Evaluation and Treatment of Colorectal Cancer in Yazd - Iran

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1 Evaluation and Treatment of Colorectal Cancer in Yazd - Iran 1 Ali Akbar Salari, 2 Mansour Moghimi, 3 Hamid Reza Dehghan, 4 Hedayat Karimi. 1 Department of Surgery, Shahid Sadoughi University of Medical Sciences and Health Service, Yazd, Iran. 2,4 Department of Pathology, Shahid Sadoughi University of Medical Sciences and Health Service, Yazd, Iran. 3 Department of Statistics and Informatics, Shahid Sadoughi University of Medical Sciences and Health Service, Yazd, Iran. ABSTRACT Background: colorectal cancer is the most common cancer of the alimentary systems. In the women is the second cause of mortality after breast cancer and in the men is the third cause of death after lung and prostate carcinoma. Prevalence of that is more in age over 50 years old and malignancy increase as patient getting old. Therefore best treatment, prognosis is early diagnosis of disease. Methods: type of this study was retrospective that have been done by cross-sectional method, files of 191 patients in Shahid Rahnemoon and Afshar hospitals (two main hospitals) in Yazd, Iran were evaluated from The aim of the evaluation of abundance distribution of colorectal cancer for staging, age, Job, place of living and clinical signs and method of treatment. Also all of patients have had cancer pathology report. Results: from 191 patients with cancer of colorectal, 186 cases adenocarcinoma and 5 cases were lymphoma. Prevalence rate in the men was more than women majority in the age of years old. 127 patients (67%) were in age group of and years and least prevalence in age years (7.3%). In sex group 106 patients (55.5%) were men and 85 patients (44.5%) were women. 64.9% living in the city and 35.1% living in the village. Surgical treatment abdominoprineal resection (A.P.R) in 55 patients (28.8%) anterior resection Key Words: Colorectal Cancer, Diagnosis, Treatment, (A.P.R), (A.R). (A.R) and anastomosis 40 patients (20.9%). Right and left hemicolectomy 25 and rectosigmoiedectomy and Anastomosis in 18 patients. Result of treatment in 177 patients, with proportional recovery and 5 cases, their satisfaction discharged from hospital and 3 cases, died and 6 cases with poor condition after laparotomy discharged. Conclusion: the most patients with colorectal cancer referred with rectorrhagia and mainly type of adenocarcinoma (97.4%) most surgical procedure of them was (A.P.R) with attention to result of present study, more research projects in field of diagnosis, treatment and prognosis of these patients can help in the treatment of them. INTRODUCTION Most cause of the colorectal cancer is still unknown, but new laboratory researches help to understand molecular basis of colorectal cancer incidence better. 1 Molecular science has caused fundamental changes in diagnosis, treatment and prognosis evaluations of colorectal cancer in future. 2 Nowadays we know that colorectal cancer is a genetically disease and is caused by abnormality or changes of genetic codes. These mutations may occur in grermlin cells which cause heredital disease or in somatic cells which cause sporadic cancer. 1 It s estimated that 10-15% of colorectal cancers are familial. One per 200 cases of population may carry high risk alleles that cause heredital colorectal cancer. Patients with familial adenoid polyposis (F.A.P) have heredital susceptibility to colorectal cancers and they need a suitable surgery. Address reprint requests and correspondence to Dr. Ali Akbar - Salari MD, Department of Surgery, Shahid Sadoughi Hospital, Yazd, Iran. 31

