Colorectal cancer (CRC) is a significant medical and social problem today. More than 500,000 new cases of this disease are recorded annually in the world. The highest incidence rate is noted in countries with high economic development. Men are more often affected than women, in more than half of cases tumor is localized in sigmoid colon and rectum. By their structure, in 95% of cases, large intestine malignant neoplasms are adenocarcinomas.
Unfortunately, CRC is often diagnosed in late stages, which entails an unfavorable prognosis. In case of timely diagnosis, complex treatment is effective, and disease is completely curable. Therefore, if you notice suspicious symptoms in yourself or you have already been diagnosed with such a diagnosis – do not waste your precious time! Seek help from highly qualified specialists who have practical experience in managing patients with such a diagnosis.
Such doctors work in Oncology Department of Maimonides Multidisciplinary Medical Center. Our clinic works in close and fruitful cooperation with the best oncology centers in Israel, we adopted their experience and organized provision of oncological care according to Israeli medicine model, as one of the best in the world. Each clinical case is conducted jointly by the attending physician, the head of the department – Dr. Stefanska Irina and the responsible oncologist-specialist directly from Israel. Thanks to work of such team, we get excellent treatment results for each individual patient, all decisions are made confidentially, and treatment is modified according to patient’s characteristics and his illness.
Maimonides Clinic works under the patronage of “Keren Or for our Child” the Charitable Foundation, so all our patients can receive financial assistance for treatment.
An absolute treatment advantage in Maimonides Oncology Department is the whole multidisciplinary specialists team involvement in diagnostic and treatment process of each individual patient. Patient is assisted by oncologists, surgeons, endoscopists, radiation therapists, chemotherapists, proctologists, psychologists, rehabilitation specialists and other narrow specialists, depending on patient’s needs. At the same time, we practice a purely individual approach to each patient. Making up an examination plan and treatment scheme, doctor does not use one template for everyone,but takes into account all the smallest features of the patient and his disease – age, gender, general health, main diagnosis, type of tumor, its characteristics, stage of the disease, concomitant severe diseases presence, patient’s wishes regarding treatment.
All our doctors have highly qualified and experienced in oncology . Most of them have repeatedly completed internships at the best oncology medical centers in the world (Israel, Germany, USA). Our medical center uses only modern medical and diagnostic equipment of an expert class. All specialists have professional communication skills with oncology patients. If a certain narrow specialist or rare medical and diagnostic equipment is not available, patient is referred to subsidiary institutions of Maimonides Medical Center or our Israeli partner clinics, where he is guaranteed to receive the full range of necessary medical services, where he is guaranteed to receive the full range of necessary medical services.
Colorectal cancer causes and symptoms
Unfortunately, for today, the true causes of colorectal cancer development are not known for sure. The disease is polyetiological, but there are certain factorsthat are associated with an increased risk of CRC developing:
- genetic predisposition (certain genetic syndromes – diffuse polyposis, Lynch syndrome);
- Western type of diet (a large number of refined products with a high content of animal saturated fats and protein);
- pre-existing chronic ulcerative colitis and Crohn's disease presence;
- obesity and type 2 diabetes;
- smoking, alcohol abuse.
Colorectal cancer is characterized by slow growth, and when it reaches large sizes, it takes quite a long time for clinical symptoms to appear. Clinical manifestations depend on localization, type, spread of tumor and possible complications. There are several syndromes that are characteristic of CRC.
Syndrome of functional gastrointestinal disorders. Patients with this disorder may complain of bowel movements disturbances in rhythm and frequency – characteristic constipation or alternating constipation and diarrhea. There are also false urges to defecate, tenesmus (painful urges to defecate that are not accompanied by feces discharge). Sometimes there is a change in feces shape (the shape of a pencil, ribbon, "sheep feces"). For some, fecal incontinence and passing gases (flatulence) are characteristic.
Pain syndrome. It can be both in the early stages of the disease and in the later stages. It is localized in sacroiliac region, perineum, lower abdomen.
Syndrome of pathological secretions . It is most characteristic for rectum lesions, but may also be present in colon cancer. Discharge from anus can be bloody, purulent, mucous. They most often appear during defecation, although they can appear from anus outside defecation act.
Syndrome of disturbed general condition. Patients may note anemia development, persistent fever, general weakness, unmotivated weight loss, etc.
Palpable tumor syndrome. This is not an early symptom, it appears when the tumor reaches large sizes. At the same time, doctor or patient himself can feel a tumor-like formation in abdomen.
Types of colorectal cancer
Depending on tumor histological structure and its origin, several types of colorectal cancer are distinguished:
- Adenocarcinoma. This is the most common type of colorectal cancer, occurring in 95% of all colon and rectum malignant tumors. Adenocarcinoma is prone to invasive growth – it grows into neighboring tissues and metastasizes early.
