Colorectal cancer is one of the common malignant tumors in China, ranking fifth among the ten types of common cancers, and the incidence of colorectal cancer has gradually increased in recent years due to changes in dietary structure. Among them, colon cancer is more obvious.
According to China’s Shanghai tumor registry, the annual incidence rate in 1960 was 6.66/100,000 population, accounting for 5.3% of all malignant tumors, and rose to 20.37/100,000 population in the 1970s. Moreover, the incidence of rectal cancer declined, while colon cancer gradually increased. Shanghai statistics of the ratio of rectal cancer to colon cancer, 1.07:1 for men and 1.12:1 for women, the age group of colorectal cancer incidence between 30 and 60 years old, 1564 cases as age analysis, between 31 and 60 years old, 1564 cases as age analysis, those aged 31 to 60 years old accounted for 69%.
Worldwide, the incidence and mortality rate of colorectal cancer is the highest in Denmark, Luxembourg and New Zealand, with an annual incidence rate of 20/100,000 people, accounting for the second highest incidence and mortality rate of malignant tumors.
This disease belongs to “dirty poison”, “lower jiao damp heat”, “intestinal wind”, “locked hemorrhoids” and “intestinal spleen” in Chinese medicine. It belongs to the category of “intestinal toxicity”, “lower jiao damp heat”, “intestinal wind”, “locking anal hemorrhoids”, “intestinal Qin” and other diseases. Chinese medicine understands the etiology and pathogenesis of colorectal cancer from internal and external factors. The external factors include the cold guest outside the intestine; or sitting on the wetland for a long time; or uncontrolled diet, eating fatty, sweet and thick tastes, damaging the spleen and stomach, losing the function of transportation and transformation, causing dampness and heat to grow inside and heat poison to flow into the large intestine and become swelling. Because of depression and worry, the spleen and stomach lose harmony, dampness and heat accumulate in the intestine, which causes blood stagnation and tumor. Therefore, this disease is caused by internal deficiency of positive energy, internal accumulation of dampness and toxicity, and stagnation of blood and Qi.
1. Diagnosis
1.1 Clinical manifestations
1.1.1 Symptoms and signs: colorectal cancer has no obvious symptoms in early stage, sometimes it can be asymptomatic for many years, and the clinical manifestations are related to the location, size and secondary changes of tumor. Left-sided colorectal cancer obstructive symptoms are more common than right-sided, while right-sided colorectal cancer is dominated by toxic symptoms, anemia and abdominal mass. The clinical frequency of right-sided colon cancer is most common in the order of abdominal mass, abdominal pain and anemia; left-sided colon cancer is most common in the order of blood, abdominal pain and stool frequency; rectal cancer is most common in the order of blood, stool frequency and stool deformation.
1.1.1.1 Blood in stool: the bleeding volume of left colon cancer is more, mostly flesh-eye blood stool; rectal cancer may have pus and blood stool due to secondary infection on the surface, while the right colon stool is fluid, so the bleeding volume is less, and the color changes due to mixing in stool, sometimes jam-like, flesh-eye blood stool is less common, and most patients have positive occult blood.
1.1.1.2 Abdominal pain: abdominal pain can appear at an early stage and is easily ignored. Tumor growth of considerable size or infiltration of intestinal wall causing intestinal obstruction can lead to paroxysmal abdominal cramps with symptoms of intestinal obstruction. Severe anal pain can be caused by rectal cancer invading the anal canal, and in a few patients, acute peritonitis may occur due to tumor perforation, and in advanced patients, invasion of the surrounding posterior abdominal wall may cause severe pain in the corresponding area.
1.1.1.3 Change of defecation habit: It is often the earliest symptom. The tumor itself secretes mucus and the secondary inflammation changes not only increase mucus stool but also stimulate intestinal peristalsis, which increases the number of defecation and makes the stool unshaped or thin stool.
1.1.1.4 Abdominal mass: When the diagnosis of colon cancer is established, some patients have already touched the abdominal mass. The malignancy of colon cancer is low compared with other gastrointestinal tumors, and there is no spread when the local growth reaches a considerable volume.
1.1.1.5 Anemia: the main cause of anemia is bleeding from cancer, which is caused by chronic blood loss. It is mostly seen in right hemicolectomy cancer. In the late stage of the disease, anemia is related to malnutrition and systemic consumption. At this time, the patient is accompanied by wasting and weakness, hypoproteinemia and other debilitating manifestations.
1.1.1.6 Others: Tumor growth causes narrowing or even complete blockage of intestinal lumen, which may cause intestinal obstruction. Tumor invasion of surrounding organs may cause internal fistula such as gastrocolic fistula, colo-vesical fistula, colo-vaginal fistula, acute perforation of tumor may cause symptoms of acute peritonitis, and metastasis may cause symptoms of metastasis.
