Colorectal Cancer

ABSTRACT: Screening options for colorectal cancer (CRC) include colonoscopy every 10 years, annual fecal occult blood testing, flexible sigmoidoscopy every 5 years, or double contrast barium enema every 5 years. In white patients at average risk, screening should begin at age 50; in African American patients, at age 45. Colonoscopy is preferred to sigmoidoscopy because it can detect proximal neoplasms and has the longest protection interval. High-risk patients include those with a family history of CRC or adenomas. These persons should begin colonoscopic screening at age 40, or 10 years earlier than the age at which CRC or adenomas were diagnosed in a first-degree relative. Other high-risk patients are those with a personal history of CRC, a genetic syndrome, or inflammatory bowel disease. In patients with CRC, the first follow-up colonoscopy is performed 1 year after surgery. If results are normal, the interval can be extended to every 3 years.

The FDA has approved injectable Acetadote (acetylcysteine)from Cumberland Pharmaceuticals Incto prevent or lessen liver damage resulting from an overdoseof acetaminophen. According to the FDA, unintentionalacetaminophen overdose is responsible for 100deaths and 56,000 emergency department visits per year.

As the population ages, physicians are seeing a greaternumber of patients with colorectal disorders. This book combinesan up-to-date survey of the latest basic and clinicalresearch in the field with practical advice for the day-to-daycare of patients with colonic diseases. The first section ofthe book covers current knowledge of normal colorectal physiology.Section 2 discusses the basic disease mechanismsinvolved in colonic disorders and reviews the uses of suchinvestigational tools as colonoscopy, colonic biopsy, anorectalmanometry, ultrasonography, motility measurement,defecography, CT, and MRI. The third section offers a fulldiscussion of the diagnosis and treatment of commoncolonic disorders, including colorectal neoplasia, inflammatorybowel disease, ulcerative colitis, diverticular disease,Crohn disease, constipation, and irritable bowel syndrome.In addition to currently recommended approaches to evaluationand treatment, chapters in this section include discussionof advanced and investigational therapies.

A 72-year-old man complains that he has been losing weightfor the last 2 months. Colon cancer was diagnosed 2 yearsearlier, and the lesion was resected; he did not receive anyadditional therapy at that time. Except for hypertension,which is well controlled with propranolol, the remainder ofthe medical history is unremarkable.

Highlights:➤What to tell your patients about thebenefits-and risks-of mammography.➤A realistic look at cancer screening: Arewe overstating the benefits?➤Which screening strategies you canrecommend with confidence.➤How best to bring the patient into thedecision-making process.

During a routine checkup, a middle-aged woman asks you whether she should stop wearing moisturizers and makeup that contain sunscreen. She has read that increased sunlight exposure enhances vitamin D production, which may prevent certain types of cancer. What would you tell her?

A 52-year-old woman was admitted tothe hospital with progressive shortnessof breath of 2 days’ duration. Bronchialasthma had been diagnosed 6 monthsearlier; inhaled corticosteroids, bronchodilators,and leukotriene antagonistswere prescribed. Despite aggressivetreatment, the patient’s dyspneaand wheezing worsened.

An 83-year-old man complains of weakness, easy fatigability, and poor appetitethat began 4 to 6 weeks ago. He becomes short of breath on his daily walksand has lost about 20 pounds over the last 3 months. He denies nocturia,paroxysmal nocturnal dyspnea, exertional chest pain, fever, cough, melena,and hematochezia. His only GI symptom is occasional crampy abdominal painwith bowel movements.

You routinely order laboratory screeningpanels, including serum liver enzymemeasurements, for nearly everypatient who has a complete physicalexamination or who is seen for any ofa host of other complaints. If you findabnormal liver enzyme levels, your familiaritywith the common causes andthe settings in which they occur mayenable you to avoid costly diagnosticstudies or biopsy.

An 80-year-old woman presented with recurrent abdominal pain for 1 month, constipation, and vomiting. She had no diarrhea, rectal bleeding, or weight loss.

Persistent collapse of the right lung led to hospitalization of a 62-year-old woman with a history of colon cancer. She had no fever, chills, rigor, or hemoptysis. The patient underwent bronchoscopy to rule out any central endobronchial obstructing lesion.

Asymptomatic facial and truncal papules began developing several years before this 55-year-old man sought medical care. The lesions were slightly yellowish or reddish, and many had a central punctum. Biopsy revealed a microscopic picture consistent with sebaceous adenoma.

