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Carcinoma Rectum PowerPoint Presentation

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Description : Check out this medical presentation on anal cancer, which is titled "Carcinoma Rectum", to know about the second most common visceral tumour of the body, i.e., Carcinoma Rectum.

Tags : anal cancer, Carcinoma Rectum, visceral tumour, Hereditery non polyposis colon cancers, Lynch syndrome 1, Lynch syndrome 2,

Published on : May 06, 2021 | Views : 2827 | Downloads : 16

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Slide 1-

CARCINOMA RECTUM
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CARCINOMA OF RECTUM Second most common visceral tumour of the body Common above 50 yrs Younger age – bad prognosis Male : female – 1.2 : 1
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AETIOLOGY Red meat & saturated fatty acids Alcohol & smoking FAP & adenomas are more prone for carcinomas Villous adenoma has 40% chance of turning malignant Ulcerative colitis, Crohns disease, HNPCC carries higher incidence of carcinoma of rectum Family history of rectal cancer – any 1st degree relative of a person with rectal cancer will show 2 times increased risk of carcinoma rectum
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DIETARY FACTORS Excess calorie intake Low content of unabsorbable vegetable fibre High content of refined carbohydrates Intake of red meat Decreased intake of protective micronutrients
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PRE-EXISTING DISEASES INFLAMMATORY BOWELDISEASE ULCERATIVE COLITIS 1% PER YEAR AFTER 10 yrs 10% RISK AFTER 20 yrs CROHNS DISEASE 7% RISK AFTER 20 yrs COLONIC STRICTURES- ADENO CARCINOMA AT THE SITE OF FIBROTIC NARROWING EXCLUDED SEGMENTS AFTER SEGMENTAL BYPASS
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HNPCC Hereditery non polyposis colon cancers 4 – 6 % rectal malignancies Lynch syndrome 1 - Autosomal dominant -Site specific within family -4% may develop carcinoma
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HNPCC Lynch syndrome 2 Autosomal dominant Deletion of mismatch repair gene Colorectal,endometrial, gastric and other types of cancers
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ADENOMA – CARCINOMA SEQUENCE Proposed by vogelstien Adenocarcinoma develop from pre-existing adenoma
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ADENOMA – CARCINOMA SEQUENCE CONTD. Adenoma has high prevelence of carcinoma Distribution of adenoma within the rectum is comparable to that of carcinoma In case of early invasive ca , sorrounding tissue shows preceding changes of evolution
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ADENOMA –CARCINOMA SEQUENCE CONTD Peak incidence of adenoma antedates by some years the peak of carcinoma rectum Risk of carcinoma declines with removal of all identified adenomas
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ADENOMA –CARCINOMA SEQUENCE CONTD. RISK OF DEVELOPING CARCINOMA Number Size – large Type – villous component
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PATHOLOGY MACROSCOPY Annular encircling lesions Central ulcerations with elevated margins Papilleferous infiltrating type Early lesions are small button like areas of elevation
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MICROSCOPY 95% are ADENOCARCINOMAS
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MICROSCOPY 10% of these are colloid carcinomas
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HISTOLOGY Well differentiated Moderately differentiated Poorly differentiated-anaplastic
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SPREAD OF THE CARCINOMA Local spread Lymphatic Haematogenous spread Peritoneal dissemination
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LOCAL SPREAD ANTERIOR- IN MALES PROSTATE,BLADDER& SEMINAL VESICLES. IN FEMALES Uterus , Cervix, Posterior wall of vagina, Pouch of Douglas
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LOCAL SPREAD Posterior sacrum&sacral plexus Lateral- ureter Downward- anaplastic carcinoma
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LYMPHATIC Above the peritoneal reflection- to the inferior mesenteric nodes Below this level to about 1-2cm of the anal orifice is also to the inferior mesenteric nodes In the field of middle rectal arteries spread along these vessels Pre aortic,internal illiac and sacral lymph nodes
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HAEMATOGENOUS SPREAD Via the venous system Anaplastic and rapidly growing tumours sites .liver- 34% .lungs- 22% .adrenals- 11% .brain,bone,ovary- 33%
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PERITONEAL DISSEMINATION Follow penetration of peritoneal cavity by a high lying rectal carcinoma
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CLINICAL FEATURES BLEEDING Earliest, common symptom Fresh bleeding Blood stained stools Blood staining the clothing
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CLINICALFEATURES SENSE OF INCOMPLETE DEFECATION Tenesmus - cancers of lower rectum Spurious diarrhoea Bloody slime
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CLINICAL FEATURES CONTD Alteration in bowel habit Early morning bloody diarrhoea Annular carcinoma- increasing constipatiion Growth at ampulla of rectum- early morning diarrhoea