2 Ali Akbar - Salari Colorectal cancer presents in 3 types: hereditary nonpolyposis colon cancer (HNPCC) and two dominant autosomal types. 3,4 Lunch syndrome type I which often appears in proximal colon involves extra colonal parts such as Endometer, stomach, superior urinary duct and ovaries. In lack of this syndrome, first degree families of patient suffering from colorectal cancer are susceptible to this cancer 3-9 times more. 4 Colorectal cancer generally occurs in old people and its incidence rate is equal in both sexes. And is second death cause in the west and its incidence is 20 per and 237 per cases in people younger than 65 and older than 60 respectively. Since general hygiene services have been improved during recent 2 decades, the incidence of this cancer has increased in adults especially in old people. 5 Factors which increases rate of right and left colon malignancies are listed below: 1- Aging 2- Inflammatory bowel disease (IBD) like ulcerative colitis 3- History of adenoma or cancer of colon 4- Familial polyposis syndromes 5- History of ovary, endometer or breast carcinoma 6- Insufficient fibers in diet 7- Large amount of unsaturated fat 5 PATIENTS AND METHODS This retrospective cross-sectional descriptive study was done on 191 patients referred to Shahid Rahnemoon and Afshar hospitals Yazd, Iran from 1992 to The aim of this research was to study frequency distribution of colorectal cancer according to disease stages, sex, age, job, place of living, clinical signs relationship and treatment type. We use chi-square and ANOVA statistical test and probabilities less than 0.05 was assigned significant. Results 186 patients (97.4%) and 5 patients (2.6%) suffers from adenocarcinoma and lymphoma respectively. (Table 1) Rate of incidence was more in males and it occurred in age of years old. Also 127 cases (67%) were and years old. Less frequency occurrence of this cancer occurred in ange of years old (7.4%), (Table 2) 106 cases (55.5%) were males and 85 cases (44.5%) were females. According to place of living, 64.9% and 35.1% of patients were urban and rural respectively. According to occupations, the patients were classified in 5 groups: workers 17 cases (8.9%), farmers 27 cases (14.1%) clerks 38 cases (19.9%), housekeepers 79 cases (41.4%), others 30 cases (15.7%) (Table 3). Most common reason of reference of the patients was rectorrhagia 96 (50.13%) and the most common associated tumor was adenocarcinoma 186 (97.41%), also the most common type of treatment was APR 55 (28.81%). According to our results, Most chief complains of our patients were rectorrhagia (50.2%), abdominal pain (38.7%), obstruction (8.9%), constipation (1.6%), and other causes (0.5 %) such as weakness sever weight loss respectively (Table 4). Table 1- Frequency distribution type of colorectal cancer in our study samples Type of cancer Number Percentage Adenocarcinoma Lymphoma Carcinoied 0 0 Total Table 2 Frequency distribution of site of tumor according age groups in our study samples Site of Rectum Sigmoid Cecum & Transverse & Lesion more Total tumor Age ascending colon descending colon than one site N % N % N % N % N % N % Total

3 Evaluation and Treatment of Colorectal Cancer in Yazd - Iran Table 3- Frequency distribution of type of cancer according to job in our study samples. Job Type oftumor Lymphoma Adenocarcinoma Total N % N % N % Free Worker Farmer Clerk Home worker Total Table 4 Frequency distribution of chief complain according to anatomic site in our study samples. Site of tumor Chief Complain Rectum Sigmoid Cecum & Transverse & Lesion more Total ascending colon descending colon than one site N % N % N % N % N % N % Abdominal Pain Rectorrhagia Obstruction Constipation Weakness Total Table 5- Frequency distribution of treatment according to discharge situation in our study samples Patient situation Type of surgery Partial Death Self Boor general Total remission satisfaction condition N % N % N % N % N % Total Right hemicolectomy & Anastomosis, 2- left hemicolectomy & Anastomosis, 3- APR 4- sigmoidectomy & Anastomosis, 5- tumor resection & Anastomosis, 6- Laparotomy and inoperable, 7- rectosigmoiedectomy & Anastomosis, 8- other 33