For 3 days, a 69-year-old man had had intermittent colicky pain on the right side of the abdomen, loose bowel movements, and a low-grade fever. Examination disclosed a mildly tender, palpable, diffuse mass in the right upper quadrant and hyperactive bowel sounds. The patient's stool was positive for occult blood, and a complete blood cell count showed a low hemoglobin level and a slightly elevated white blood cell count.

A 78-year-old woman with carcinoma of the right colon underwent CT of the abdomen and pelvis to rule out metastasis. The scan showed a musculoaponeurotic defect above the left iliac wing, with a herniated loop of colon. A soft, reducible 4 × 6-cm mass that increased with coughing was found in her left flank. The patient had not had any surgery in this area.

A 65-year-old woman with metastatic adenocarcinoma of the colon was undergoing chemotherapy following a colectomy and a hepatic wedge resection. The physical examination and laboratory data were unremarkable.

During investigation of a long-standing iron-deficiency anemia, a 67-year-old woman was found to have cecal colon cancer, Duke's stage B. A right hemicolectomy was performed at that time, and she had periodic follow-up examinations. Four years later, during a routine outpatient visit, her carcinoembryonic antigen (CEA) serum level was found to be 27.7 ng/mL (upper normal limit, 5 ng/mL). Four months earlier, her CEA level had been normal.

A 65-year-old woman, who was confined to a wheelchair because of severe rheumatoid arthritis, was concerned about nodules that had erupted on her fingers and hands during the previous 3 weeks. Her medical history included colon cancer, chronic renal insufficiency, anemia, and hypertension. The nonpruritic nodules were painful when they began to form under the skin; however, once they erupted, the pain disappeared.

A 56-year-old man comes to see you2 weeks after an emergency departmentvisit for GI bleeding, which resultedin a diagnosis of colon cancer.Endoscopy revealed a lesion in theproximal sigmoid colon that wasfound on biopsy to be a primary adenocarcinoma.A CT scan of the abdomenand pelvis that was performedto stage the lesion showed a liverlesion suggestive of metastatic diseasebut no evidence of extrahepaticdisease.

During an evaluation to detect metastatic disease in a 75-year-oldwoman with recently diagnosed cecal cancer, a CT scan of the abdomenand pelvis revealed an incidental finding of a heavily calcifiedgallbladder. No metastases were found. The patient had nosymptoms related to gallbladder disease.

A 70-year-old woman with no previousmedical problems had had progressivedyspnea and generalized weaknessfor the past several days. She washypotensive (73/31 mm Hg), tachycardic(120 beats per minute), andtachypneic (28 breaths per minute);oxygen saturation (room air) via pulseoximetry was 84%.

A 65-year-old woman, who was confined to a wheelchairbecause of severe rheumatoid arthritis, was concernedabout nodules that had erupted on her fingers and handsduring the previous 3 weeks (A). Her medical historyincluded colon cancer, chronic renal insufficiency, anemia,and hypertension. The nonpruritic nodules were painfulwhen they began to form under the skin; however, oncethey erupted, the pain disappeared.

Vague abdominal pain, malaise, anorexia,and the loss of 10 lb in 2months prompted a 65-year-old manto seek medical evaluation. A yearearlier he had undergone surgery forstage III carcinoma of the sigmoidcolon. Because metastases to thelymph nodes were found in the resectedcolon, the patient was given postoperativechemotherapy. Histologicexamination revealed poorly differentiatedadenocarcinoma.

An 85-year-old man was admitted to the hospital with acough and shortness of breath of 1 week’s duration anda fever and increased sputum production for 2 days. Hishistory included renal cell carcinoma and metastatic renalcancer for 2 years. The patient had smoked cigarettesfor 30 years. He had lost 30 lb during the last few months.A chest film revealed pneumonia of the right lowerlobe. Metastatic nodules were noted on the scalp; extensivelung, bone, and brain metastases also were found.

A 40-year-old man was concerned about an enlarging painlessmass on the right side of his neck that had been presentfor 6 months (A). The patient reported no other healthproblems; his medical history was unremarkable, and hewas taking no medications.There was no family or personal history of thyroiddisease or of exposure to radiation. Thyroid function testresults were within normal limits. A chest film revealed nopathology.

A 74-year-old woman was admitted to the hospital with abdominal pain, weight loss, fatigue, and change in bowel habits of 6 months’ duration. Her hemoglobin level was 7 g/dL; carcinoembryonic antigen, 672 ng/dL.