By AMGAD FOUAD. MD Professor Of GIT Surgery Gastroenterology Center Gastroenterology Center Mansoura...

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AMGAD FOUADAMGAD FOUAD . MD . MDProfessor Of GIT SurgeryProfessor Of GIT Surgery Gastroenterology CenterGastroenterology Center

Mansoura University.Mansoura University.

COLO-RECTAL COLO-RECTAL

MALIGNANCY MALIGNANCY

CARCINOMA CARCINOMA

CARCINOID CARCINOID

SARCOMA SARCOMA

LYMPHOMA LYMPHOMA

MALIG. MELANOMA MALIG. MELANOMA

SECONDARIES SECONDARIES

INCIDENCEINCIDENCE

Geographical distribution Europe & Geographical distribution Europe &

USA USA ↑↑

Age: Age:

Common 60-70 y. however !!Common 60-70 y. however !!

Younger age ( Egypt ) 20 % before 30 y. Younger age ( Egypt ) 20 % before 30 y.

Sex : Equal Sex : Equal

Risk FactorsRisk Factors 1.1. DietDiet : :

Low cellulose & CHOLow cellulose & CHO High proteins & Fats High proteins & Fats

2.2. Age :Age : ↑↑ Age.Age. ↑↑ after 50 Yafter 50 Y..

3.3. Polyps:Polyps: Adenomatous polypsAdenomatous polyps Familial polyposis coliFamilial polyposis coli..

4.4. U.C :U.C : 10-20 % > 10 y → CRC10-20 % > 10 y → CRC

5.5. Previous Ca :Previous Ca : Colon or rectum Metachronous ( 5 %)Colon or rectum Metachronous ( 5 %)

6.6. Genetic Factors.Genetic Factors.7.7. Uretro-colic anastomosisUretro-colic anastomosis8.8. Leukoplakia: Leukoplakia: ↑↑ Sq.cc Sq.cc

SITES OF CRCSITES OF CRCSiteSitePercentPercent

Cecum:Cecum:

Ascending colon.Ascending colon.

Hepatic Flexure. Hepatic Flexure.

Transverse colon.Transverse colon.

Splenic flexure.Splenic flexure.

Descending colon.Descending colon.

Sigmoid colon.Sigmoid colon.

Recto-sigmoid junctionRecto-sigmoid junction

Rectum.Rectum.

9%9%

2%2%

1.5%1.5%

4%4%

2%2%

5%5%

11 %11 %

4.5%4.5%

60%60%

MACROSCOPIC PICTURE OF MACROSCOPIC PICTURE OF CARCINOMA (NFA)CARCINOMA (NFA)

TypeType%%Description Description 1.1. CaulifloweCauliflowe

r r TypeType::

40%40%A fungating mass with ulceration & A fungating mass with ulceration & bleeding. It is common on the right side bleeding. It is common on the right side of the colon. It is the least malignantof the colon. It is the least malignant

2.2. Ulcer Ulcer Type:Type:

25%25%25% Almost ill the cecum & is the most 25% Almost ill the cecum & is the most mailgnant.mailgnant.

3.3. Annular Annular Type Type

25%25%Common in. the left side of the colon & is Common in. the left side of the colon & is relatively of good prognosis probably relatively of good prognosis probably because it causes early obstruction because it causes early obstruction

4.4.InfiltratingInfiltrating (Tubular)(Tubular) Type:Type:

7%7%It produces a diffuse thickening of the It produces a diffuse thickening of the intestinal wall (tubular). It corresponds to intestinal wall (tubular). It corresponds to linitis plastica of the stomach. linitis plastica of the stomach.

5.5. ColloidColloid Type:Type:

3%3%A bulky growth with ulceration & infiltration. A bulky growth with ulceration & infiltration. It is a mucoid type with power of mucus It is a mucoid type with power of mucus production.production.

Microscopic Microscopic PicturePicture A.A. Adenocarcinoma (co lumnar cell Adenocarcinoma (co lumnar cell

adenocarcinoma):adenocarcinoma):It is the most common, with varying degrees (grades) of It is the most common, with varying degrees (grades) of

malignancy:malignancy:

Grade Grade I : Low grade.I : Low grade.

Grade Grade II : Average grade.II : Average grade.

Grade Grade III : High grade.III : High grade.

Grade Grade IV : Very high grade (undifferentiaIV : Very high grade (undifferentia ..

B.B. Colloid or Mucoid carcinoma. Colloid or Mucoid carcinoma.

C.C. Squamous cell carcinoma (2%). Squamous cell carcinoma (2%).

SPREADSPREAD 1.1. Direct:Direct:

Transverse > Longitudinal Transverse > Longitudinal 4-5 cm beyond macroscopic edge 4-5 cm beyond macroscopic edge Surrounding structures Surrounding structures

2.2. Lymphatic:Lymphatic: Common ( 50 % )Common ( 50 % ) Stations:Stations:

** EpicolicEpicolic ** ParacolicParacolic** IntermediateIntermediate ** CentralCentral

Reduces survival Reduces survival

3.3. Hematogenous :Hematogenous : Less common Less common Liver (portal circulation )Liver (portal circulation ) Bones & lungBones & lung

4.4. Rare forms :Rare forms : Trans – celomic ( gravitational )Trans – celomic ( gravitational ) Peri- neural Peri- neural Seedling ( implantation ) Seedling ( implantation )

CLINICAL FEATURESCLINICAL FEATURESSymptoms: Symptoms:

Vary according to the site Vary according to the site

1.1. Rt. Colon:Rt. Colon:

Bowel disturbance.Bowel disturbance.