4 Ali Akbar - Salari Results of clinical signs according to frequency were rectorrhagia, anemia, abdominal pain, rectal mass, pelvic pain, abdominal mass and constipation and tenesmus. According to anatomical location, the involved parts were as below: Rectum: 62 cases (32.5%) Sigmoid: 25 cases (13.1%) Transverse and descending colons: 42 cases (22%) Cecum and ascending colons: 31 cases (16.2%) Multiple involvements were seen in 31 patients (16.2%) (Table 4). Most frequent surgery done on patients was (APR) in 55 cases (28.8%). 179 patients (92.7%) were discharged while they recovered relatively. Other patients conditions were as below: 1- Right and left hemicolectomy 2- Sigmoidectomy 3- Tumor resection and anastomosis 4- Transverse colectomy 5- Recto sigmoidectomy, anastemosis, etc 6- Other complex surgeries, discharging based on selfsatisfaction. (Table 5) DISCUSSION The results of this study which was done on 191 patients of Shahid Rahnemoon and Afshar hospitals showed that most of patients were old urban men who had consulted the Doctor because of rectorrhagia, abdominal pain and bowel habit changes. Although their diseases were chronic, were diagnosed in a suitable stage. (Stage B). Surgical therapy fundamentals which are based on age, sex, signs and symptoms, type and location of tumor and disease stage were similar to other studies. 4, 7, 16 Vafaee et al. Chen, Cotran and Kumar reported that prevalence of colorectal cancer in age older than 60 is higher in men than women. 4-13,19 The proportion incidence of this cancer in the urban to the rural is 1per 8. As we know low vegetable fibers, high purified carbohydrates and fat in diet are risk factors for colon and rectum cancers. 1 So may be one of the reasons of more prevalence of these cancers incidence is diet. It should be noted that occupation factor didn t have any role in colorectal cancer which was similar to the results of moertel Fleming et al study. 6 The symptoms made patients to consult a Doctor were respectively as noted; Rectorrhagia (50.3%), abdominal pain (38.7%), obstruction (8.9%) and constipation (1.6%). 1,4,7 Since suitable surgical procedure depends on mass location, primary surgical findings, experience and judgment of surgery. 3,8 the results of our study different from other studies in other hospitals. Most common procedures used by surgeons of this study are listed below APR (28.8%), AR (20.9%), right or left hemicolectomy (13.1% equally) and transverse colectomy (3.7%). While in another study done by Vafaee et al on 236 colon and rectum cancer cases, proportion of APR and AR methods were 34% and 35.5% respectively. 13 According to the location of tumor involved, the results were as below: rectum and sigmoid: 58% Cecum, ascending, transverse and descending colons: 42% Since 31 cases of this study had multi locations involved, the results of our study were similar to some other studies. 4, 10, 11 In this study rate of lymphoma was less than adenocarcinoma (2.6% vs. 97.4%) 4-9, 12-14, 19 which was similar to other studies too. Nowadays, colorectal cancers are diagnosed in primary stage of T1, Nx, Mx using colonoscopy. Although most primary colon and rectum cancers can be resected properly through anus, we should consider some risk factors such as undifferentiated cancer invasive to lymphatic and blood vessels or previous partially resected carcinoma. Also in inferior rectal cancers, supportive treatments such as chemotherapy and radiotherapy are needed. 15,16 Molecular biologic progresses help to diagnose specific antigens which are presented just in colorectal cells and we can stimulate immunological response against them specifically. Since we are not able to increase their lifetimes, radiotherapy is considered as a potential therapy, so it s recommended that all surgeons will be aware of different immunotherapy methods to cure their patients better. 17 The survival of colorectal cancer is 5 years in 90% patients. Since in metastatic stage other therapies are not useful, we should consider chemotherapy and controlling factors involve cancer progress such as genetic and epigenetic factors (age, sex and immune response).the results of some studies revealed that nonsteroidal anti-inflammatory drugs (NSAIDs) can decrease rate of death followed by colorectal cancers by 40-50%. 18 Suggestions Patients with ambiguous abdominal pain or bowel habit change and also old people suffering from anemia, weakness and fecal color change should undergo sigmoidoscopy and colonoscopy. PR (per rectal) examination and blood test should be done annually in these patients especially after age of 40 years. 34

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