Transcript The cancer has grown beyond the muscularis of the colon or rectum

Cancer colon and rectum
(Incidence)
 General
 2nd
common after brochogenic carcinoma in
men
 4th common in females
 Age
– Abroad old
– Egypt 40y
Etiology Of Colon Cancer
Hereditary nonpolyposis colon cancer
5-6%
Sporadic Colon Cancer
92%
Chronic IBD 1%
Familial Adenomatous polyposis
and rare syndromes
1%
Cancer colon and rectum (Etiology)
 Diet
– Diet lacking vegetables
– Low residue diet---increase constipation
– High fiber diet----increase bile--carcinogens
– Cooked meat -----carcinogens
 Precancerous
lesions
– Polyps--- tubuls, villous, FAP
– IBD
– Uretrocolic anastomsis
Familial Adenomatous Polyposis
(FAP)
 Autosomal
dominant inheritance of
mutated APC gene in chromosome 5
 Hundreds to thousands of colorectal
adenomas, average age of onset 16
 Colon cancer by age 45 (mean age
39, &% by age 21)
Familial Adenomatous Polyposis
(FAP)
 Genetic
tests, counseling age 10 to
12
 Flexible sigmoidoscopy
– annually or biannually for positive
genetic test
 Colectomy
when adenomas develop
Hereditary Nonpolyposis Colorectal
Cancer Syndrome (HNPCC)
 Autosomal
dominant inheritance of
altered mismatch repair gene
 Cancers preceded by a few rapidly
growing adenomas
 Cancers multiple, proximal, younger
age of onset
Cancer colon and rectum
(pathology)
3%
5%
3%
5%
5%
12 %
7%
2%
38%
21%
Pathology ( NEA)
Pathology (MP)
 Adenocarcinoma
95%
– Well differentiated
– Moderately differentiated
– Poorly differentiated
 Mucoid
or colloid signet ring
 Squamous cell carcinoma
 Rare types
Stage 0 Colorectal Cancer


Known as “cancer
in situ,” meaning
the cancer is
located in the
mucosa
Removal of the
polyp
(polypectomy) is
the usual
treatment
Stage I Colorectal Cancer
cancer has
grown
through
mucosa
and
invaded
the
muscularis
(muscular
coat)
Treatment is
surgery to
remove the
tumor and some
surrounding
lymph nodes
Stage I Colorectal Cancer
Stage II Colorectal Cancer
The cancer has
grown beyond
the muscularis of
the colon or
rectum but has
not spread to the
lymph nodes
Stage II Colorectal Cancer
Stage III Colorectal Cancer
The cancer has spread
to the regional lymph
nodes (lymph nodes
near the colon and
rectum)
Stage III Colorectal Cancer
Stage IV Colorectal Cancer
The cancer has spread
outside of the colon or
rectum to other areas of
the body
Stage IV Colorectal Cancer
Stage IV Colorectal Cancer
Stage IV Colorectal Cancer
Methods of spread

Intramural spread
– Spread is three-dimensional;
 the
distal margin is of great concern in low rectal
cancers (2-3 cm are considered enough)
 Extension to adjacent structures

Lymphatic spread
–
–
–
–
N
N
N
N
1
2
3
4
Epicolic
paracolic
intermediate (SMA, IMA)
central groups of LN (para Aortic).
IMA
Superior rectal
Internal iliac
Middle rectal
Inferior rectal
Inguinal LN
Methods of spread
 Hematogenous
spread
– Predominantly to the liver
– The lung is the second affected organ
 Transperitoneal
spread
– Seedlings
– malignant ascites
– omental deposits
– Specially occurring in mucinous cancer
and is beyond surgical cure.
Clinical picture of cancer
Colon & Rectum
Alteration in bowel habit
Sever form mainly
constipation
Alteration in bowel habit in
the form of mild diarrhea
Anemia, which is quite severe
Intestinal obstruction is late
A mass
felt in advanced cases
Complication of
Acute appendicitis
Intussussption
Perforation
hge
Vague upper
abdominal pain
Intestinal obstruction
early
A mass
felt in early cases
Complication of
Perforation
hge
1- Rectal bleeding most frequent
presentation.
2-Sense of incomplete
evacuation
3-Tenesmus is prominent in
rectal cancer
4- Recent alteration in bowel
habit (increasing constipation
alternating with diarrhea or
spurious morning diarrhea
Signs
Cancer colon
 General
– Anaemia & loss of
weight
– Virchow’s LN
– Oedema of LL
 Abdominal
– Abdominal Mass
– Liver mass
– Ascites
– PR & PV
 Krukenberg
 Plummer’s shelf
Cancer Rectum
 General
– Anaemia & loss
of weight
– Lung metastases
 Abdominal
– Liver mass
– Ascites
– PR
Mass in the
rectum 90 %
of cases
Investigations

Laboratory
–
–
–
–
Liver function
CBC anaemia
Stool for occult blood
Tumor markers (CEA
&Ca19)
Investigations

Radiological
–
–
–
–

Proctosigmoidoscopy
–

Chest x ray or CT
Double contrast barium enema
Ultrasonography for the liver and LN
CT or MRI which will more accurately
delineate the LN and perirectal fat
Diagnose almost 50% of the cases
Colonoscopy
–
It is the gold standard
Rectal cancer
Cancer colon
Cancer caecum
Cancer sigmoid
General Rules (1)
Preoperative preparation
 Traditional
–Pre
–Pre
–Pre
–Pre
–Pre
by
by
by
by
by
5
4
3
2
1
method
days ----- low residue diet
days ----- low residue diet
days ----- fluid only
days ------ NPO
days ------ NPO
Mechanical &
Chemical
General Rules (1)
Preoperative preparation
 Mechanical
–Laxative at night 60 cm parrafin
–Cleaning enema up to 4 time per
day
 Chemical
–Neomycin
–Erythromycin
–Metronidazole
General Rules (1)
Preoperative preparation
 Rapid method
–Polyethylene glycol can be drunk or
given through NG Tube 2-3 liters
over 24 hours
–Alternatively (in urgent cases) on
table lavage using appendix stump
as a portal of entry can be very
effective
General Rules (2)
Radical resection
 Any
surgical resection requires 5 cm
proximal and 2 cm distal clearance
for colonic lesions
 Radial margin should be
histopathologically free of tumor if
possible
 Lymph node resection should be
performed to the origin of the
feeding vessel
General Rules (3)
During resection
1.
2.
3.
4.
5.
Surgical resection requires 5 cm
proximal and 2 cm distal clearance
for colonic lesions
Early vein ligation
High artery ligation
Non touch technique
En block resection
General Rules (3)
Asses operability
1.
2.
3.
4.
5.
Tumor mobile or fixed
LN involvement
Peritoneal; seedlings
Malignant ascites
Liver metastases
Depending on site of lesion surgical
options
Caecum, ascending colon,– Right
hemicolectomy
 hepatic flexure --Extended right
hemicolectomy
 Transverse colon – transverse colectomy
or Extended right hemicolectomy
 Splenic flexure, descending colon – Left
hemicolectomy
 Sigmoid colon – sigmoidectomy or
Anterior resection

Caecum
Cancer rectum
Upper
1/3 --–Anterior resection
Lower 1/3
–Abdomino-perineal
resection with proximal
permanent stoma
Cancer rectum
 Middle
1/3 --–Abdomino-perineal resection with
proximal permanent stoma
–Low Anterior resection with stapler
–Sphincter saving options
Abdoinosacral
approach
Pull-through with trans-anal colo-anal
anastmosis
Rectal Dissection
Anterior
Rectal Dissection
Posterior
–Low Anterior resection with stappler
–Low Anterior resection with stappler