1.2 Auxiliary examination
1.2.1 Rectal palpation: It is simple and easy to detect rectal masses within 7-8 cm from the anus, and if the patient is asked to hold the breath to increase the abdominal pressure, it can reach higher parts. Most rectal cancers can be detected by rectal diagnosis.
1.2.2 Endoscopy: including proctoscopy, sigmoidoscopy and fiberoptic colonoscopy. Proctoscopy is the most convenient for tumors in the lower rectum, and no bowel preparation is required. Sigmoidoscopy can examine the whole rectum and part of sigmoid colon within 25 cm from the anal verge. For patients who are more than 25 cm from the anal verge, fiberoptic colonoscopy is currently the most reliable examination method.
1.2.3 X-ray examination: It is the most common and effective method to diagnose colorectal cancer. At present, colon double contrast imaging is the preferred method to diagnose colorectal cancer.
1.2.4 CT diagnosis: Pre-operative CT examination of colorectal cancer is helpful to judge the stage of the disease and the possibility of resection.
1.2.5 MRI examination: the same as CT examination.
1.2.6 B-type ultrasound examination.
1.3 Diagnostic criteria
Clinical symptoms and signs combined with anal finger examination, X-ray barium enema examination and various endoscopic examinations can reveal the swelling, pathological examination can confirm the diagnosis, and stool routine has an auxiliary diagnostic role.
1.4 Differential diagnosis
Since the clinical manifestation of colorectal cancer is not specific, many non-neoplastic diseases can show symptoms and signs similar to those of colorectal cancer. Right hemi-colon cancer may have right lower abdominal pain and abdominal mass, etc. Sometimes it needs to be differentiated from appendicitis, appendiceal abscess, intestinal tuberculosis and Crohn’s disease. Some patients with colon cancer have anemia as the first symptom. A few patients may be misdiagnosed as ulcerative colitis or schistosomiasis granuloma. Colonoscopy can differentiate them.
Rectal cancer and sigmoid colon cancer have pus and blood stool and urgency, and a considerable number of patients are misdiagnosed as “dysentery” and “enteritis”. Patients with pus and blood stools should be further examined in the following cases: 1.
1. Non-infectious disease epidemic season;
2. More blood than pus in the stool;
3. Inflammatory treatment is ineffective or relapses after the effect is seen;
4. The patient is older;
5. Persistent positive fecal occult blood.
Rectal cancer with bleeding as the first symptom can be easily misdiagnosed as “hemorrhoid”, and should be distinguished by routine anal finger examination.
1.5 Staging and staging
Since Dukes proposed the staging of rectal cancer in 1935, there have been many modified Dukes staging schemes. However, the basic principles of Dukes’ staging are still recognized internationally.
Dukes’ stage A – the cancer does not penetrate the muscle layer and there is no lymph node metastasis.
Dukes’ B stage – the cancer has penetrated deep into the muscular layer and may invade the plasma membrane, extra-plasma membrane or perirectal tissue, but there is no lymph node metastasis.
Dukes’ C stage – the cancer is accompanied by lymph node metastasis.
Stage C1: cancer with lymph node metastasis in the parietal and mesenteric areas;
Stage C2: cancer with lymph node metastasis at the ligature of the mesenteric artery.
Dukes’ D stage – cancer with metastasis to distant organs or incurable or unresectable after resection due to extensive local infiltration or extensive lymph node metastasis.
TNM clinical staging (UICC 1997)
T Primary tumor
Tx Primary tumor cannot be estimated
T0 No primary tumor found
T1s Carcinoma in situ: located in the mucosal layer or invading the lamina propria
T1 Tumor invades the submucosal layer
T2 Tumor invades the muscular layer
T3 Tumor invades the muscular layer up to the subplasma, or invades the paracolon or pararectal tissue, but does not penetrate the peritoneum
T4 Tumor directly invades other organs or structures and/or penetrates the peritoneum of the visceral layer
N Local lymph nodes
Nx Local lymph nodes cannot be estimated
N0 No local lymph node metastasis
N1 1-3 local lymph node metastases
N2 4 or more local lymph node metastases
M Distant metastasis
Mx Unable to estimate distant metastases
M0 with distant metastases
Clinical staging.
Stage 0
T1s
N0
M0
Stage I
T1
N0
M0
T2
N0
M0
DukesA
Phase II
T3
N0
M0
DukesB
T4
N0
M0
Phase III
Any T
N1
M0
Any T
N2
M0
DukesC
Phase IV
Any T
Any N
M1
DukesD
2.Cognitive evidence
2.1 Damp-heat infusion: abdominal pain at times, red and white dysentery, shortness of breath, visible fever, nausea and dryness of the chest, red tongue with yellow greasy coating, slippery pulse.
2.2 Internal obstruction by stasis: abdominal pain, dysentery with pus and blood, shortness of breath, abdominal lump hard and immovable, irritability and thirst, purple tongue or petechiae, yellow fur or dryness with little fluid, and string pulse.
