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SURG > Anorectal Neoplasms > Flashcards

Anorectal Neoplasms Flashcards

1
Q

4 tissue layers of colonic wall

A

1) mucosa (columnar epithelium)
2) submucosa
3) muscular propria
4) serosa

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2
Q

What is muscularis mucosa?

A

small interwoven inner muscle layer just below mucosa but above basement membrane

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3
Q

What portions of colon are retroperitoneal?

A

ascending, descending, sigmoid

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4
Q

What are the transverse bands that form the haustra called?

A

Plicae semilunares

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5
Q

What are Taenia coli?

A

3 bands that run longitudinally along colon. At rectosigmoid junction, the taeniae become broad and completely encircle the bowel.

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6
Q

Blood supply for ascending and 2/3 of transverse colon

A

SMA (ileocolic, right and middle colic arteries)

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7
Q

Blood supply for 1/3 transverse, descending, sigmoid colon and upper portion of rectum

A

IMA (left colic, sigmoid branches, superior rectal artery)

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8
Q

This artery provides collateral flow by connecting SMA to IMA

A

Marginal artery

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9
Q

This is a short direct connection between SMA and IMA

A

Arc of Riolan

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10
Q

Superior rectal artery is a branch of what artery?

A

IMA

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11
Q

Middle rectal artery is a branch of what artery?

A

Internal iliac (the lateral stalks during LAR or APR contain the middle rectal arteries)

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12
Q

Inferior rectal artery is a branch of what artery?

A

internal pudendal (which is a branch of internal iliac)

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13
Q

Where do superior and middle rectal veins drain?

A

IMV and eventually the portal vein

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14
Q

Where do inferior rectal veins drain?

A

internal iliac veins and eventually the caval system

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15
Q

Lymphatic drainage of:
Superior/Middle rectum
Lower rectum

A

Superior/Middle rectum- drain to IMA nodal lymphatics

Lower rectum- drains primarily to IMA nodes, also to internal iliac nodes

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16
Q

Watershed areas of colon and rectum

A 
Splenic flexure (Griffith's point)- SMA and IMA junction
Rectum (Sudak's point)- superior rectal and middle rectal junction
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17
Q

External Sphincter:
Muscle
Innervation

A 
Puborectalis muscle (continuation of elevator ani muscle)
under CNS voluntary control
Inferior rectal branch of internal pudendal nerve
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18
Q

Internal Sphincter:
Muscle
Innervation

A

Muscularis propria
involuntary control
is normally contracted
Pelvic splanchnic nerves (parasympathetic)

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19
Q

Inner nerve plexus

A

Meissner’s plexus

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20
Q

Outer nerve plexus

A

Auerbach plexus (between inner circular and outer longitudinal muscle)

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21
Q

Measurements from anal verge:

Anal Canal

A

0-5 cm

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22
Q

Measurement from anal verge:

rectum

A

5-15 cm

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23
Q

Measurement from anal verge:

rectosigmoid junction

A

15-18 cm

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24
Q

What structure marks the transition between anal canal and rectum?

A

Levator ani

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25
Q

Main nutrient of colonocytes

A

short-chain fatty acids

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26
Q

Denonvilliers fascia

A

Anterior
rectovesicular and rectoprostatic fascia in men
rectovaginal fascia in women

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27
Q

Waldeyer’s fascia

A

Posterior

rectosacral fascia

28
Q

T1 staging CRC

A

invasion into submucosa

29
Q

T2 staging for CRC

A

invasion into muscularis propria

30
Q

T3 staging for CRC

A

invasion into subserosa or through muscular propria if no serosa present

31
Q

T4 staging for CRC

A

through serosa into free peritoneal cavity or into adjacent organs/structures if no serosa is present

32
Q

The most common polyp; no cancer risk

A

hyperplastic polyp

33
Q

most common (75%) intestinal neoplastic polyp

A

tubular adenoma

34
Q

These characteristics of polyps increase cancer risk:

A

> 2 cm
sessile
villous

35
Q

If unable to excise all of polyp endoscopically, next step is

A

segmental resection (often occurs with sessile polyp)

36
Q

When to start screening for CRC?

A

50 for normal risk

40, or 10 years before youngest case for intermediate risk (family history)

37
Q

Treatment if polypectomy shows T1 lesion

A

polypectomy is adequate if margins are clear (2mm), is well differentiated, and has no vascular/lymphatic invasion; otherwise, need formal colon resection

38
Q

Treatment for extensive low rectal villous adenomas with atypia

A 
transanal excision (can try mucosectomy)
No APR unless cancer is present
39
Q

Pathology shows T1 lesion after transanal excision of villous rectal polyp

A

transanal excision if adequate if margins are clear (2mm), it is well differentiated, and it has no vascular/lymphatic invasion

40
Q

Pathology shows T2 lesion after transanal excision of villous rectal polyp

A

APR or LAR

41
Q

Dietary risk factors for CRC

A

red meat and fat

42
Q

Most common sight of primary in CRC

A

sigmoid colon

43
Q

CRC disease spread

A

nodal metastasis first

44
Q

Most important prognostic factor in CRC

A

nodal status

45
Q

Top 2 sights of metastasis of CRC

A

1) Liver 2) lungs

46
Q

Prognosis of patients with CRC with liver metastases

A

if resectable and leaves adequate liver function, patients have 35% 5 year survival rate

47
Q

Prognosis of patients with CRC with lung metastasis

A

25% 5 yr survival rate in selected patients after resection

48
Q

Rectal carcinoma can metastasize directly to spin via

A

Batson’s plexus (venous)

49
Q

Goals of CRC resection

A

En bloc resection
adequate margins (2 cm? 5 cm?)
mesocolon
regional adenectomy

50
Q

What fascia do you need to take for excision of rectal tumors?

A

Waldeyer’s (posterior) and Denonvillier’s (anterior) fascia

51
Q

Size of margin needed for LAR

A

Need at least a 2 cm margin (meaning 2 cm from elevator ani muscles) for LAR otherwise will need APR

52
Q

Morbidity of APR

A

Impotence and bladder dysfunction if pudendal nerve injured

53
Q

If patient with rectal cancer with complete response to chemo-XRT, what do you do

A

Surgical resection based on initial pathology, watch and wait strategy shown to have worse survival, higher rate of distant progression

54
Q

Stage 0

A

Tis, N0, M0

55
Q

Stage I

A

T1-2, N0, M0

56
Q

Stage IIa

A

T3, N0, M0

57
Q

Stage IIb

A

T4, N0, M0

58
Q

Stage 3a/b/c

A

N1+

59
Q

Stage 4

A

Any T, Any N, M1

60
Q

Low rectal T2 or higher gets what treatment

A

LAR or APR

61
Q

Low rectal T1 gets what treatment

A

transanal excision if <4 cm, has negative margins (need 2 mm), well differentiated, no LVI

62
Q

Stage 2 and Stage 3 rectal cancer get what initial tx

A

neoadjuvant chemo + XRT (followed by re-staging)

63
Q

Stage 4 rectal Ca Tx

A

neoadjuvant chemo + XRT, +/- APR (may want to avoid morbidity of APR in patients with metastatic disease, can divert via colostomy)

64
Q

Chemo for CRC

A

5FU, leucovorin, oxaliplatin (FOLFOX)???

65
Q

XRT damage

A

rectum most common site of injury (vasculitis, thrombosis, ulcers, strictures, bleeding)

66
Q

Limitations of TAE

A

Lesion must be:
within 8 cm of anal verge
no more than 3 cm in size
occupy no more than 40% rectal circumference

SURG (6 decks)

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