Rectal Cancer Flashcards
Examination to detect rectal wall defects and blood ?
Rectal Examination
Intraperitoneal rectal injury can cause ….
Peritonitis
Workup rectal trauma:
– Rectosigmoidoscopy
– Water soluble contrast enema
– Contrast enhanced CT scan
Treatment for Anorectal trauma?
suture repair (absorbable suture)
Treatment for lower subperitoneal rectum trauma ?
Endoanal rectal suture
Perirectal debridement + drainage (high risk of
cellulitis)
Left colostomy (double-barrel colostomy type - to avoid fecal contamination)
Treatment for superior (subperitoneal and
intraperitoneal) rectum trauma ?
suture repair through laparotomy + / -
protective colostomy
Epidemiolgy: rectal cancer prevalence?
Male > female
Factors that reduce the risk of rectal cancer
development:
High fiber diet
Vegetables - protective effect: cabbage
Calcium and Vit. D
Vitamins and antioxidants - vitamin. A, C, E, beta carotene
Other factors:
Coffee
Aspirin
NSAIDs
Factors that increase the risk of rectal cancer
development:
High protein diet
– red meat – unfavorable effect
Rectal cancer appears on preexisting ….
Adenoma
Which adenoma has the highest risk of malignant transformation ?
Villouso adenomas
Macroscopic aspect of rectal cancer:
Exophytic ulcerated tumors: common ‼️
________
- Exophytic tumors: low malignancy
- Ulcerated tumors: increased malignancy
- Stenosing tumors
- Diffuse infiltrative tumors - uncommon
Microscopic aspect of rectal cancer ?
•Adenocarcinoma – glandular epithelium with
tubular or villous structures
- Mucinous adenocarcinoma
- Signet ring cell carcinoma
- Squamous cell carcinoma
- Adenosquamous carcinoma
- Small cell carcinoma – oat cell carcinoma
- Undifferentiated carcinoma
Dissemination rectal cancer: local
Local Extension
Direction of spread
- longitudinal
- circumferential
- wall penetration
Invasion of the vagina, uterus, adnexas, bladder, seminal vesicles, prostate, ureters, peritoneum – pouch of Douglas
Dissemination of rectal cancer: Lymphatic
Lymphatic spread
It begins when the tumor invades the
lymph vessels:
-Submucosal
-Perirectal
Extension - lymphatic vessel permeation –
din aproape în aproape - lymph nodes embolization
Cel mai frecvent:
Ascendent
ggl mezenterici inferiori
ggl paraaorticic
Lateral
ggl fosei obturatorii
ggl iliaci
Retrograd - ggl inghinali
Dissemination: hematogen - venous
- Low differentiated forms
- Metastasis: hepatic, pulm, gl suprarenal / bones / muscles / thyroid / spleen (rare)
Dissemination: perineural
- invasion of the hipogastric plexus
Dissemination: distant
The cancer cells leave the tumor and travel to other sites of the lumen
Dukes Classification
Grad A: tumor limited to rectal wall
Grad B: tumor goes out of rectal wall
Grad C: invasion of regional limphnodes
Grad D: distant metastasis
Astler - Coller Classification
Tx - not assesed
T0 - no evidence of tumor
Tis - in situ
T1 - invasion lamina propria / submucosa
T2 - muscular invasion
T3 - subserosa invasion ( perirectal tissues w/o peritoneu)
T4 - peritoneal invasion or adiacent organs
Nodes: Nx - not assesed N0 - no adenopathies N1 - invasion of 1-3 perirectal nodes N2 - invasion of >3 perirectal nodes
Metastasis:
Mx - not assesed
M0 - without metastasis
M1 - distant metastasis
Stadium: 0 - Tis N0 M0 I - T1, T2 N0 M0 IIA - T3 N0 M0 IIB - T4 N0 M0 IIIA - T1-2 N1 M0 IIIB – T3-4 N1 M0 IIIC – any T N2 M0 IV – any T any N M1
Rectal cancer
Clinical
Long time asimptomatic
First signs: Change in stools - frequency and consistency Diarrhea / Constipation Fecal incontinence + urge Bleeding ‼️ - fresh blood on stool surface Pain moderate, sporadic Inconstant mucous Pruritus
Emergency: (1/3 sup rect) ‼️
- occlusion
- massive bleeding
- perforation
Rectal cancer
Clinical - advanced
Tenesmus - massive exophytic tumors Pain = very bad prognostic ‼️ -> invasion of extrarectal nerve plexus and bones Rectoragii - anemia Incomplete defecation Anal incontinence Recto-vaginal fistula Weight loss / anorexia Jaundice => hepatic metastasis Lymphadenopathy (cervical, inghinal) Intestinal occlusion Perforation / peritonitis Rectovezical fistula -> feces/gas through uretra
Rectal cancer
Rectal examination
Tumors of inferior rectum are palpable! How mobil? - depends on infiltration into the wall Dimension? Consistency? Ulceration? Lumen occlusion? Invasion of adiacent structures? Perirectal adenopathy? Dimension of prostate?
