Kanker usus besar00:00 Overview Ca Colon Pengertian Epidemiologi Etiologi Pathologi Gejala Terapi Askep klinis A B D C Intestinal tumors Non-neoplastic Polyps Hyperplastic polyps Hamartomatous polyps Juvenile polyps Peutz-Jeghers polyps Tumor epitel merupakan penyabab terbesar angka kesakitan dan kemarian di dunia Inflammatory polyps Lymphoid polyps Neoplastic Epithelial Lesions Benign polyps Adenomas Malignant lesions Usus meliputi rektum merupakan organ pertama terkena neoplasma Adenocarcinoma Squamous cell carcinoma of the anus Other Tumors Gastrointestinal stromal tumors Carcinoid tumor Lymphoma Adenocarcinoma 98% kanker berada di usus besar Kebanyakan kanker colorectal berkembang dari polip, oleh karena itu polypectomy colon mampu menurunkan kejadian kanker colorectal. Epidemiology peak incidence: 60 to 70 years of age < 20% cases before age of 50 adenomas – presumed precursor lesions for most tumors males affected ≈ 20% more often than females Epidemiology worldwide distribution World Cancer Report WHO, diperkirakan 944.717 kasus ditemukan di seluruh dunia pada tahun 2000. highest incidence rates in United States, Canada, Australia, New Zealand, Denmark, Sweden, and other developed countries Etiology genetic influences: kecenderungan genetik tertentu, seperti Hereditary Nonpolyposis Colorectal Cancer (HNPCC; 4-7% dari semua kasus) dan Familial Adenomatosa Polyposis (FAP, 1%) serta Inflammatory Bowel Disease (IBD; 1% dari semua kasus). Etiology environmental dietary practices influences: low content of unabsorbable vegetable fiber corresponding high content of refined carbohydrates high fat content decreased intake of protective micronutrients (vitamins A, C, and E) use of Aspirin® and other NSAIDs: protective effect against colon cancer? cyclooxygenase-2 & prostaglandin E2 Carcinogenesis chromosome instability pathway Carcinogenesis mismatch repair (microsatellite instability) pathway Karsinoma Colon Sebelah Kanan Karsinoma pada caecum atau pada ascending colon biasanya memperlihatkan gejala nonspesifik seperti kekurangan zat besi (anemia). Kejadian anemia ini biasanya meningkatkan kemungkinan terjadinya karsinoma colon yang belum terdeteksi, yang lebih cenderung berada di proksimal daripada di colon distal. Beberapa tanda gejala yang terlihat yaitu berat badan yang menurun dan sakit perut pada bagian bawah yang relatif sering, tetapi jarang terjadi pendarahan di anus. Pada 50-60% pasien terdapat massa yang teraba di sisi kanan perut Karsinoma Colon Sebelah Kiri Karsinoma terletak pada bagian distal---gangguan buang air besar Adanya darah di feses. Beberapa karsinoma pada transversa colon dan colon sigmoid dapat teraba melalui dinding perut. Karsinoma sebelah kiri lebih cepat menimbulkan obstruksi, sehingga terjadi obstipasi. Tidak jarang timbul diare paradoksikal, karena tinja yang masih encer dipaksa melewati daerah obstruksi partial Karsinoma Rektum Gangguan defekasi, misalnya konstipasi atau diare. Sering terjadi perdarahan yang segar dan sering bercampur lendir, berat badan menurun. Perlu diketahui bahwa rasa nyeri tidak biasa timbul pada kanker rectum. Kadang-kadang menimbulkan tenesmus dan sering merupakan gejala utama Morphology 25% of colorectal carcinomas berada di cecum atau ascending colon Proporsi yang sama berada di rectum dan distal sigmoid 25% di descending colon dan proximal sigmoid remainder scattered elsewhere multiple carcinomas present → often at widely disparate sites in the colon Morphology Semua kanker kolon dimulai dari in situ lesions tumors in the proximal colon: polypoid, exophytic masses dapat melebar sepanjang cecum dan ascending colon Morphology Tumbuh berbentuk cincin menimbulkan napkin-ring. Pada permulaan, tumor tampak seperti massa berbentuk sesil, kemudian tumbuh berbentuk plak melingkar yang menimbulkan obstipasi. Kemudian bagian tengah mengalami ulserasi yang menimbulkan simtom diare, tinja campur lendir dan darah, konstipasi dan tenesmus mirip dengan sindrom disentri Morphology all colon carcinomas - microscopically similar almost all - adenocarcinomas range from well-differentiated to undifferentiated, frankly anaplastic masses many tumors produce mucin secretions dissect through the gut wall, facilitate extension of the cancer and worsen the prognosis cancers of the anal zone are predominantly squamous cell in origin Clinical Features may remain asymptomatic for years symptoms develop insidiously cecal and right colonic cancers: fatigue weakness iron deficiency anemia left-sided lesions: occult bleeding changes in bowel habit crampy left lower quadrant discomfort anemia in females may arise from gynecologic causes, but it is a clinical maxim that iron deficiency anemia in an older man means gastrointestinal cancer until proved otherwise STADIUM KANKER Lanjutan....... Clinical Features spread by direct extension into adjacent structures and by metastasis through lymphatics and blood vessels favored sites for metastasis: regional lymph nodes liver lungs bones other sites including serosal membrane of the peritoneal cavity carcinomas of the anal region → locally invasive, metastasize to regional lymph nodes and distant sites TNM Staging of Colon Cancer Tumor (T) T0 = none evident Tis = in situ (limited to mucosa) T1 = invasion of lamina propria or submucosa T2 = invasion of muscularis propria T3 = invasion through muscularis propria into subserosa or nonperitonealized perimuscular tissue T4 = invasion of other organs or structures Lymph Nodes (N) 0 = none evident 1 = 1 to 3 positive pericolic nodes 2 = 4 or more positive pericolic nodes 3 = any positive node along a named blood vessel Distant Metastases (M) 0 = none evident 1 = any distant metastasis 5-Year Survival Rates T1 = 97% T2 = 90% T3 = 78% T4 = 63% Clinical Features detection and diagnosis: digital rectal examination fecal testing for occult blood loss barium enema, sigmoidoscopy and colonoscopy confirmatory biopsy computed tomography and other radiographic studies serum markers (elevated blood levels of carcinoembryonic antigen) molecular detection of APC mutations in epithelial cells, isolated from stools tests under development: detection of abnormal patterns of methylation in DNA isolated from stool cells Therapy chemotherapy radiotherapy photodynamic therapy radical surgery gene therapy ASUHAN KEPERAWATAN True or false? 98% of all cancers in the large intestine are adenocarcinomas. Use of Aspirin® and other NSAIDs may cause development of colon cancer. Chromosome instability and the mismatch repair are two carcinogenesis pathways. Tumors in the proximal colon tend to be annular, encircling lesions that produce “napkin-ring” constrictions of the bowel and narrowing of the lumen, while those in the distal colon tend to grow as polypoid, exophytic masses. Colorectal carcinoma may remain asymptomatic for years. References: http://www.liebertonline.com/doi/abs/10.1089/pho.2008.2238 http://clincancerres.aacrjournals.org/cgi/content/abstract/5/9/2359 Elsevier. Kumar et al: Robbins Basic Pathology 8e Zahari Ari. Deteksi Dini diagnosis dan penatalaksanaan kanker kolon dan rektum. Suplemen majalalah kesehatan Andalas Timothy J Yeatman, Cancer colon. University of South Florida, Tampa, Florida, USA