This document discusses cancer of the anal canal. It compares mitomycin vs cisplatin for treating anal canal cancer and finds that mitomycin, 5-FU and radiation led to significantly lower rates of colostomy at 5 years compared to cisplatin. It recommends the combination of 5-FU, mitomycin and radiation as the standard of care. The combination was associated with 5-year survival rates of 80% for small cancers down to 45-55% for larger or more invasive cancers, with overall survival of 65-75%.
Radical hysterectomy is a surgical procedure for treating cervical cancer. It involves removing the uterus, cervix, part of the vagina, and nearby lymph nodes and tissue. There are different classifications of radical hysterectomy based on the extent of tissue removed. Complications can include bleeding, infection, injury to nearby organs like the bladder or ureters. Radical hysterectomy is indicated for early stage cervical cancer and may provide better survival outcomes than radiation alone for some patients.
Locally advanced breast cancer refers to stage IIIA and IIIB breast cancer where the cancer has spread locally but not to distant sites. It is typically treated with a multi-pronged approach including neoadjuvant chemotherapy to shrink the tumor followed by surgery if possible. Post-operatively, patients receive adjuvant chemotherapy, radiation therapy, and hormone therapy if the cancer is hormone receptor positive. The goal of neoadjuvant chemotherapy is to downstage the tumor to allow for breast conserving surgery rather than mastectomy in some cases. Prognosis depends on response to neoadjuvant chemotherapy and surgical margins. Inflammatory breast cancer, a rare but aggressive form of locally advanced disease, has a poorer prognosis despite intensive treatment
1) Aggressive fibromatosis is a rare soft tissue tumor that typically affects young adults. Surgery is the main treatment but recurrence is common.
2) New evidence shows systemic therapies like sorafenib, hormonal therapies, and chemotherapy can control the disease. A large trial found sorafenib significantly reduced recurrence compared to placebo.
3) Further research is still needed to determine optimal chemotherapy regimens and biomarkers to predict response to various treatments. "Wait and watch" may be suitable for less aggressive cases. Management of fibromatosis remains challenging due to the lack of high-quality data from India and validated patient-reported outcome measures.
This document discusses injuries to the ureter during gynecological surgeries. It provides details on the surgical anatomy of the ureter, risk factors for injury, common sites of injury, grading of injuries, prevention strategies and intraoperative diagnosis. The key points are:
1. The ureter's course makes it susceptible to injury during pelvic surgeries, especially at the pelvic brim.
2. Injuries occur in 0.3-1% of cases and are most common during hysterectomy.
3. Risk factors include large fibroids, adhesions, and prior pelvic surgery.
4. Prevention relies on proper surgical technique including identification and
MRI is useful for staging rectal cancer and assessing tumor involvement of surrounding structures. It can determine the depth of tumor invasion beyond the muscularis propria (T stage), evaluate the circumferential resection margin (CRM) distance between the tumor and mesorectal fascia, and identify suspicious lymph nodes. A tumor-mesorectal fascia distance of less than 1mm on MRI indicates a positive CRM, which is associated with higher rates of local recurrence. MRI is also used to assess nodal metastases based on node size, borders, and signal intensity. Accurate pre-treatment staging with MRI allows for optimal surgical planning and identification of patients who may benefit from neoadjuvant chemoradiation.
The document summarizes revisions to the FIGO staging system for endometrial cancer in 2023. Key changes include distinguishing aggressive from non-aggressive histological subtypes and assessing lymphovascular space invasion. The revised system incorporates prognostic molecular markers like POLE mutations and p53 abnormalities. Stage I is now restricted to non-invasive tumors. Stage IA3 includes some ovarian involvement by low-grade endometrial cancer. The revisions aim to better stratify patients by risk to guide treatment decisions.
