

84

48.89

Burst abdomen

28

17.78

Fecal fistula

21

13.33

Chest complications

56

35.55

Cardiac

11

6.67

Renal

18

11.11

Death after elective surg

14

8.89

Death after emergency surg

18

11.11

Table 15: post operative complications

 

DISCUSSION: Most colorectal cancers are due to lifestyle factors and increasing age, with only a small number of cases due to underlying genetic disorders(10) Risk factors include diet, obesity, smoking, and not enough physical activity.(11) Dietary factors that increase the risk include red and processed meat, as well as alcohol.(12) Another risk factor is inflammatory bowel disease, which includes Crohn's disease and ulcerative colitis.(13) Some of the inherited conditions that can cause colorectal cancer include: familial adenomatous polyposis and hereditary non-polyposis colon cancer; however, these represent less than 5% of cases.(14) It typically starts as a benign tumor which over time becomes cancerous.(15)

Bowel cancer may be diagnosed by obtaining biopsy during a sigmoidoscopy or colonoscopy.(16) This is then followed by medical imaging to determine if the disease has spread. Screening is effective at decreasing the chance of dying from colorectal cancer and is recommended starting at the age of 50 and continuing until the age of 75. Aspirin and other non-steroidal anti-inflammatory drugs decrease the risk. Their general use is not recommended for this purpose, however, due to side effects.(17)

Treatments used for colorectal cancer may include some combination of surgery, radiation therapy, chemotherapy and targeted therapy. Cancers that are confined within the wall of the colon may be curable with surgery while cancer that has spread widely is usually not curable with management focusing on improving quality of life and symptoms. Five year survival rates in the United States are around 65%. This, however, depends on how advanced the cancer is, whether or not all the cancer can be removed with surgery, and the person's overall health. Globally, colorectal cancer is the third most common type of cancer making up about 10% of all cases. In 2012 there were 1.4 million new cases and 694,000 deaths from the disease. It is more common in developed countries, where more than 65% of cases are found. It is less common in women than men.(18)

Colorectal cancer (CRC) is prevalent in Western developed countries. Compared to the Western world India has allowed incidence of CRC. Reports from Japan and Korea suggest that the incidence of CRC is increasing in Asia. It is found that the age at presentation of CRC in Indians (58.4 years) was a decade earlier compared to non-African Americans in the USA (70.5 years). Some studies from India have suggested that CRC may occur even earlier. Deo et al reported a mean age at presentation of 45.3years.(19) One study from Srinagar noted that 68.7% of the CRC patients’ age at diagnosis was between 41 and 60 years. Similar to our observation, CRC in Asian and African countries occurs one decade earlier than in the Western population. The most common location of CRC is left side of the colon and rectum. However reports from the West suggest that there is a shift of tumor location to proximal parts of the colon. This trend has been noticed in Asian countries such as Korea and Japan. In Japan the rightward shift was due to decrease in the proportion of rectal cancer.(20)

In a retrospective study comparing the anatomical distribution of CRC in whites and Chinese patients, the latter were found to have more distal CRC. Majority of CRC from Malaysia, Iran, Japan, Africa, India, and Egypt are on the left side of the colon. Symptoms and signs at presentation were different for proximal and distal CRC. Presence of bleeding per rectum and constipation were highly suggestive of distal CRC. Abdominal pain, anorexia, low hemoglobin, and a palpable mass were highly suggestive for proximal CRC.

Multivariate logistic regression analysis showed bleeding per rectum associated with distal CRC and palpable mass with proximal CRC. CRC in Indians occurs at a younger age and is often distal to the splenic flexure. CRC should be suspected irrespective of the patients’ age and a simple measure like sigmoidoscopy may pick up majority of cases of CRC in India.(21)

About 80% of patients undergo surgery, usually with the hope of cure. Fewer than half survive more than five years(22) Long term survival is only likely when the tumour is completely removed. Microscopic cancer cells left behind after surgery in tissue close to the rectum (the mesorectum) can become foci of incurable local recurrence. Preoperative radiotherapy was associated with 14% (SD 4%, p=0.002) fewer deaths from colorectal cancer: 43.9% v 49.2% dead. The benefit is greater in patients who go on to have curative resections. Postoperative radiotherapy leads to a 33% (SD 11%, p=0.003) reduction in local recurrence but no clear evidence of improved survival(23) The effectiveness of adjuvant chemotherapy was assessed in a meta-analysis by the Colorectal Cancer Collaborative Group of individual five year survival data for 12 000 patients in 33 randomized controlled trials This suggests that for every 100 patients with Dukes’ stage C cancer treated for six months with 5-fluorouracil/folinic acid (FUFA), six deaths can be avoided (95% CI 2% to 10%). A one week postoperative infusion of 5-FU directly into the liver may also be effective.

These show that early chemotherapy increases median survival by three to six months and that symptom free survival increases from a median of two months to 10 months (p<0.001) (24). In cases of Chemotherapy for advanced or recurrent colorectal cancer improved response rates can be achieved by supplementing 5-FU with methotrexate or folinic acid and that continuous infusion of 5-FU is more effective than bolus administration.(25) Patients who have had surgery with the intention of cure are often followed up to detect recurrences of the cancer in the hope that they will be resectable. Tests may include colonoscopy; laboratory analysis of carcinoembryonic antigen, liver function, and faecal occult blood; radiological investigations such as chest and colonic x ray films; liver ultrasound and CT.(26)

 

CONCLUSION: Colorectal cancer is the second most common cause of cancer death in indian males. Prompt investigation of suspicious symptoms is important, but there is increasing evidence that screening for the disease can produce significant reductions in mortality. High quality surgery is of paramount importance in achieving good outcomes, particularly in rectal cancer, but adjuvant radiotherapy and chemotherapy have important parts to play. The treatment of advanced disease is still essentially palliative, although surgery for limited hepatic metastases may be curative in a small proportion of patients.