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CLINICAL FEATURES PAIN Colicky type- advanced growth at rectosigmoid junction Severe – deep carcinomatous ulcer erodes the prostate or bladder Pain in back or sciatica –sacral plexus
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CLINICAL FEATURES WEIGHT LOSS ANAEMIA
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EXAMINATION ABDOMINAL EXAMINATION Normal in early lesions Advanced growths- signs of large intestinal obstruction, colon loaded with faeces may be felt Liver palpated for metastasis Ascites
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EXAMINATION PER RECTAL EXAMINATION Early cases – plateau or a nodule with an indurated base Centre ulceration – shallow depression with everted raised edges Finger smeared with blood or mucopurelent material tinged with blood
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STAGING OF CANCER Dukes staging a- growth limited to the rectal wall b- the growth extended to the extra rectal tissue but no metastasis to regional lymph nodes c- there are secondary deposits in the regional lymphnodes .c 1- local pararectal lymphnodes alone .c 2- nodes accompanying the supplying vessels d D - presence of wide spread metastasis
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STAGING ASTER COLLER STAGING A- MUCOSA ONLY B1- SUBMUCOSA INVOLVED B2- MUSCULARIS INVOLVED C1- INVOLVEMENT OF MUSCULARIS AND NODES C2- INVOLVEMENT OF SEROSA AND NODES D- DISTANT METASTASIS
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TNM STAGING Tx – Primary tumour cannot be assessed Tis – Confined to the mucosa T1 - Extend upto submucosa T2 – Extends into the muscularis propria T3 – Extends in to the sub serosa but not to adjacent structures T4 – Involves adjacent structures
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TNM STAGING Nx – cannot be assessed N0 – no lymph node metastasis. N1 – cancer cells found in 1 to 3 nearby nodes N2 – cancer cells in 4 or more nodes N3 – cancer cells in nodes along named vessels
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TNM STAGING Mx – distant metastasis. cannot be assessed M0 – no distant metastasis. M1 – distant metastasis present
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INVESTIGATIONS Proctoscopy Sigmoidoscopy Biopsy Barium Enema Colonoscopy USG abdomen to look for secondaries CT to check for operability
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SURGERIES ABDOMINO-PERINEAL RESECTION Wherein sigmoid, descending colon & upper rectum is mobilised per abdomen Anal canal with perianal & perirectal tissues are dissected per anally Retained colon is bought out as end colostomy in left iliac fossa
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TYPES MILES – Abdomen first, perineum later GABRIEL – perineum first, abdomen later Lloyd Davis – synchronised(combined)
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PROCEDURE APR is done through lower midline incision in lithotomy position Left sided colon & entire rectum is mobilised from above Rectum is mobilised posteriorly in avascular plane in front of the nerve plane between mesorectum & sacrum Inferior mesentric artery is ligated high proximal at its origin or just beyond its first branch
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CONTD…. Colon is transected & proximal cut end is fashioned from end colostomy in left iliac fossa Through perineum a purse string suture is place around anal margin Circumferential suture is placed around the anus Dissection is deepened using scissor & cautery into the perineal body First posterior & lateral dissections are undertaken, then anterior dissection Perineal wound is closed in layers,Abdomen drain is placed, colostomy is created
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COMPLICATIONS Bleeding Infection of perineal wound Complications of colostomy like prolapse, stenosis & infection Injury to urinary system, ureter, impotence, urinary incontinence
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Sphincter Saving APR with Colo-Anal Anastamosis Done in operable distal rectal tumor in young individual Here permanent colostomy is avoided
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ANTERIOR RESECTION Also called anterior procto-sigmoidectomy through abdominal approach wherein rectum above peritoneal reflection is resected with colorectal anastamosis Done in growths in the mid & upper parts of the rectum
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LOW ANTERIOR RESECTION CRITERIA Upper & middle third growth Above peritoneal reflection Well differentiated tumor < 4cm in size tumor In females growth 7 cm above the anal verge T1 N0/T2 N0 tumor Tumor without lymphatic or venous spreas
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ADVANTAGES OF LAR Avoids permanent colostomy Sphincter retained Patients acceptance DISADVANTAGES Uncertainity of clearance Anastamotic leak, infection, stenosis
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HARTMANN’S OPERATION Palliative procedure Done in elderly people not fit for major surgery Here rectal growth is resected & upper end of rectum is closely approximated Proximal colon is brought out as end colostomy
