Epidemiology
Referring to the incidence the colon – rectal cancer is listed on the second place for males, (12%) following the bronchial cancer and on the second place for females with 16% following the breast cancer.
Scope of Work
1 – The main objective of this paper is the evaluation of sensitiveness of different examining methods and the comparison among their results.
2 – The post intervention staging according TNM and the comparison with the pre intervention stage is another object of this paper.
3 – The comparison of the tumor stage against histology and the grade of tumor differentiation is the third object of this study.
4 – The final object is the R classification (residual tumor).
Patients and methods
330 patients in the Chirurgical Service of the Hospital University Center Nene Tereza, Tirana, Albania during the period December 2005 April 2009 have been studied.
The data and results from the objective examination, images, fibro colonoscopy and biopsy have been collected. One file for every patient was prepared and completed. The following examination methods were used for our patients:
1.Objective examination
2.Abdominal X-ray, which was realized by the same examiner.
3.Fibro colonoscopy
4.CT-scanner
5.Trans rectal X-ray
6.Pre intervention biopsy
7.Post intervention biopsy
:
These patients were considered at high risk if one or more statements below was true:
1.At age of fifty years old or older.
2.they had a history of adenomatous polyps
3.recent sigmoidoscopic evidence of one or more polyps
4.a positive finding on fecal occult-blood testing
5.history of colorectal cancer in one or more first-degree relatives
378 patients were recovered and treated. 31 of them were excluded from the examination and the study in the case when:
1.history of colorectal cancer in one or more first-degree relatives were noticed
2.colonic biopsy or polypectomy within the previous 14 days was taken
3.barium on a scout film retained
4.colostomy
5.allergy to glucagons
6.known glucagonoma, insulinoma
Only 14 patients didnt agree on the examinations.
The colon was prepared before the endo luminal examinations in the same way for every patient according a hydrate and laxative diet. The material for the biopsy has been taken for laboratory results in the same way for every patient as well. The material has been taken for biopsy results a day after the intervention and has been saved in formalin solution 100%.
Biopsy was taken for the primar tumor in the aboral part of the resectat, distal part from Stapler when it is not used, lateral parts including meso colon and meso rectum.
Based on the collected results and pre intervention examinations the clinical classification of the tumor stages was done. The final staging was done based on the intra intervention data and post intervention biopsy data.
The classification by TNM recommended by U.I.C.C. was used for the post and pre intervention staging.
For the post intervention staging we used also the classifications of the grade of tumor differentiation (G) and by the residual tumor (R). After that, we compared the pre and post intervention stages for every patient and finally a final comparison.
The sensitivity of the pre intervention examination got estimated having compared with each other and with the intra intervention and post intervention results.
The statistical data was found based on:
The average results
Standard deviation
Z Test
Wilcoxon Test for comparing the pre and post intervention data.
Results
The ratio Males/Females was 1.2/1. 160 patients had the blood group 0, 90 of them had the A blood group, other 60 patients had B and 20 of them had AB.
Referring to the tumor localization we came across that it was localized in the Colon in 240 patients and in Rectum in 90 of them. The distribution of the Colon tumor was as following: find
Colon ascendens 40 patients 12%
Hepatic Flexure 20 patients 6%
Transverse Colon 20 patients 6%
Lienal Flexure 20 patients 6%
Descendent Colon 50 patients 15%
Sigma 90 patients 27.5%
Rectum 90 patients 27.5%
Objective examination
In 100 patients with colon tumor or 42% was identified a real material mass during the abdomen palpation.
Out of 100 patients 70 had a stage III tumor and 30 of them Stage IV tumor.
Rectal touch was performed in all patients and resulted positive in 80 out of 90 with Ca. Recti, with a sensitivity of 88%.
Both examinations identified a primary tumor in 180 patients with colon rectal cancer.
Abdominal X-ray: primary tumor was found in 150 patients with colon cancer or 62.5%. Lymphonodus were found in 40 patients out of 110 with I/O or in 36.4%. In 30 patients distant metastasis (hepatic) were found out of 60 patients with I/O or 50% and it was not found by the X-ray in 20 patients with ascid resulted with I/O. In total the sensitivity of the X-ray in detecting the primary tumor was 45%.