REFERENCES:
1.    Cooper GS, Yuan Z, Landefeld CS, Johanson JF, Rimin AA. A national population-based study of incidence of colorectal cancer and age; implication for screening in older Americans. Cancer. 1995; 75: 775–81.
2.    Demers RY, Severson RK, Schottenfeld D, Lazar L. Incidence of colorectal adenocarcinoma by anatomic subsite; An epidemiologic study of time trend and racial difference in the Detroit, Michigan area. Cancer. 1997; 79: 441–7.
3.    Shah A, Jan GM. Pattern of cancer at Srinagar (Kashmir). Indian J Pathol Microbiol. 1990; 33: 118–23.
4.    Boyle P, Langman JS. ABC of colorectal cancer: Epidemiology. BMJ 2000; 321: 805–8.
5.    Goh KL, Quek KF, Yeo GT, et al. Colorectal cancer in Asians: a demographic and anatomic survey in Malaysian patients undergoing colonoscopy. Aliment Pharmacol Ther 2005; 22: 859–64.
6.    Mohandas KM, Desai DC. Epidemiology of digestive tract cancers in India. V. Large and small bowel. Indian J Gastroenterol 1999; 18: 118–21.
7.    Cheng X, Chen VW, Steele B, et al. Subsite-specific incidence rate and stage of disease in colorectal cancer by race, gender, and age group in the United States, 1992–1997.Cancer 2001; 92: 2547–54.
8.    Mensink PB, Kolkman JJ, Van Baarlen J, Kleibeuker JH. Change in anatomic distribution and incidence of colorectal carcinoma over a period of 15 years: clinical considerations. Dis Colon Rectum 2002; 45: 1393–6.
9.    Goh KL. Changing trends in gastrointestinal disease in the Asia–Pacific region. J Dig Dis 2007; 8: 179–85.
10.    Bae JM, Jung KW, Won YJ. Estimation of cancer deaths in Korea for the upcoming years. J Korean Med Sci 2002; 17: 611–5.
11.    Tamura K, Ishiguro S, Munakata A, Yoshida Y, Nakaji S, Sugawara K. Annual changes in colorectal carcinoma incidence in Japan. Analysis of survey data on incidence in Aomori Prefecture. Cancer 1996; 78: 1187–94.
12.    Deo SV, Shukla NK, Srinivas G, et al. Colorectal cancers– experience at a regional cancer centre in India. Trop Gastroenterol 2001; 22: 83–6.
13.    Shah A, Wani NA. A study of colorectal adenocarcinoma. Indian J Gastroenterol 1991; 10: 12–3.
14.    Stewart RJ, Stewart AW, Turnbull PR, Isbister WH. Sex differences in subsite incidence of large-bowel cancer. Dis Colon Rectum 1983; 26: 658–60.
15.    Sharma VK, Vasudeva R, Howden CW. Changes in colorectal cancer over a 15-year period in a single United States city. Am J Gastroenterol 2000; 95: 3615–9.
16.    Gomez D, Dalal Z, Raw E, Roberts C, Lyndon PJ. Anatomical distribution of colorectal cancer over a 10-year period in a district general hospital: is there a true “rightwar shift”? Postgrad Med J 2004; 80: 667–9.
17.    A. Melville, T. A. Sheldon, R. Gray, and A. Sowden Management of colorectal cancerQual Health Care. Jun 1998; 7 (2): 103–108.
18.    A Leslie, Management of colorectal cancer Postgrad Med J 2002; 78: 473-478.
19.    Yin L, Grandi N, Raum E, Haug U, Arndt V, Brenner H. Metaanalysis: longitudinal studies of serum vitamin D and colorectal cancer risk. Aliment Pharmacol Ther. 2009; 30: 113–25.
20.    Javid G, Zargar SA, Rather S, et al. Incidence of colorectal cancer in Kashmir Valley, India. Indian J Gastroenterol. 2011; doi: 10.1007/s12664-010-0071-7.
21.    Jussawalla DJ, Gangadharan P. Cancer of the colon: 32 years of experience in Bombay, India. J Surg Oncol. 1977; 9: 607–22.
22.    The Consultant Surgeons and Pathologists of the Lothian and Borders Health Authority. Lothian and Borders large bowel cancer project: immediate outcome after surgery. Br J. Surg 1995; 82: 888–90.
23.    Darby CR, Berry AR, Mortensen N. Management variability in surgery for colorectal emergencies. Br J Surg 1992; 79: 206–10.
24.    Swedish Rectal Cancer Group. Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med 1997; 336: 980–7.
25.    Stockholm Rectal Cancer Study Group. Preoperative short term radiation therapy in operable rectal carcinoma: a prospective randomized trial. Cancer 1990; 66: 49–55.
26.    Medical Research Council Rectal Cancer Working Party. Randomised trial of surgery alone versus radiotherapy followed by surgery for potentially operable locally advanced rectal cancer. Lancet 1996; 348: 1605–10.

 

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