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Flashcards in Rectal Cancer Deck (40):
0

Intraperitoneal rectal injury can cause ....

Peritonitis

1

Examination to detect rectal wall defects and blood ?

Rectal Examination

2

Workup rectal trauma:

– Rectosigmoidoscopy

– Water soluble contrast enema

– Contrast enhanced CT scan

3

Treatment for Anorectal trauma?

suture repair (absorbable suture)

4

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)

5

Treatment for superior (subperitoneal and
intraperitoneal) rectum trauma ?

suture repair through laparotomy + / -
protective colostomy

6

Epidemiolgy: rectal cancer prevalence?

Male > female

7

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

8

Factors that increase the risk of rectal cancer
development:

High protein diet
– red meat – unfavorable effect

9

Rectal cancer appears on preexisting ....

Adenoma

10

Which adenoma has the highest risk of malignant transformation ?

Villouso adenomas

11

Macroscopic aspect of rectal cancer:

Exophytic ulcerated tumors: common ‼️
________

•Exophytic tumors: low malignancy
•Ulcerated tumors: increased malignancy

•Stenosing tumors
•Diffuse infiltrative tumors - uncommon

12

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

13

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

14

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

15

Dissemination: hematogen - venous

-Low differentiated forms
- Metastasis: hepatic, pulm, gl suprarenal / bones / muscles / thyroid / spleen (rare)

16

Dissemination: perineural

- invasion of the hipogastric plexus

17

Dissemination: distant

The cancer cells leave the tumor and travel to other sites of the lumen

18

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

19

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

20

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

21

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

22

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?

23

Rectal cancer

Physical exam

Abdominal palpation:

Ascitis
Hepatomegaly = hepatic metastasis
Massive tumors (1/2 sup)

24

Paraclinical

Tumor presence
Location?
Biopsy - Histology
Other tumors or benign adenomas present ?
Metastasis?


25

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)

26

Screening for rectal cancer

Adults over 65 years
Test: occult blood in stools

27

Most important Diagnostic tool:

Histopathologic exam

28

Diferential diagnosis:

Benign:
- hemoroids
- polips
- benign tumors

Inflamation:
- Anite
- Crypts

29

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

30

Treatment - surgery

Superior rectal / rectosigmoidian cancer

1. Rectosigmoidian resection
-> through anterior abdomen (DIXON)
2. Then colorectal anastomosis (T-T or L-T)

Possible: Manual or mechanical

31

Surgery

Middle rectal ampula cancers

Rectosigmoidian resection abdomino-perineal / endoanal -> pulling down transfincterian of the colon -> colon anastomosis
(saving the sphincter - BABCOCK - BACON)

32

Surgery

Inferior rectal ampula

.

33

Surgical treatment

Palliative

Indication:
-Massive extension of tumor
-Metastasis (hepatic / pulmonary)

34

Rectal cancer

Chemotherapy

Tumors of digestive tract do not response well to chemotherapy❗️

5-FU = anti-tumoral agent
(mono-therapy / association)

35

Surgical treatment

Rectal cancer complication: occlusion

3 steps solution:
1. Colostomy
2. Tumor resection
3. Close colostomy + reconnect remaining parts

2 steps solution: = HARTMANN❗️
1. Resection of sup rectal tumor + closure of distal rectum with proximal colostomy
2. Reconnection of rectum to transit

36

Surgical treatment

Rectal cancer: perforation

Possible perforation:

-at tumor level through necrosis
-at the cecum (diastatic perforation) -> do total colectomy with ileo-rectal anastomosis‼️

37

Middle ampullary cancer resection

Name der prozedur?

BABCOCK - BACON

-> danach: colo-anal anastomose

-> rettung des schließmuskels ‼️

38

Sup rectal cancer / rectosigmoid cancer

Radical intention

Name der prozedur?

DIXON

-> danach: colo rectal anastomose

-> mechanisch oder manuell

39

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