1
Forth stage
Surgery
Lec-5
د.هيثم النجفي
1/1/2014
Rectal Carcinomas
- In male, rectum is the 3
rd
most common site of malignancy (1
st
lung, 2
nd
prostate).
- In female, rectum 2
nd
most common site for malignancy (1
st
breast).
- Colon and rectum are the commonest site for oncology in gastrointestinal tract.
N.B. Polyp = tumor unless proven otherwise.
Histopathology:
A. Columnar cell carcinoma
B. Colloid carcinoma (colon or rectum)
- Primary colloid carcinoma: where the mucous us inside the cell (intracellular mucous)
and the nucleus of the cell is compressed and pushed by mucous to the periphery of
the cell like signet so called signet cell carcinoma, it is very malignant, 0zero 5 years
survival, very rapidly metastasize, the tumor is large in size, fragile and most of the
time is present with intestinal obstruction.
N.B. patients present with duplication of rectum (congenital anomaly) later on may
develop primary colloid carcinoma.
- Secondary colloid carcinoma: mucous degeneration of tumor, mucous in between the
cell (not intracellular).
Macroscopic
Ulcerative, cauliflower, nodular, and uncommonly tubular (annular). Each type has different
presentation (read colon cancer)
- Ulcerative type presented with early morning bloody diarrhea and penetration rapidly
especially sacral plexus.
- Annular type has best prognosis because lead to intestinal obstruction.
- Cauliflower type presented with feeling of incomplete evacuation of rectum.
Microscopic
(stages of differentiation): Depending on the following points:
1- Architecture of acinus
2- Number of mitotic figure
3- Atypical nucleus
4- Invasion of lamina propria
N.B. in Iraq the well differentiated type is rare, intermediate and poor are very common. In
UK intermediate is 64%, well differentiated 11%.
2
Stages of differentiation:
1- Dukes staging (stage of progression)
A, The growth is limited to the rectal wall (15 per cent): prognosis excellent (90 per cent
year survival).
B, The growth is extended to the extrarectal tissues, but no metastasis to the regional
lymph nodes (35 per cent): prognosis reasonable (70 per cent year survival).
C, there are secondary deposits in the regional lymph nodes (50 per cent). These are
subdivided into C1, in which the local pararectal lymph nodes alone are involved, and C2,
in which the nodes accompanying the supplying blood vessels are implicated up to the
point of division. This does not take into account cases that have metastasised beyond the
regional lymph nodes or by way of the venous system: prognosis is poor (40 per cent year
survival).
N.B stage D (modified duke’s stage) is often included, which was not described by Dukes.
This stage signifies the presence of widespread metastases, usually hepatic.
2- TNM staging
T represents the extent of local spread and there are four grades:
T1 tumor invasion through the muscularis mucosae, but not into the muscularis propria;
T2 tumor invasion into, but not through the muscularis propria;
T3 tumor invasion through the muscularis propria, but not through the serosa (on surfaces
covered by peritoneum) or mesorectal fascia;
T4 tumor invasion through the serosa or mesorectal fascia.
N describes nodal involvement: (From short practice)
N0 no lymph node involvement;
N1 between one and three involved lymph nodes;
N2 four or more involved lymph nodes.
M indicates the presence of distant metastases:
M0 no distant metastases;
M1 distant metastases.
Newly added, the prefix ‘p’ indicates that the staging is based on histopathological analysis,
and ‘y’ that it is the stage after neoadjuvant treatment, which may have resulted in
downstaging.
Spread
Local spread: all types are local invasion slow except anaplastic is rapid.
Local spread occurs circumferentially rather than in a longitudinal direction
18 months until development of intestinal obstruction.
As Doctor Said:
N1 no LN involvement
N2 LN involvment
3
Lymphatic spread: epicolic, paracolic, intermediate, central and distant.
Lymphatic spread from a carcinoma of the rectum above the peritoneal reflection occurs
almost exclusively in an upward direction; downward spread is exceptional,
1- If the tumor in the lower one third inguinal lymph node.
2- If tumor in the middle portion of rectum iliac lymph node.
3- If patient with previous operation (pelvic operation) there will be disturbance of
lymphatic, so course of lymphatic drainage become odd.
Blood: Because rectum is part of GIT so following blood upward (superior haemirrhoidal
vein which go to portal system) so liver is the first organ to be affected, US of liver, lung and
adrenal glands should be done preoperatively.
Clinical features:
Symptoms:
Bleeding: earliest symptom but the problem here is that the bleeding is similar to
bleeding of hemorrhoids. Ulcerative type early morning diarrhea + mucous.
Sense of incomplete evacuation: patient visit W.C many times with straining but no
feces, or tensmus with passage of scanty amount of mucous.
Alteration in bowel habit:
Diarrhea + colic pain ulcerative
Constipation with laxative use (increase dose of laxative with no response)
annular type with obstruction.
Pain: either deep seated pain (very late) means tumour invade sacral plexus, or pain
due to tensmus and change bowel habit usually with ulcerative type.
Intestinal obstruction: especially if old.
N.B no age can be excepted, but the commonest age is above 40 years.
Signs:
- Abdominal examination is –ve, but very very late you feel a mass (this mass is feces above
the tumour), it is pitting mass.
- P. rectum: feel ulcer, nodule and/or stricture.
- Protoscope and sgmoidoscopy
- Biopsy
If do them (or one of them) and see tumour, this alone is not enough, you have to examine
colon above tumour to exclude synchronous tumor (double tumor 5-10%) because if
synchronous tumor is present there are different planning of treatment.
N.B palpable liver (by abdominal examination) mean 2
nd
ry in the liver
N.B. abdominal examination in patient with rectal malignancy can be non-specific.
N.B. general appearance of patient with rectal ca, the look healthy
4
Investigations:
1- General stool examination for occult blood.
2- P. rectum (part of examination)
3- Protoscope and sgmoidoscop if 1
st
one –ve, do 2
nd
one if also –ve exlude malignancy.
If one of them show mass do colonoscopy to exclude synchronous tumour.
4- Biopsy via 3 quadrable biopsy (edge, central, left and right).
5- Decide preoperatively if this patient is operable or not, by intra-rectal US which give
us the staging (invasion) of tumour.
6- CT scan of pelvis as anatomical section, give the confirm decision to do the operation
or no.
7- US of liver for curability.
8- CT of liver
9- Lab : α-feto protein not diagnostic,
CA-125: diagnostic
General lab: CBP, ESR, Hb, Blood sugar
10- X-ray of chest and ECG
11- IVU: invasion of ureter if present, send for urologist.
Treatment
1- Sphincter saving (i.e patient post-operatively is continent)
2- Non-sphincter saving (i.e patient post operatively is incontinent).
Tumour above 7cm low anterior resection with anastomosis.
Tumour below 7cm abdomino-perineal resection with permanent colostomy.
Now if tumour just above ano-rectal ring, do sphincter saving with stapling gun.
Indication for abdomino-perineal resection
- Tumour by US ± serosa better to do operation.
- Lymphatic invasion
- Tumour involved
Complication of operation
:
Non-specific complications:
- Bleeding
- Fistula
- Stricture
- Stenosis
- Peritonitis
Specific complications
- In male, impotence (due to loss of hypogastric plexus)
- In male and female disturbance or difficulty in micturition, due to pelvic surgery
DVT of pelvic veins.