- Squamous cell carcinoma. This is a malignant neoplasm that grows from glandular cells of intestinal mucosa. It occurs quite rarely, mainly in men after 45 years.
- Colloid rectal cancer. This is a malignant tumor that quickly grows into neighboring structures and metastasizes throughout the body.
- Large intestine lymphoma. It occurs quite rarely as an extranodal lesion in Hodgkin's lymphoma or non-Hodgkin's lymphomas.
- Mucocellular cancer (ring cell) . This is a rather rare pathology, a very aggressive form of cancer. Occurs in people over 50 years old. It metastasizes early, has the ability for aggressive invasive growth in neighboring tissues and organs.
- Undifferentiated cancer. This is an aggressive form of intestine malignant neoplasm from undifferentiated cells. It metastasizes quickly, has a disappointing prognosis.
- Neuroendocrine tumors. Quite rare neoplasms, which are difficult to diagnose, are characterized by a not very favorable prognosis.
- Squamous cell cancer of anal canal and rectum. Malignant tumor growing from squamous epithelial cells lining intestinal mucosa.
According to tumor growth characteristics, colorectal cancer can be exophytic and endophytic. The exophytic form of cancer is when tumor grows into intestinal tube lumen, has a clear base and visible borders with surrounding healthy tissues. Symptoms of the disease appear quite early, which are primarily associated with a violation of fecal masses passage through intestines. The endophytic form of cancer is when the tumor grows deep into intestinal wall, has no clear boundaries, and grows into neighboring organs and tissues. Such a tumor is not detected for a long time, since cancer symptoms appear already in the late stages of process, when there are metastases and sprouting into neighboring organs.
Colorectal cancer diagnosing methods
The golden rule of oncology sounds like this: "the earlier diagnosis is established, the better prognosis and treatment result". Therefore, high-quality and quick diagnosis is an extremely important stage when it comes to a malignant disease. Maimonides Clinic uses only modern equipment of expert class, all our doctors are perfectly familiar with all examination methods of a patient CRC suspected, and are able to interpret received data without error.
The process of patient’s examining with colorectal cancer pursues 2 main aims: to establish and confirm (or refute) diagnosis, as well as to determine the stage of the disease ( oncological process prevalence in the body). Colorectal cancer screening is separately allocated, that is, regular patient's examinations from risk groups for this disease development to detect it early.
There are several screening options for CRC, including:
- Colonoscopy every 10 years.
- Fecal occult blood test annually (fecal immunochemical tests mainly – FIT).
- Flexible sigmoidoscopy every 5 years (every 10 years if combined with FIT).
- CT colonography every 5 years.
- Fecal DNA test in combination with FIT every 3 years.
Fecal immunochemical tests for blood are more sensitive and specific for human blood than previous methods of similar tests. However, a positive blood test can occur as a result of benign disease (for example, ulcers, diverticulosis), and a negative test does not rule out cancer possibility, because cancers do not bleed continuously.
Fecal DNA testing detects DNA mutations and methylation markers released from colon tumors. This test is usually combined with a fecal immunochemical test (FIT). Almost 10% of patients with a positive excrement DNA test result have a normal colonoscopy.
CT colonography (virtual colonoscopy) allows гі to obtain images of large intestine in 2D and 3D mode with the help of multidetector CT and with double intestine contrast by injecting contrast and gas. High-resolution images obtained in 3D mode are close to endoscopic examination in terms of informativeness, hence the name of the method. CT colonography is a promising screening method if contraindications to endoscopy or refusal to perform it are present. But it has a lower sensitivity and depends on radiologist’s experience. This study does not require sedation, but thorough bowel preparation is required; gas distention can cause discomfort. Unlike optical colonoscopy, this diagnostic procedure does not allow to conduct a biopsy from the detected suspicious area. So this is a significant disadvantage of CT colonography.
Colonoscopy is the main diagnosing method of CRC. This is an endoscopic examination of rectum and colon using a modern fiber-optic colonoscope. During examination, specialist has the opportunity not only to examine the entire mucous membrane in detail, but also to take a photo or video recording all diagnostic process. And the most important thing is to perform a biopsy from suspicious area.
After the biopsy we send all materials for revision to the best pathogistological laboratories in the world (Israel, USA, Germany). Thanks to such double checks, we are absolutely sure of diagnosis correctness and subsequent selected treatment tactics.
Our patients also have access to innovative molecular diagnostics of biopsy specimens of biopsy specimens (molecular genetic studies). This is a mandatory part of modern oncological diseases diagnosis. As is known, the direct cause of many tumors is certain gene mutation. Thanks to molecular genetic diagnostics, we can find these mutations and choose the most effective treatment regimens. Because the response to certain drugs effect depends on the type of changes. An example of such modern diagnostics is Foundation One and Caris Molecular Testing.
Irigoscopy (x-ray examination of intestine with contrast), especially with double contrast, can detect many lesseons, but has a slightly lower accuracy compared to colonoscopy.
Establishing a diagnosis of cancer, it is necessary to conduct ultrasound, MRI, CT scan of abdominal cavity, chest organs X-ray and standard laboratory tests to detect signs of metastatic lesions. This will allow us to accurately determine the stage of disease and choose appropriate treatment methods. In order to detect distant metastases, patient may be offered such a modern study as PET-CT or PET-MRI. It allows us to scan the whole body quickly and detect all metastatic lesions, even the smallest ones.
Nowadays colon malignant tumors that have been removed during surgery are required to be tested for mutations in genes that cause Lynch syndrome. People who have relatives with colon, ovarian, or endometrial cancer diagnosed at an early age, or who have several relatives with these diseases, should be tested for Lynch syndrome.
For the purpose of relapses and metastases early detection in patients who received radical treatment course, it is advisable to periodically determine the level of tumor markers – REA and CA 19-9.
Based on obtained data during examination, doctor makes an accurate diagnosis indicating the stage of malignant process and formulates a treatment scheme, according to patient’s individual characteristics and modern clinical recommendations. All necessary diagnostic procedures can be performed directly in clinic, without leaving Ukraine.
Colorectal cancer modern treatment
The indisputable and perhaps the greatest treatment advantage at Maimonides Medical Center is a comprehensive approachapplication. For malignant disease treatment, only one method is never used, but a combination of two or three, or even more treatment methods. This approach gives good results and significantly improves the prognosis. Typically, treatment regimen includes tumor surgical removal in combination with chemotherapy and/or radiation therapy. In some cases, certain innovative treatment methods (target drugs, immunobiological drugs, etc.) or experimental ones are added to treatment program.
Surgical treatment can be performed in 70% of patients without signs of metastatic lesions. Extent of such surgery involves a large tumor resection and its regional lymph nodes, followed by reanastomosis of intestinal segments.
Patients with rectal cancer can undergo sphincter-preserving surgical resection, at a distal distance of ≥ 2,54 inch from primary tumor edge, instead of usual 12.7 inchs, without significant risk of local recurrence or decreased long-term survival. If after sphincter-sparing surgery there is a local recurrence or intestinal dysfunction, which is poorly tolerated, then an abdominoperineal resection is performed with permanent colostomy imposition.
All our surgeons master all intervention techniques and perform all the necessary surgeries. The main principle of a surgeon's work is to perform (if possible) an organ-sparing operation. If a stoma is imposed after initial stage of treatment, then the second stage of surgery treatment is carried out, which is reconstructive and plastic and involves the restoration of fecal masses natural passage through intestines.
Chemotherapy Chemotherapy is used in colorectal cancer treatment. It is used before surgery to reduce the size of primary tumor and after surgery to reduce recurrence risk. In some cases, chemotherapy may be used as the main treatment in combination with radiation therapy. This is necessary in cases of disease late stages and impossibility of tumor radical surgical removal. In our clinic, only modern chemical medicine of well-known global pharmaceutical manufacturers are used. So we are sure of drugs quality, their predicted effect and side effects minimum number. Chemotherapy scheme, doses of drugs, its duration and number of courses are selected for each patient by an oncologist and a chemotherapist. Chemotherapy scheme may include the following drugs - fluorouracil, tegafur, capecitabine, raltitrexide, irinotecan, mitomycin C, adriamycin, oxaliplatin.
Radiation therapy is also used in CRC complex treatment, although certain tumors types of this localization are insensitive to ionizing radiation. Radiation therapy can be used preoperatively when used together or in combination with chemotherapy to reduce primary tumor size and improve outcome of subsequent surgery. In our department, radiation therapy is performed with the help of modern new devices – linear accelerators. Such expert-class equipment allows accurate calculation of required radiation dose for one session and directs it clearly to pathological formation area, while irradiation of adjacent healthy tissues is minimal, which significantly reduces likelihood of side effects after treatment.
Targeted therapy is currently actively used in modern oncology centers for patients with CRC treatment, especially in late stages. A feature of targeted therapy drugs is not cytotoxic (destruction of malignant cells), but mainly cytostatic action (they stop growth and division); therefore, their combination with traditional chemotherapy is expedient. The following targeted drugs are used for CRC: bevacizumab, cetuximab.
Decision regarding certain methods combination of colorectal cancer treatment (which methods to start with, what to add next, at what stage of treatment to perform surgery, when and according to which scheme to use chemotherapy, whether to applicate targeted drugs or other immunobiological drugs) is made consularly by the team specialists and for each patient. Because each person and their disease is different, so our doctors, relying on their experience in oncological pathologies treatment, often depart from standard protocols, changing treatment regimen and doses of necessary drugs, radiation in order to obtain the best possible results for their patients.