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Diseases & Conditions

Colorectal Cancer

(Also Called 'Carcinoma of the Colon', 'Carcinoma of the Rectum', 'Familial Inherited Colorectal Cancer', 'Rectal Cancer')




The bile ducts connect the liver to the intestine and their function is to drain the bile, a waste product of normally functioning liver cells, which are also called hepatocytes. Diseases of the bile ducts usually result in narrowing of the duct, which is called a stricture.

Strictures can be characterized as:

  • Scarring (primary sclerosing cholangitis, secondary sclerosing cholangitis)
  • Traumatic (usually surgical injury)
  • Stone forming
  • Neoplastic (cancerous growths or tumors and polyps).

Jaundice or abnormal liver enzyme blood tests are the most common reasons physicians would suspect a problem with the bile ducts.

Bile Duct Cancer

Bile duct cancer is called cholangiocarcinoma. It arises from the epithelium or biliary tree lining either within the liver or in ducts located outside of the liver. Cholangiocarcinoma is difficult to cure and many cases are sporadic with no identifiable etiology or cause.

Risk factors associated with cholangiocarcinoma include:

  • Primary sclerosing cholangitis (PSC)
  • Ulcerative colitis
  • Liver fluke infestations
  • Chronic cholestasis with chronic stone disease
  • Congenital biliary cystic anomalies

Staging

Cancer staging is the process health professionals use to determine where cancer may have spread. It is used to find out if the cancer stayed in the bile ducts or worked its way to the lymph nodes or to other parts of the body.

Current methods of staging cholangiocarcinoma include:

  • Computed tomography (CT)
  • Magnetic resonance imaging (MRI)
  • Endoscopic retrograde cholangiopancreatography (ERCP)
  • Endoscopic ultrasound (EUS)

Each method has advantages and limitations. A combination of tests can select candidates for surgical resection, which affords long-term survival in a minority of patients.

Treatment

Relief of biliary obstruction is the most accepted treatment approach for most patients with cholangiocarcinoma. Stents are useful in providing adequate draining of the bile ducts.

Two types of stents are employed:

  • Endoscopic stents administered with the use of an endoscope or a slender, tubular optical instrument
  • Percutaneous stents administered through the skin

The best approach is dependent upon patient characteristics, location of the tumor and physician expertise.

Photodynamic therapy may have a role in selected patients not well palliated or relieved by routine stents based on preliminary trials.

Chemotherapy

Interpretation of the available, limited data that exists suggests a small survival advantage of chemotherapy and radiation for cholangiocarcinoma.

Liver Transplantation

Liver transplantation is currently an effective method of treatment for cholangiocarcinoma of the hilum of the liver in patient who cannot undergo surgical resection. Patients who are eligible for this protocol at Cleveland Clinic undergo chemotherapy and radiation therapy followed by liver transplantation. Long-term survival following this treatment protocol is similar to survival following liver transplantation for other conditions.

To understand colorectal cancer, it is first helpful to understand what parts of the body are affected and how they work.

The colon

The colon is an approximately 5 to 6-foot long tube that connects the small intestine to the rectum. The colon—which, along with the rectum, is called the large intestine—is a highly specialized organ that is responsible for processing and storing waste. The colon periodically empties its contents—stool—into the rectum to begin the process of elimination.

The rectum

The rectum is a 5- to 6-inch chamber that connects the colon to the anus. It is the job of the rectum to hold the stool until defecation (evacuation) occurs.

What is colorectal cancer?

Cancer that begins in the colon is called a colon cancer, while cancer in the rectum is known as a rectal cancer. Cancers affecting either of these organs also may be referred to as a colorectal cancer. Colorectal cancers generally develop over time from adenomatous (precancerous) polyps—growths—after a series of mutations (abnormalities) arise in their cellular DNA. The exact cause of colorectal cancer is not known. Some of the risk factors for colorectal cancer involve a family history of colon or rectal cancer, diet, alcohol intake, smoking, and inflammatory bowel disease.

What are the signs and symptoms of colorectal cancer?