2.3 Spleen and kidney yang deficiency: fatigue, cold and sleepy limbs, soreness and weakness of the waist and knees, diarrhea on the fifth shift, fat and light tongue, white and greasy coating, sunken and thin pulse.
2.4 Deficiency of both qi and blood: white face, shortage of energy and weakness, or even large meat off, unformed stool or anal dislodgment, pale tongue with thin white coating, weak pulse.
3.Treatment
3.1 Chinese medicine treatment
3.1.1 Discriminatory treatment
3.1.1.1 Damp-heat infusion evidence
Treatment: Clearing heat and relieving dampness.
Formula: Bai Tou Weng Tang with addition and reduction. Sophora japonica 9g, Diyu 9g, Baitou wong 12g, Fructus septica 15g, Angelica sinensis 9g, Fangfeng 9g, Huangbai 9g, Baiying 9g, Shengcoi 30g, Horsetail 12g.
3.1.1.2 Evidence of internal obstruction by stasis and toxins
Treatment: Removal of blood stasis and toxins.
Formula: Sophora Jiao Di Yu Tang with addition and subtraction. Guiweiwei 6g, red peony 9g, peach kernel 9g, safflower 6g, honeysuckle 9g, forsythia 9g, baiying 9g, locust flower 9g, raw earth 12g, septoria 15g.
3.1.1.3 Evidence of Yang deficiency in the spleen and kidney
Treatment: Strengthening the spleen and benefiting the kidney.
Formula: Spleen and Kidney formula with addition and subtraction. Huang Qi 30g, Huang Jing 15g, Fructus Lycii 15g, Semen Cuscutae 15g, Atractylodes Macrocephala 12g, Poria 12g, Fructus Cyperus 15g, Semen Cyperus 30g, Bai Ying 12g, Sophora flavescens 9g, Fructus Sulcus 15g.
3.1.1.4 Evidence of double deficiency of Qi and Blood
Treatment: Tonifying Qi and nourishing Blood.
Formula: Bajhen Tang with addition and subtraction.
3.1.2 Commonly used Chinese patent medicines
Jian spleen and kidney punch, 30g (1 bag) each time, taken orally, twice daily.
Zhenqi Fuzheng capsule, 3-6 capsules per day, taken orally, 3 times daily.
Ligia Tablets, 5mg per time, orally, 3 times daily.
Pingxiao Tablets, 6 tablets each time orally, 3 times daily.
Huaqansu Tablet, 4-6g orally each time, 3 times daily.
Jinlong Capsules, 3-4 capsules orally 3 times a day.
Sambucus Erythrina Punch, 20g per dose, orally, 3 times daily.
Ginseng and Astragalus tablets, 4-6 tablets each time, orally, 3 times daily.
Plum Blossom Pointed Tongue, 2 tablets per dose, orally, 3 times daily.
Eleutherococcus injection, 0.4~0.6 added to 500ml of glucose or saline in a sedative drip, once a day, 15 times for 1 cycle.
Huachanin injection, 20ml added to 500ml of glucose or saline in a sedative drip, once a day, 28 times for 1 cycle.
Add 50-100ml to 500ml of glucose or saline as a sedative drip, once a day, 15 times a cycle.
Compound bitter ginseng base injection, 20ml in 250ml of glucose or saline, 1 time a day, 10 times a cycle.
The above drugs can be adjusted according to the patient’s condition.
3.2 Western medical treatment
3.2.1 Surgical treatment
3.2.1.1 Colon cancer: surgical resection as far as possible. If the lesion is confined to the mucosa or submucosa layer and no lymph node metastasis is seen, regular observation after surgery; if the lesion invades beyond the muscle layer or has lymph node metastasis, adjuvant chemotherapy is needed after surgery.
3.2.1.2 Rectal cancer: surgical resection as far as possible. If the lesion invades pararectal tissue, preoperative radiotherapy can be chosen according to the situation; if the lesion invades deep muscle layer or has lymph node metastasis after surgery, postoperative radiotherapy is feasible, and chemotherapy is regularly administered after radiotherapy.
3.2.1.3 Liver metastasis of colorectal cancer: those who can be operated should be operated as much as possible. For those who cannot be operated, hepatic artery cannulation chemotherapy (embolization) is feasible.
3.2.2 Chemotherapy
Commonly used chemotherapy regimen:CF+5-FU, platinum oxalate+CF+5-FU, CPT-11+ CF+5-FU. 2-4 weeks after surgery, start chemotherapy and complete 4-6 cycles after surgery.
3.2.3 Immunobiologic therapy
While applying radiotherapy, chemotherapy and Chinese medicine, biological treatment with thymidine, immune ribonucleic acid, IL-2 and interferon will also be used to improve the immune function of the body.
3.2.4 Radiotherapy
Colorectal cancer can be treated with preoperative and postoperative radiotherapy, late palliative radiotherapy and internal irradiation.
3.2.5 Targeted therapy
The most used targeted therapies in colorectal cancer with impressive achievements are cetuximab and bevacizumab.