Dyspepsia.Dyspepsia.

Abd. Mass (Rt side)Abd. Mass (Rt side)

Fatigue.Fatigue.

Metastatic manifestationMetastatic manifestation

JaundiceJaundice

Abd. Distention.Abd. Distention.

SYMPTOMS SYMPTOMS (CONTINUE)(CONTINUE)

22. Lt. colon. Lt. colon

↑↑constipationconstipation

Annular.Annular.

Solid content.Solid content.

Narrow lumen.Narrow lumen.

Bleeding PRBleeding PR

Loss of wtLoss of wt

Abd Mass (Lt side)Abd Mass (Lt side)

SYMPTOMS SYMPTOMS (CONTINUE)(CONTINUE)

3. 3. Rectum:Rectum:

Bleeding PR.Bleeding PR.

Alteration of bowel habits.Alteration of bowel habits.

Discharge.Discharge.

Pain & Tenesmus.Pain & Tenesmus.

Urinary symptoms.Urinary symptoms.

Clinical Clinical ExaminationExamination1-General:1-General:

Anaemia.Anaemia.

Loss of wt.Loss of wt.

Jaundice.Jaundice.

Cx LN.Cx LN.

2-Abd examinat:2-Abd examinat:Abd distention.Abd distention.

Mass.Mass.

Ascitis.Ascitis.

3-Rectal digital ex:3-Rectal digital ex:Mass is felt in 90% of cases (RDE +Abd ex)Mass is felt in 90% of cases (RDE +Abd ex)

Rectal ca may be.Rectal ca may be. Mass.Mass. UlcerUlcer Constrictiny.Constrictiny.

STAGING OF COLON CASTAGING OF COLON CA..

StagStag

ee

Description Description

AA

B1B1

B2B2

C1C1

C2C2

DD

lesion confined to lesion confined to the the mucosa only.mucosa only.

Extension into but not through the muscularis Extension into but not through the muscularis

propria.propria.

Extension through the muscularis propria, -ve Extension through the muscularis propria, -ve

L.NsL.Ns

Same level of penetration as B1. but with +ve Same level of penetration as B1. but with +ve

L.NsL.Ns

Same level of penetration as B2. but with +ve Same level of penetration as B2. but with +ve

L.NsL.Ns

Distant MetastasesDistant Metastases

Dukes Astler – celler systemDukes Astler – celler system

Staging of Rectal caStaging of Rectal ca

Dukes classificationDukes classification

StageStageDescription Description

AAThe growth is limited to the rectal wallThe growth is limited to the rectal wall

BBThe tumor extends to extra-rectal tissues (NOT The tumor extends to extra-rectal tissues (NOT regional L.Ns)regional L.Ns)

CCC1:C1:→→L.Ns near the rectum (local para-rectal LNs of L.Ns near the rectum (local para-rectal LNs of GEROTA) GEROTA)

C2 :C2 :→→ LNs near the main vesselsLNs near the main vessels

TNM classification of CRCTNM classification of CRC

Primary Tumor (T)Primary Tumor (T)

TxTx

T0T0

TisTis

T1T1

T2T2

T3T3

T4T4

11ry ry tumor can not be assessedtumor can not be assessed

No evidence 1No evidence 1ry ry tumor.tumor.

Carcinoma in-situ.Carcinoma in-situ.

TumorTumor invades submucosa invades submucosa

TumorTumor invades muscularis propria invades muscularis propria

TumorTumor invades through muscularis propria into invades through muscularis propria into

subserosa or non-peritooealizod peri-colic or peri-subserosa or non-peritooealizod peri-colic or peri-

roctal tissuesroctal tissues

Tumor perforates the visceralTumor perforates the visceral peritioneum , or peritioneum , or

directly invades other organs structuresdirectly invades other organs structures

REGIONALREGIONAL

NxNx

N0N0

N1N1

N2N2

N3N3

Regional L. Ns can not be assessedRegional L. Ns can not be assessed

NO regional LN. metastasesNO regional LN. metastases

Metastasis in 1-3 peri-colic Or peri-recta L.Ns.Metastasis in 1-3 peri-colic Or peri-recta L.Ns.

Metastasis in 4 or more peri-colic or peri-rectal L.Ns.Metastasis in 4 or more peri-colic or peri-rectal L.Ns.

Metastasis in any LN. along the course of a named Metastasis in any LN. along the course of a named

vascular truk.vascular truk.

DISTANT METASTASESDISTANT METASTASES

MxMx

M0M0

M1M1

Evidence of distant metastases can not be assessed Evidence of distant metastases can not be assessed ..

No distant metastases.No distant metastases.