CT-scanner was performed in 270 patients. The number of patients with primary tumor, lymphonodus, distant meta and ascid are listed in the table below:
Colon-rectal
270 patients Primar TumorLymphonodusDistant Meta Ascid
CT-scanner270806020
I/O1601106020
Sensitivity 100%73%100%100%
Fibro-colonoscopy was performed in 330 patients. The examination was done properly in 327 patients where material for the pre intervention biopsy was taken. The examination was not fully performed in 6 patients because the radioscopy didnt go through the intestine lumen in the descendent colon level because of a malign polyp. The irrigography was done which found bipolar tumors in the lienal flexure level.
Trans rectal Echo – was performed in 90 patients with rectal cancer. The primary tumor was found in 80 of them or 88.9%; lymphonodus were found in 10 patients out of 40 who resulted I/O and post intervention ( 50%).
Pre intervention biopsy It was performed in all patients and adenoma carcinoma resulted in 270 patients, Ca. Muchoid in 40 patients and negative in 20 patients when the post intervention biopsy was positive. The histological pre and post intervention diagnosis resulted similar.
Based on the pre intervention examinations results the clinical staging was achieved and the result showed 20 patients with a stage I tumor or 6%; stage II in 60 patients (18%); stage III in 180 patients (55%) and stage IV in 70 patients (21%).
Based on the intra intervention data the post intervention staging was achieved and the results were as in the following table. 30 patients had a stage I tumor (9%), 110 patients stage II tumor (31%), 130 patients stage III tumor (40%) and 60 patients stage IV tumor or 20%.
FIGURE
The classification according the differentiation grade of the tumor was achieved and the results showed 120 cases or 36.4% where the tumor was differentiated properly, in 130 cases or 40% the tumor was fairly differentiated, in 40 cases or 12% it was differentiated not properly and in 40 patients or 12% was not differentiated.
The classification according the residual tumor was also achieved and the results showed that a resection R0 was performed in 250 patients or 76%, R1 in 20 patients or 6% and R2 in other 60 patients or 18%. (FIGURE)
STATISTICAL ANALYSIS
1.The statistical analysis carried out with the Z test showed that the higher sensitivity of the scanner in detection of the lymphonodus and metastasis comparing to the abdominal X-ray has a statistical value (p
2.The statistical comparison through the Wilcoxon test between the pre and post intervention stages shows a discordance between the stage II and II with a statistical value of (p
DISCUSSION
Te colon rectal cancer is one of the most common malign pathologies of the gastro intestinal tract and it is accompanied by a very high mortality. Te survival rate depends on the stage of the tumor. Many authors have shown a high increase of the survival rate with 5 years through a good diagnostic procedure and treatment in the early stages of this pathology.
From the above written data it is obvious the high importance of the early diagnostic revealing of the colon rectal cancer. The various examination methods should tend:
a- To be as more accurate as possible in detecting or excluding of this pathology
b-To perform a real pre intervention staging in order to choose the most proper surgical method.
The patients survival rate according many authors depends on how radical the surgical intervention is and that is expressed by the R classification (residual tumor). This classification helps also to select the most appropriate and correct schemes of the post intervention neo adjuvant therapy (chemo and radio therapy).
In our series we have analyzed the objective examination data, different types of the images and fibro colonoscopy comparing those results with the intra intervention findings.
1-Pre intervention examination
a-Objective examination— Our data shows a high sensitivity in the primary tumor determination, both palation and rectal touch. The sensitivity is higher when they are getting analyzed together. This shows despite the computerized medicine era, the traditional methods are still important and of high significance. The throughout and careful examination of the patients who are in doubt of the existence of the colon rectal cancer is a necessary condition.
If our data was compared to those of other authors a high sensitivity of our series of data is visible. We are of the opinion that this is because of the advanced stages in that our patients present themselves for examination and for that reason the probability of the primary tumor detection during the objective examination is higher.
b-Abdominal X-ray The X-ray is a simple examining method, with a lower cost and not risky for the patients.
c-In our series of results it is obvious a high sensitivity regarding the colon tumors, and there is no sensitivity in finding the rectum tumors. If we make a comparison of our data with those of other authors it is distinctive a high sensitivity in our data regarding the colon tumors but the sensitivity against the rectum tumors is very low. This shows that X-ray is necessary to be performed in all patients that are in doubt of a colon rectal cancer, but its results should be taken with reserves into consideration. The higher sensitivity in our data like for the objective examination, we think, appears because of the advanced stages of the tumor in our series.