This document discusses Enhanced Recovery Programs (ERPs), which aim to reduce stress response to surgery and accelerate recovery through a multimodal perioperative care pathway. Key elements of ERPs include preoperative counseling and carbohydrate loading, avoiding mechanical bowel preparation and nasogastric tubes, use of thoracic epidurals, short-acting anesthetics, goal-directed fluid therapy, normothermia, short incisions or laparoscopy, early oral intake and mobilization, and clear discharge criteria focused on independence rather than length of stay. Strict adherence to an ERP can reduce typical hospital stays for major colorectal surgery from 7-14 days to 2-3 days. ERPs require a multidisciplinary team
URETHRAL INJURY- Trauma Surgery
#surgicaleducator #babysurgeon
Dear viewers,
Greetings from “Surgical Educator”
Today I have uploaded a video on URETHRAL INJURY- one more in Trauma Surgery. I haven’t talked elaborately but have included the essential minimum an undergraduate medical student should know. I have talked about anatomy, classification, etio-pathogenesis, symptoms, signs, investigations, grading, treatment, complications, treatment algorithm and case vignettes of urethral injuries. My aim is, after watching this video all of you should be able to arrive at a correct working diagnosis of the type of urethral injury and should also be able to institute immediate treatment to the patients if there is a need. The definitive urethroplasty should be done by a Urologist. You can watch the video in the following links:
surgicaleducator.blogspot.com
youtube.com/c/surgicaleducator
Thank you for watching the video.
Types of Urethral injury, Mechanism of Urethral injury, Classification of Urethral injury, Symptoms of Urethral injury, Signs of Urethral injury,
Investigations for Urethral injury, Grading of Urethral Injury, Treatment for Urethral injury, Complications of Urethral Injury
Radical hysterectomy is a surgical procedure for treating cervical cancer. It involves removing the uterus, cervix, part of the vagina, and nearby lymph nodes and tissue. There are different classifications of radical hysterectomy based on the extent of tissue removed. Complications can include bleeding, infection, injury to nearby organs like the bladder or ureters. Radical hysterectomy is indicated for early stage cervical cancer and may provide better survival outcomes than radiation alone for some patients.
Locally advanced breast cancer refers to stage IIIA and IIIB breast cancer where the cancer has spread locally but not to distant sites. It is typically treated with a multi-pronged approach including neoadjuvant chemotherapy to shrink the tumor followed by surgery if possible. Post-operatively, patients receive adjuvant chemotherapy, radiation therapy, and hormone therapy if the cancer is hormone receptor positive. The goal of neoadjuvant chemotherapy is to downstage the tumor to allow for breast conserving surgery rather than mastectomy in some cases. Prognosis depends on response to neoadjuvant chemotherapy and surgical margins. Inflammatory breast cancer, a rare but aggressive form of locally advanced disease, has a poorer prognosis despite intensive treatment
1) Aggressive fibromatosis is a rare soft tissue tumor that typically affects young adults. Surgery is the main treatment but recurrence is common.
2) New evidence shows systemic therapies like sorafenib, hormonal therapies, and chemotherapy can control the disease. A large trial found sorafenib significantly reduced recurrence compared to placebo.
3) Further research is still needed to determine optimal chemotherapy regimens and biomarkers to predict response to various treatments. "Wait and watch" may be suitable for less aggressive cases. Management of fibromatosis remains challenging due to the lack of high-quality data from India and validated patient-reported outcome measures.
This document discusses injuries to the ureter during gynecological surgeries. It provides details on the surgical anatomy of the ureter, risk factors for injury, common sites of injury, grading of injuries, prevention strategies and intraoperative diagnosis. The key points are:
1. The ureter's course makes it susceptible to injury during pelvic surgeries, especially at the pelvic brim.
2. Injuries occur in 0.3-1% of cases and are most common during hysterectomy.
3. Risk factors include large fibroids, adhesions, and prior pelvic surgery.
4. Prevention relies on proper surgical technique including identification and
MRI is useful for staging rectal cancer and assessing tumor involvement of surrounding structures. It can determine the depth of tumor invasion beyond the muscularis propria (T stage), evaluate the circumferential resection margin (CRM) distance between the tumor and mesorectal fascia, and identify suspicious lymph nodes. A tumor-mesorectal fascia distance of less than 1mm on MRI indicates a positive CRM, which is associated with higher rates of local recurrence. MRI is also used to assess nodal metastases based on node size, borders, and signal intensity. Accurate pre-treatment staging with MRI allows for optimal surgical planning and identification of patients who may benefit from neoadjuvant chemoradiation.