Unfortunately, some colorectal cancers might be present without any signs or symptoms. For this reason, it is very important to have regular colorectal screenings (examinations) to detect problems early. The best screening evaluation is a colonoscopy. Other screening modalities include fecal occult blood tests, flexible sigmoidoscopy, barium enema, and CT colonography (virtual colonoscopy). The age at which such screening tests begin depends upon your risk factors, especially a family history of colon and rectal cancers.

However, most colorectal cancers are associated with signs or symptoms. One of the early signs of colorectal cancer is bleeding. However, tumors often bleed only small amounts, off and on, so that evidence of the blood is found only during chemical testing of the stool, which is called a fecal occult blood test. Other signs and symptoms include:

  • Change in bowel habits — Constipation, diarrhea, narrowing of stools, incomplete evacuation, and bowel incontinence—although usually symptoms of other, less serious problems—can also be symptoms of colorectal cancer.
  • Blood on or in the stool — By far the most noticeable of all the signs, blood on or in the stool can be associated with colorectal cancer. However, it does not necessarily indicate cancer, since numerous other problems can cause bleeding in the digestive tract, including hemorrhoids, anal tears (fissures), ulcerative colitis, and Crohn's disease, to name only a few. In addition, iron and some foods, such as beets, can give the stool a black or red appearance, falsely indicating blood in the stool. However, if you notice blood in or on your stool, see your doctor to rule out a serious condition and to ensure that proper treatment is received.
  • Unexplained anemia — Anemia is a shortage of red blood cells, the sort that carry oxygen throughout the body. If you are anemic, you may experience shortness of breath. You may also feel tired and sluggish, so much so that rest does not make you feel better.
  • Abdominal pain or bloating
  • Unexplained weight loss
  • Vomiting

If you experience any of these signs or symptoms, it is important to see your doctor for evaluation. For a patient with colorectal cancer, early diagnosis and treatment can be life-saving.

What are the stages of colorectal cancer?

Colorectal cancer is described clinically by the stages at which it is discovered. The various stages of a colorectal cancer are determined by the depth of invasion through the wall of the intestine; the involvement of the lymph nodes (the drainage nodules); and the spread to other organs (metastases). Listed below is a description of the stages of colorectal cancer and their treatment. In most cases, treatment requires surgical removal (resection) of the affected part of the intestine. For some tumors, chemotherapy or—for rectal cancers—radiation are added to manage the disease.

Stage 0. For cancers that are stage 0—also known as carcinoma in situ—the disease remains within the lining of the colon or rectum. Therefore, removal of the cancer, either by polypectomy via colonoscopy or by surgery if the lesion is too large, may be all that is required for treatment.

Stage 1. Stage 1 colorectal cancers have grown into the wall of the intestine but have not spread beyond its muscular coat. The standard treatment of a stage I colon cancer is usually a colon resection alone, in which the affected part of the colon and its lymph nodes are removed. The type of surgery used to treat a rectal cancer is dependent upon its location, but includes a low anterior resection or an abdominoperineal resection, which are described in other patient information forms.

Stage 2. A stage 2 colorectal cancer has penetrated beyond the muscular layers of the large intestine (stage 2B) and even spread into adjacent tissue (stage 2C). However, it has not yet reached the lymph nodes. Usually the only treatment for this stage of colon cancer is a surgical resection, although chemotherapy after surgery may be added. For a stage 2 rectal cancer, a surgical resection is sometimes preceded or followed by chemotherapy and/or radiation.

Stage 3. A stage 3 colorectal cancer is considered an advanced stage of cancer as the disease has spread to the lymph nodes. For a colon cancer, surgery is usually done first, followed by chemotherapy. Chemotherapy and radiation may precede or follow surgery for a stage 3 rectal cancer.

Stage 4. For patients with stage 4 colorectal cancer, the disease has spread (metastasized) to distant organs such as the liver, lungs, or ovaries. When the cancer has reached this stage, surgery is generally used for relieving or preventing complications as opposed to curing the patient of the disease. Occasionally the cancer's spread is restricted enough to where it can all be removed by surgery. In the case of minimal disease in the liver, the tumor may be treated with radiofrequency ablation (destruction with heat), cryotherapy (destruction by freezing), or intra-arterial chemotherapy. For stage 4 cancer that cannot be surgically removed, chemotherapy, radiation therapy, or both may be used to relieve, delay, or prevent symptoms.

References

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 10/29/2013…#14501