d-Trans rectal X-ray The above mentioned data shows the necessity of the trans rectal X-ray in the patients with Ca recti. It is necessary especially in the pre intervention staging and the evaluation of the possibility for a radical treatment.
e-CT-scanner The scanner sensitivity is the highest from all other examinations undertaken in this study. It helps not only in the determination of the primary tumor but also in the right evaluation of all components that serve for the pre intervention staging of the colon rectal cancer. In our series the CT scanner has classified some of the patients resulted in post intervention stage II in the stage III. This is explained by the fact that CT scanner has interpreted a part of the lymphonodus as metastasis that in the post intervention resulted reactive.
f-Fibro colonoscopy – Fibro colonoscopy is a procedure that often is accepted with difficulty by the patients. It is very sensitive and its reliability is getting increased in a impressive way compared to our previous studies.
This increase of the reliability is affected by the improvement of the colonoscopies examination comparing to the previous studies. This is because of more capable examiners and also of a better preparation of the colon. Colonoscopy should be achieved not only in the patients where a primary tumor has been detected with other methods, but in all patients where there is a clinical uncertainty of the presence of the colorectal cancer, and for the post intervention follow up, as well. The advantages of the colonoscopy against the scanner stay in the possibility that the colonoscopy gives for a histological confirmation of the diagnosis, whereas the scanner has the advantage of a large possibility for a more precise pre intervention examination. A combined evaluation of the colonoscopy, biopsy and scanner data allows a more precise pre intervention determination of the colon rectal tumor stage.
g-Pre intervention biopsy the pre intervention biopsy has been achieved on all patients with colonoscopy. False negativity identified is because the biopsy was not taken in the right area, because of the small portions of the biopsy or a superficial treatment with fewer cuts by the anatomist and pathologist. The improvement of these three steps would lead to a decrease of the false negativity. False negativity shows that not always we should totally rely on the biopsy results, but a complex judge and discussion should lead to the decision for a surgical intervention taking into consideration all the available elements we have.
2-Pre intervention staging Our series data shows different sensitivity of the used examination methods depending on the tumor stage and also on its localization. The scanner and fibro colonoscopy stay on the first place. When the abdominal X-ray and Trans rectal data and those of the objective examination have been analyzed together the sensitivity is high. This high sensitivity of the last two elements (abdominal X-ray and Objective examination) is result of the advanced stages of the tumor of the presented patients; in the cases of patients with stage I and II tumor the sensitivity is lower. To get a very correct pre intervention staging is necessary and important to use the received data from all examinations.
3-The comparison of the pre and post intervention stage. In our series data it is clear a variance between stages II and II, for stages I and IV there is a good correlation of the results. This variation as above mentioned, we think comes from the wrong interpretation of the lymphonodus from the CT scanner which result reactive in the final biopsy.
4-The tumor stage and differentiation grade. It is clear from our data that the higher differentiation grades tumors are presented in advanced stages. The reasons that influence these results is impossible to get identified by our data, but those shows a low level of the medical culture of the population, for the lack of the revealing policies and strategies in that direction, for the low level of the primary health care as well.
5-R classification (Residual tumor). R classification has been used in the last 10 years. It allows judging of the radical stage of the intervention prognosis of the disease and the need for a neo adjuvant therapy. In our data even in the advanced stages the radical interventions are the most used techniques, what shows the competence and ability of our surgeons who are capable of using the most advanced surgical techniques. This classification serves not only for what above mentioned but is also a test for the professional education (background) of every surgeon.
Conclusions
-All the examining methods used in this study show sensitivity in the detection of the colon rectal cancer.
-Fibro colonoscopy, biopsy and scanner are the most convincing and secure procedures with a high sensitivity.
-The received results from all examining methods are necessary for a most accurate pre intervention staging.
-The variation between pre and post intervention stages was distinctive for the stages II and III.
-The pre intervention staging classifies a part of the tumors of stage II into the stage III.
-Despite the differentiation grade of tumors, they are present more in the stages III, IV showing not appropriate medicine.
-The R classification allows to judge on the radicalism of the intervention, disease prognosis, need for a neo adjuvant therapy and serves as a test for the level of the surgical techniques.
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