Transcript curs 16 Cancer rectum+prolaps22

RECTAL
PROLAPSE
Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.
Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.
In children:
Aetiology
the predisposing causes are:-
 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.
In adult:
the predisposing causes depend
on type of the prolapse.
Partial prolapse




Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.
Complete prolapse
is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.
 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to
incontinence.
Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?
Examining for rectal prolapse
Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients
Radiologic
examination
Complications of rectal prolapse:




Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene
the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.
Prolapse in children:
 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.
 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.
Partial prolapse:
 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.
Complete prolapse:
Surgery always necessary, none are
ideal.






Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)
Rectal cancer
2005 Estimated US Cancer Deaths*
Lung and bronchus 31%
15% Breast
Prostate
10%
10% Colon and rectum
Colon and rectum
10%
 6% Ovary
Pancreas
5%
 6% Pancreas
Leukemia
4%
 4% Leukemia
Esophagus
4%
 3% Non-Hodgkin
lymphoma
Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma
3%
 3% Uterine corpus
 2% Multiple myeloma
Urinary bladder
3%
 2% Brain/ONS
Kidney
3%
22% All other sites
All other sites
24%
27% Lung and bronchus
Decreasing mortality of CRC
5-year Survival
1960-70
1980-90
Colon cancer
40-45%
60%
Rectal cancer
35-40%
58%
Anatomic Location of CRC
 Cecum
14 %
 Ascending colon
10 %
 Transverse colon
12 %
 Descending colon
7 %
 Sigmoid colon
25 %
 Rectosigmoid junct.9 %
 Rectum
23 %
70%
Epidemiology
 Increasing Incidence of CRC
 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death
Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased
Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer
WHO Classification of CRC









Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma
Anal Cancer
Anal cancer
Middle rectal cancer
Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor
 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.
!!! RECTAL EXAMINATION
Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS
 RECTOSCOPY
 COLONOSCOPY
+ BIOPSY
Indications
- Suggestive
images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy
EUS
 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion
Requires contact with tumor and a
lumen in which to be inserted.
MRI – standard of care
Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence
Clinical Staging of CRC
TNM
stage
Primary
tumor
Lymph-node
metastasis
Distant
metastasis
Dukes
stage
Astler-Coller
modified
Dukes stage
Stage 0
Tis
N0
M0
A
A
Stage I
T1
N0
M0
A
A1
T2
N0
M0
A
B1
T3
N0
M0
B
B2
T4
N0
M0
B
B2
A
any T
N1
M0
C
C1/C2
B
any T
N2, N3
M0
C
C1/C2
Stage IV
any T
any N
M1
D
D
Stage II
Stage III
TNM Classification
Tis
T1
T2 T3
T4
Mucosa
Muscularis mucosae
Submucosa
Muscularis propria
Subserosa
Serosa
Extension
to an adjacent
organ
Stage and Prognosis
Stage
5-year Survival (%)
0,1
Tis,T1;No;Mo
> 90
I
II
T2;No;Mo
T3-4;No;Mo
80-85
70-75
III
T2;N1-3;Mo
70-75
III
III
T3;N1-3;Mo
T4;N1-2;Mo
50-65
25-45
IV
M1
<3
Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk
Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences
Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%
relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction
ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+
 Non-resectable cases: local recurrences
– Preoperative RT with or without CT
Predicting risk of recurrence in RC
 Surgery-related
 Tumor-related
-Low anterior resection
-Anatomic location
-Excision of the mesorectum
-Histologic type
-Extent of lymphadenectomy
-Tumor grade
-postoperative anastomotic
-Pathologic stage
leakage
-Tumor perforation
-radial resection margin
-neural, venous, lymphatic
invasion
Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)
Type of surgery
INVOLVEMENT OF MESORECTAL FASCIA
Abdomino-perineal resection
MILES
Anterior resection and very low
anterior resection
Follow up!!
Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass
 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes
Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure
Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative
Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins
Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision
Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma