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Colorectal Carcenoma - Copy by undergraduate .pptx
- 1. Colorectal Carcinoma Cadet Ye Htut CadetYe Sithu Aung Year 5 – Group B 22.7.2024
- 2. Contents Anatomy Epidemiology Aetiology Pathology Spread Staging Clinical features Investigations Management
- 3. Anatomy of Colon Length – 1.5m (5 feet) Parts – Caecum with appendix, ascending colon, hepatic flexure, transverse colon, splenic flexure, descend colon, sigmoid colon Characteristic features 3 taneniae coli Appendices apiploicae haustration
- 5. Blood supply • Ileo-colicartery • Right colic artery • Middle colic artery • Left colic artery • Sigmoid artery • Superior rectal artery • Marginal artery of Drummond
- 6. Anatomy of Rectum Length – 12-18cm Start – S3 End – Coccyx (anorectal junction) Parts Upper third 4 cm Middle third 4cm (ampulla of rectum) Lower third 4 cm
- 7. Relations of therectum Anterior Bladder Seminal vesicles and prostate (males) Denonvillier’s fasia (males) Pouch of Douglas and rectovaginal septum (females) Uterus and cervix (females) Ureters Lateral Lateral ligaments and middle rectal artery Obturator internus muscle and side wall of pelvis Pelvic autonomic plexus Levator ani muscle
- 8. Relations of therectum Posterior Sacrum and coccyx Waldeyer’s fascial condensation Superior rectal artery and lymphatics Hypogastric nerves
- 9. Relations of therectum
- 10. Blood supply • Superiorrectal artery • Middle rectal artery • Inferior rectal artery
- 11. What is colorectalcancer? Colorectal cancer starts in the colon or the rectum. Colon cancer and rectal cancer are often grouped together because they have many features in common. Cancer starts when cells in the body start to grow out of control.
- 12. Epidemiology Second mostcommon causes of cancer death in UK One-third of diseases in rectum and two-thirds in colon Men : women = 3 : 1 Peak age of incidence 45-65 but is increasing in younger ages Occurs frequently in resource-poor world than in resource-rich countries
- 13. Aetiology 1. Genectics APC(adenomatous polyposis coli) gene mutation(chromosome 5) – 60% of cases FAP (familial adenomatous polyposis) Autosomal dominant inherited disease due to mutation of APC gene >100 colonic adenomas are diagnostic Prophylactic surgery is indicated to prevent colorectal cancer Polyps and malignant tumours can develop in the duodenum and small bowel
- 14. FAP (Familial adenomatouspolyps)- usually visible on sigmoidoscopy by the age of 15 years.
- 15. HNPCC (hereditarynon-polyposis colorectal cancer) or Lynch’s syndrome Autosomal dominant Mutation in one of the DNA mismatch repair genes Increase risk of colorectal cancer and cancers of endometrium, ovary, stomach and small intestine Risk of cancer – 80% Mean age – 45 years Site – proximal colon Females – 30-50% risk of Ca endometrium
- 16. Aetiology 2. Diets dietaryfibres decrease risk dietary animal fat increases risk 3. Life style Smoking alcohol drinking 4. Predisposing conditions Inflammatory bowel diseases (UC and Crohn) Cholecystectomy Strong family history of colorectal cancer
- 18. Pathology Macroscopically 1. Annular 2.Tubular 3. Ulcer 4. Cauliflower Microscopically Columnar cell adenocarcinoma
- 19. Distribution of colorectal cancerby site Most large bowel cancers arise from the left colon
- 20. Spread Direct spread Ureter, duodenum and posterior abdominal wall muscles Adjacent organs or anterior abdominal wall Lymphatic spread Progress from closest to central nodes Blood-borne metastases Liver by portal vein, lung, ovary, brain, kidney and bone Transcoelomically spread From the serosa of bowel or subperitoneal lymphatics Peritoneum, ovary and omentum
- 21. Staging colon cancer Based on pathological reporting to predict prognosis and guide adjuvant treatment Two systems Dukes’ classification TNM system TNM system is regarded as the international standard.
- 22. Staging colon cancer Dukes’ staging for colorectal cancer A : invasion of but not breaching the muscularis propria B : breaching the muscularis propria but not involving the lymph nodes C : lymph node involved Dukes himself never describes a stage D, but this is often used to describe metastatic disease.