Rectal cancer
Physical exam
Abdominal palpation:
Ascitis Hepatomegaly = hepatic metastasis Massive tumors (1/2 sup)
Paraclinical
Tumor presence Location? Biopsy - Histology Other tumors or benign adenomas present ? Metastasis?
Tumoral marker
✔️ SCCTA4
✔️ CEA - not specific, post-op: detects recurrences
✔️ CA 19-9
✔️ CA 50
(In studium: CA-72, CA-125/TPA)
Radioimunscintigraphy:
- monoclonal AB (MAb)
Screening for rectal cancer
Adults over 65 years
Test: occult blood in stools
Most important Diagnostic tool:
Histopathologic exam
Diferential diagnosis:
Benign:
- hemoroids
- polips
- benign tumors
Inflamation:
- Anite
- Crypts
Treatment for rectal cancer:
Remove:
Tumoral rectum
Mezorectum
Lymphnodes (regional)
Prevention of recurrence.
Radiotherapy = first intention!
Radical Radiotherapy:
-inoperable tumors (invasion of other organs)
-cardiovascular/respiratory diseases
After reducing the size of the tumor -> surgery
Radiotherapy curative/conservative intention:
-preserve sfincter function
Radiotherapy adjuvant:
-before surgery, to reduce the size of tumor
Radiotherapy palliative:
- if not operable
- recurrence or metastasis
Surgical Treatment:
= Initial treatment just when small lesions
Respect 4 anatomical rules:
- curving of Denonvilliers fascia
- remove mezorectum
- section lateral ligaments & medial rectal arteries
- respect pelvis nervous plexus
Treatment - surgery
Superior rectal / rectosigmoidian cancer
- Rectosigmoidian resection
- > through anterior abdomen (DIXON) - Then colorectal anastomosis (T-T or L-T)
Possible: Manual or mechanical
Surgery
Middle rectal ampula cancers
Rectosigmoidian resection abdomino-perineal / endoanal -> pulling down transfincterian of the colon -> colon anastomosis
(saving the sphincter - BABCOCK - BACON)
Surgery
Inferior rectal ampula
.
Surgical treatment
Palliative
Indication:
- Massive extension of tumor
- Metastasis (hepatic / pulmonary)
Rectal cancer
Chemotherapy
Tumors of digestive tract do not response well to chemotherapy❗️
5-FU = anti-tumoral agent
(mono-therapy / association)
Surgical treatment
Rectal cancer complication: occlusion
3 steps solution:
- Colostomy
- Tumor resection
- Close colostomy + reconnect remaining parts
2 steps solution: = HARTMANN❗️
- Resection of sup rectal tumor + closure of distal rectum with proximal colostomy
- Reconnection of rectum to transit
Surgical treatment
Rectal cancer: perforation
Possible perforation:
- at tumor level through necrosis
- at the cecum (diastatic perforation) -> do total colectomy with ileo-rectal anastomosis‼️
Middle ampullary cancer resection
Name der prozedur?
BABCOCK - BACON
- > danach: colo-anal anastomose
- > rettung des schließmuskels ‼️
Sup rectal cancer / rectosigmoid cancer
Radical intention
Name der prozedur?
DIXON
- > danach: colo rectal anastomose
- > mechanisch oder manuell
Rektum amputation
Bei: unterem ampula rektum krebs
MILES
- mit linkem iliac anus
- > danach: colo-anal anastomose
- > KEINE rettung des Schließmuskels ‼️ komplette resektion des inneren analen Schließmuskels