Distant metastases Distant metastases

TNM classification of CRC TNM classification of CRC (CONTINUE)(CONTINUE)

STAGE GROUPINGSTAGE GROUPINGStageStageTTNNMMDukesDukes

00TisTisN0N0M0M0

IIT1T1N0N0M0M0AA

T2T2N0N0M0M0AA

IIIIT3T3N0N0M0M0BB

T4T4N0N0M0M0BB

IIIIIIAny TAny TN1N1M0M0CC

Any TAny TN2,N3N2,N3M0M0CC

IVIVAny TAny TAny NAny NM1M1

INVESTIGATOININVESTIGATOIN1.1. Laboratory:Laboratory:

• Routine.Routine.• Specific.Specific.

2.2. Radiology:Radiology:• CXRCXR• Ba. StudiesBa. Studies• Abd U/S.Abd U/S.• CT ScanCT Scan• Virtual colonoscopy.Virtual colonoscopy.

3.3. Endoscopy:Endoscopy:• Diagnosis.Diagnosis.• Bx.Bx.• TypesTypes

Colonoscopy.Colonoscopy.Sigmoidoscopy.Sigmoidoscopy.CystoscopyCystoscopy

• Endo luminal U/S staging.Endo luminal U/S staging.

PRE-OP STAGING OF CRCPRE-OP STAGING OF CRC

CT CT →→Identifying patients with Mets.Identifying patients with Mets.

MRI MRI → → Assessment of recurrent Assessment of recurrent

tumour.tumour.

Endo U/SEndo U/S →→ Assessment of extent of Assessment of extent of

local disease.local disease.

TREATMENTTREATMENT Depend upon:Depend upon:

1.1. Operability .Operability .

2.2. Resectability.Resectability.

3.3. Obstruction.Obstruction.

Rational:Rational:1.1. Excision ofExcision of

• Tumour.Tumour.

• Regional LN.Regional LN.

• Drainging lymphatics.Drainging lymphatics.

• Intervening tussuesIntervening tussues

2.2. Surgery provides best palliation.Surgery provides best palliation.

OPERATIVE PROCEDURESOPERATIVE PROCEDURES

The abd is first explored for:The abd is first explored for:

1.1. Liver Mets.Liver Mets.

2.2. Peritoneal seedling.Peritoneal seedling.

3.3. LN involvement.LN involvement.

4.4. Resectability.Resectability.

5.5. Other tumours.Other tumours.

SURGERY OF COLONIC CASURGERY OF COLONIC CA1.1. Ceacum & Assending colon.Ceacum & Assending colon.

• Rt. Hemicolectomy.Rt. Hemicolectomy.

• Illeo – Transverse colostomy.Illeo – Transverse colostomy.

2.2. Hepatic flexureHepatic flexure• Extanded Rt hemicolectomy.Extanded Rt hemicolectomy.

• I-T colostomyI-T colostomy

3.3. Tr. Colon:Tr. Colon:• Transvers colectomy.Transvers colectomy.

• C-C bypass.C-C bypass.

4.4. Splenic flexure:Splenic flexure:• Extended Lt hemicolectoy.Extended Lt hemicolectoy.

• Tr colostomy.Tr colostomy.

5.5. Lt colon: Lt colon: • Lt hemicolectomy.Lt hemicolectomy.

• Tr. Colostomy.Tr. Colostomy.

6.6. Sigmoid colon:Sigmoid colon:• Ant resection.Ant resection.

• Proximal colostomy.Proximal colostomy.

SURGERY OF RECTAL CA SURGERY OF RECTAL CA

1.1. Sphincter saving procedures:Sphincter saving procedures:• Dixon:Dixon:

Low ant resection.Low ant resection. Tumour stiuated >7-10 cm.Tumour stiuated >7-10 cm. Trans abd.Trans abd. Advaotage →s.savingAdvaotage →s.saving disadvantage →↑local recurrence.disadvantage →↑local recurrence.

2.2. Percy & parks:Percy & parks:• Abd – anal pull- through op.Abd – anal pull- through op.• Diverting colostomy.Diverting colostomy.• Disadvantage:↑ incidence of leakage & Disadvantage:↑ incidence of leakage &

infection.infection.

SPHINCTER SAVING SPHINCTER SAVING PROCEDURES PROCEDURES (CONTINUE)(CONTINUE)

3.3. Localio:Localio: It provid low colo- rectal anastomosis via It provid low colo- rectal anastomosis via

sacral wound.sacral wound. Not widely procticed.Not widely procticed.

4.4. Local eradication & SurveillanceLocal eradication & Surveillance Local excision.Local excision. Electrocoagulation.Electrocoagulation. Laser therapy.Laser therapy. Endocavitary Irradiation.Endocavitary Irradiation.

NON – SPHINCTER SAVING NON – SPHINCTER SAVING PROCEDURESPROCEDURES

1.1. Abd – perineal resection Abd – perineal resection (Miles)(Miles)

2.2. Perineo- Abd Resection Perineo- Abd Resection (Gabriel)(Gabriel)

3.3. Synchronous Resection Synchronous Resection (Lioyd – Davis)(Lioyd – Davis)