- 23. Dukes’ staging forcolorectal cancer
- 24. Staging colon cancer TNM classification for colonic cancer T Tumour stage • T1 Into submucosa • T2 Into muscularis propria • T3 Into pericolic fat or subserosa fat but not breaching serosa • T4 Breach serosa or directly involving another organ N Nodal stage • N0 No nodes involved • N1 1-3 nodes involved • N2 Four or more nodes involved M Metastases • M0 No metastases • M1 Metastases
- 25. TNM classification forcolonic cancer
- 26. Clinical features Dependson site of the tumour Right sided (caecum and ascending) location • Mass in RIF • Iron deficiency anaemia Descending-sigmoid location • PR bleeding – typically dark red, mixed with stool, sometime clotted • Change in bowel habit – typically increase frequency, varieable consistency, mucus PR, bloating and flatulence • Colicky abdominal pain • Abdominal distension
- 27. Clinical features Transverselocation • Mass in epigastrium • Iron deficiency anaemia Emergency presentations • Occurs in 20% of cases • Large bowel obstruction (colicky pain, bloating, bowel not open) • Perforation with peritonitis • Acute PR bleeding
- 28. Clinical features Featuresdue to blood-borne metastases • Liver – hepatomegaly and jaundice • Lungs – cough, chest pain and haemoptysis • Bone – bone pain • Brain – fits and headache
- 29. Investigations Screening • Fecaloccult blood test (FOBT) • Flexible sigmoidoscopy • Colonoscopy • Air contract barium enema (ACBE) • CT colonography
- 30. Endoscopy Good fordirect visualization of tumor Can take biopsy for histological assessment Two types of scope for lower GI • Flexible sigmoidoscopy (60 cm long ) • Colonoscopy (120-180 cm long ) - gold standard investigation highly sensitive and specific and can detect adenomas, polyps, synchronous tumors.
- 32. Radiology Barium enemaX ray • useful for visualizing of right side of large bowel • persistent irregular filling defect with apple core deformity • biopsy is no possible and small lesions may be missed Fig: Apple Core appearance in CA colon
- 33. CT scan •virtual colonoscopy, which is extremely sensitive in picking up polyps down to a size of 6mm • used as a diagnostic tool in patients with palpable abdominal masses • CT of the chest, abdomen and pelvis represents the standard means of staging colorectal cancer • biopsy cannot be taken PET scan • Good for assessment of loco-regional lymph nodes, primary tumossr and distant metastasis
- 34. Ultrasound abdomen •Shows metastasisin liver before and after surgery •Detects tumor, ascites, lymph node enlargement and hydronephrosis MRI •Requires additional staging for local spread
- 35. Laboratory For preoperativeassessment • Blood for complete picture • BTCT, PT • Sugar, electrolyte • Urea and creatinine • Liver function test • ECG • Grouping and matching
- 36. Management Potentially curativetreatment suitable for technically resectable tumors with no evidence of metastasis Surgical resection (with lymphadenectomy) is the only curative treatment. Typical operations are • Right and transverse – right or extended right hemicolectomy • Left - left hemicolectomy • Sigmoid – sigmoid colectomy Laparoscopic surgery • Short-term benefits for patient recovery • Reduced hospital stay, earlier return of bowel function • Reduced morbidity in comparison with open surgery
- 37. Extended right hemicolectomyLeft hemicolectomy
- 38.
- 39. Preoperative preparation Optimusfitness • General condition of patient • Respiratory and nutritional status • If obstructed emergency, resuscitation, adequate rehydration, correction of electrolytes imbalance Counselling and consent Bowel preparation • For 48 hours before surgery, liquid diet only and two sachets of picolux to purge the colon • Rectal washout • In emergency, on-table colonic lavage
- 40. Prophylactic antibiotics •Immediately before the start of surgery Prophylactic lower molecular weight heparin • For deep vein thrombosis prevention Neo-adjuvant therapy Cont.
- 41. Emergency surgery Inthe obstructed emergency cases, the primary relief of obstruction with a primary resection or colostomy is done In right sided, usually possible to perform a right hemicolectomy and anastomosis in the usual manner If perforation, bring out an ileocolostomy rather than forming an anastomosis In left sided, the decision lies between a Hartmann’s procedure or resection and anastomosis An expanding endoluminal metal stent can be treated Three stage procedure – primary decompression, resection of tumour at a later date and closure of colostomy
- 42. Postoperative care Hydrationand monitoring of electrolytes Prophylactic antibiotics – cephalosporin and metronidazole Analgesia Catheterization Careful nursing and dressing wound Early enteral feeding DVT prophylaxis Care of colostomy
- 43. Palliative treatment •For unresectable metastases or unresectable tumors, right sided - ileocolic bypass left sided - colostomy Radiotherapy Chemotherapy Hepatic Metastasis • Can be resected and series have demonstrated 5 year survival of over 30% in resectable disease
- 44.
- 45. Staging of rectalcancer Dukes’ staging A : The growth is limited to rectal wall (15%) B : The growth extends to extra rectal tissues, but without metastases to the regional lymph node (35%) C : Secondary deposit in the regional lymph node. C1 : Local para rectal lymph node alone are involved. C2 : The nodes accompanying the supplying blood vessels to their origin from the aorta are involved.