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RADIOTHERAPY Only rectal carcinoma in GIT responds well to RT Pre- op RT can be given to downstage the tumor Intra-operative RT is used in pelvic wall disease Short course 25GY in 5 fractions in 5 days Long course 5040 Gy in 28 fractions in 6 weeks
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CHEMOTHERAPY Drugs like Endoxan, 5 FU, semustine also with leucovarine Capecitabine & oxaloplatin are newer drugs Biological Agents- - Bevacizumab VEGF receptor antagonist - Cetuximab EGFR antagonist
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RECTAL PROLAPSE Circumferential descent of rectum through the anal canal Commonly seen in infants, children & elderly individuals Common in females (6:1)
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Rectal prolapse can be : Partial Complete Hidden/Concealed – internal intussusception of the sigmoid into the rectum distally, they do not come out of the anal orifice.Here only mucosa & submucosa separates from muscularis layer & descends
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AETIOLOGY Decreased sacral curvature & decreased anal canal tone are the probable causes in infants Chronic constipation with straining is the common cause Diarrhoea, cough & malnutrition Reduced ischiorectal fossa fat Pudendal nerve damage  pelvic floor & anal canal weakness In adult females- repeated birth injuries in the perineum results in damage to perineal nerve supply
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TYPES Partial rectal prolapse Complete rectal prolapse
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PARTIAL RECTAL PROLAPSE Here only mucosa & submucosa descends Less than 3.75 cm No descent of the muscular layer
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CLINICAL FEATURES Mass per anum Pink in color & circumferential Differ from piles in that they are not circumferential & blue in color
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TREATMENT OF PARTIAL PROLAPSE Nutrition of child is improved Correction of constipation Submucosal injections of 10ml of 5% phenol in almond oil or ethanolamine oleate is given into the apex of the prolapse Thiersch wiring Goodsalls operation – excision of the prolapsed mucosa at its base Stapled transanal rectal surgery (STARR)
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COMPLETE RECTAL PROLAPSE Also called procidentia Common in females Descent more than 3.75 cms Contains all the layers of rectum Often associated with uterine descent Complete prolapse of more than 5 cms drags peritoneum as pouch containing small intestine
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CLINICAL FEATURES Complete descent of rectum as mass per rectum Maybe associated with uterine prolapse Fecal incontinence is very common Bleeding can occur because of congestion Sepsis, discharge, fever, anemia are other features P/R shows lax sphincter
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INVESTIGATIONS Defecography grading – N- Normal rectal fixation & sphincter relaxation& rectal emptying 1- Non relaxed puborectalis 2- Mild intussusception 3- Moderate intussusception 4- Severe intussusception 5- Prolapse 6- Rectocele
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INVESTIGATIONS Sigmoidoscopy Anal Manometry Electromyographic study of the puborectalis muscle
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TREATMENT AIM – To control prolapse To restore continence To prevent constipation In young individuals abdominal repair should be avoided to prevent damage to pelvic nerves –sexual impotence Choice of procedure depends on age, sex, operative risk, pelvic floor defect, degree of incontinence
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Surgery - Types Abdominal Procedures LAPAROSCOPIC RECTOPEXY Here laparoscopic posterior mesh rectopexy is done Mesh is sutured to the rectal wall & on both sides using interrupted polypropylene sutures
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WELL’S OPERATION Polyvinyl alcohol sponge is wrapped around the mobilised rectum & is fixed to sacrum. Polypropylene mesh is now used as a modification instead of polyvinyl sponge
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RIPSTEIN OPERATION A teflon mesh sling is passed around the rectum to fix it behind to fascia 5 cm below & in front of sacral promontery GOLIGHER’S OPERATION Rectum is entirely mobilised upto anorectal ring & its posterior muscle layer is fixed to presacral fasica using interrupted polypropylene sutures LAHAUT’S OPERATION Mobilised loop of rectosigmoid is passed in front through posterior rectus sheath behind the rectus muscle Extra peritonealisation is done to pull the rectus forward to prevent descent
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PERINEAL PROCEDURES Delorme’s operation Wyatt operation Altemeir’s rectosigmoidectomy Mickulicz Miles Surgery
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COMPLICATIONS OF SURGERY Injury to hypogastric nerve causing impotence Bladder dysfunction Bleeding from sacral venous plexus Injury to rectum & colon causing faecal fistula Constipation after rectopexy Recurrence of prolapse Infection