- 46. Staging of rectalcancer TNM staging – radiological staging T represents the extent of local spread TX : Primary tumour cannot be assessed. T0 : No evidence of primary tumour Tis : intraepithelial or invasion of the lamina propria T1 : tumour invades the submucosa T2 : tumour invades the muscularis propria T3 : tumour invades through the muscularis propria to the pericolorectal tissues T4a : tumour penetrates the surface of the visceral peritoneum T4b : tumour directly invades or is adherent to other organs or structures
- 47. N describesthe nodal involvement NX : regional node cannot be assessed N0 : no regional lymph node metastases N1 : metastases in 1-3 regional lymph nodes N1a : in one regional lymph node N1b : in 2-3 regional lymph nodes N1c : tumour deposit in the subserosa, mesentery or pericolic or perirectal tissues without regional nodes metastases N2 : metastases in 4 or more regional lymph nodes N2a : in 4-6 regional lymph nodes N2b : in 7 or more regional lymph nodes
- 48. M indicatesthe presence of metastasis M0 : no distant metastasis M1 : distant metastasis M1a : metastasis confined to one organ or site M1b : metastasis in more than one organs
- 49. Clinical features Featuresdue to primary tumor 1. Bleeding per rectum – earliest and most common symptom 2. Sense of incomplete defecation – important early symptom 3. Alteration of bowel habit – increasing constipation and early morning bloody diarrhea 4. Pain – late symptom 1. Colicky pain : IO due to advanced carcinoma of rectosigmoid junction 2. Severe pain in SPA : invasion of prostate or bladder 3. Back pain or sciatica : invasion of sacral plexus
- 50. Features dueto blood-borne metastases • Liver – hepatomegaly and jaundice • Lungs – cough, chest pain and hemoptysis • Bone – bone pain • Brain – fits and headache
- 51. On PRexamination Early case – a nodule with an indurated base Ulcerated type – shallow depression with raised and everted edges Lower margin of tumor – distant from anal verge Examining finger – smeared with blood stained mucopurulent discharge On proctoscopy examination, good for Direct visualization of tumor Can take Punch biopsy ( Yeoman’s biopsy forceps) For female, vaginal examination and bimanual examination done for anterior tumor
- 52. Investigations Endoscopy Rigidsigmoidoscopy Colonoscopy Radiology Barium enema X ray CT scan MRI for staging PET scan for distant metastasis
- 53. Laboratory Investigations Forpreoperative assessment • Blood for complete picture • BTCT, PT • Sugar, electrolyte • Urea and creatinine • Liver function test • ECG • Grouping and matching
- 54. Management Curative procedure •Surgical resection Palliative procedure • Surgical by pass and stoma • Radiotherapy • Chemotherapy
- 55. Surgery Surgery remainsthe mainstay of curative treatment for carcinoma of rectum Surgical management depends on the stage and location of the tumor within the rectum The general principles of a surgical approach remain the removal of all gross and microscopic disease with negative proximal, distal, and circumferential margins Reserve intestinal continuity and the sphincter mechanism whenever possible while still maximizing tumor control
- 56. Different surgical options For early cancers ; limited surgeries like • Polypectomy • Transanal excision • Transanal endoscopic microsurgery (TEM) For advanced cancers • Low anterior resection (LAR) or • Abdominoperineal resection (APR)
- 57. Trans-anal excision •Selected T1, N0 early stage cancers • Small (<3cm) • Well to moderately differentiated tumors • Within 8cm of the anal verge • Limited to less than 30% of the rectal circumference • No evidence of nodal involvement
- 58. Abdominoperineal resection(APR) • The gold standard for surgical resection of distal rectal cancer located within 6cm of the anal verge. • This procedure requires a transabdominal as well as a transperineal approach with removal of the entire rectum and sphincter complex. • A permanent end colostomy is created and the perineal wound either closed primarily or left to granulate in after closure of the musculature
- 59. Low anteriorresection • Sphincter saving operation • Suitable for tumors of upper third, middle third and even some tumor of lower third Laparoscopic resection • Short-term benefits for patient recovery • Reduced hospital stay, earlier return of bowel function • Reduced morbidity in comparison with open surgery
- 60. Other operations •Hartmann’s operation • Palliative colostomy Adjuvant therapy • Only radiotherapy • Radiotherapy + chemotherapy Other palliative procedures • Self expanding metal stent (SEMS)
- 61.
- 62. References Bailey andLove’s Short Practice of Surgery ( Norman S. Williams, Ronan O’Connel, Andrew W. McCaskie ).27th Edition. 2018 Oxford Handbook of Clinical Surgery. 4th Edition. 2013 Harold Ellis and Vishy Mahadevan’s Clinical Anatomy. 13rd Edition. 2013 www.radiopaedia.com
- 63. THANK YOU FORYOUR ATTENTION