The document summarizes revisions to the FIGO staging system for endometrial cancer in 2023. Key changes include distinguishing aggressive from non-aggressive histological subtypes and assessing lymphovascular space invasion. The revised system incorporates prognostic molecular markers like POLE mutations and p53 abnormalities. Stage I is now restricted to non-invasive tumors. Stage IA3 includes some ovarian involvement by low-grade endometrial cancer. The revisions aim to better stratify patients by risk to guide treatment decisions.
This document discusses Enhanced Recovery Programs (ERPs), which aim to reduce stress response to surgery and accelerate recovery through a multimodal perioperative care pathway. Key elements of ERPs include preoperative counseling and carbohydrate loading, avoiding mechanical bowel preparation and nasogastric tubes, use of thoracic epidurals, short-acting anesthetics, goal-directed fluid therapy, normothermia, short incisions or laparoscopy, early oral intake and mobilization, and clear discharge criteria focused on independence rather than length of stay. Strict adherence to an ERP can reduce typical hospital stays for major colorectal surgery from 7-14 days to 2-3 days. ERPs require a multidisciplinary team
URETHRAL INJURY- Trauma Surgery
#surgicaleducator #babysurgeon
Dear viewers,
Greetings from “Surgical Educator”
Today I have uploaded a video on URETHRAL INJURY- one more in Trauma Surgery. I haven’t talked elaborately but have included the essential minimum an undergraduate medical student should know. I have talked about anatomy, classification, etio-pathogenesis, symptoms, signs, investigations, grading, treatment, complications, treatment algorithm and case vignettes of urethral injuries. My aim is, after watching this video all of you should be able to arrive at a correct working diagnosis of the type of urethral injury and should also be able to institute immediate treatment to the patients if there is a need. The definitive urethroplasty should be done by a Urologist. You can watch the video in the following links:
surgicaleducator.blogspot.com
youtube.com/c/surgicaleducator
Thank you for watching the video.
Types of Urethral injury, Mechanism of Urethral injury, Classification of Urethral injury, Symptoms of Urethral injury, Signs of Urethral injury,
Investigations for Urethral injury, Grading of Urethral Injury, Treatment for Urethral injury, Complications of Urethral Injury
The anal canal is approximately 4 cm in length extending from the anorectal junction to the anal verge. Anal cancers are rare and mostly squamous cell carcinomas arising from the anal transitional zone. Risk factors include HPV infection and immunosuppression. Combined chemoradiotherapy is the standard first-line treatment and results in high response rates and organ preservation compared to radiation alone. Salvage surgery may be considered for select cases after failed nonsurgical treatment or as primary treatment for those who cannot tolerate chemoradiotherapy. Prognosis depends on tumor stage, with 5-year survival rates ranging from 45-86% depending on depth of invasion and nodal involvement.
Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface MalignanciesMary Ondinee Manalo Igot
Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is emerging as a new standard treatment for peritoneal surface malignancies. Traditionally, peritoneal carcinomatosis was considered incurable and treated only with palliative chemotherapy. However, CRS-HIPEC aims to remove all visible tumor deposits surgically and then uses heated chemotherapy in the abdominal cavity to target any remaining microscopic disease. Studies show CRS-HIPEC provides significantly longer survival times compared to intravenous chemotherapy alone, with median overall survivals of 16-36 months. Experts indicate CRS-HIPEC should now be considered the standard of care for select patients with peritoneal metastases from conditions like ovarian
Peritoneal carcinomatosis refers to the spread of cancer to the peritoneal cavity. It has traditionally had a poor prognosis with best supportive care or chemotherapy alone. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) or early postoperative intraperitoneal chemotherapy (EPIC) has emerged as a treatment approach that can provide long-term survival or cure in properly selected patients. Key factors in patient selection include ensuring no distant metastases, thorough staging to determine peritoneal cancer index and completeness of cytoreduction, and histology of primary tumor. The goal of CRS is to remove all visible tumor nodules followed by HIPEC or EPIC to treat any remaining microscopic
The document discusses carcinoma of the pancreas. It covers the anatomy, epidemiology, risk factors, genetics, screening, staging, pathologic conditions, clinical presentation, evaluation, management approaches for resectable, borderline resectable, and unresectable disease, surgical procedures including Whipple procedure and distal pancreatectomy, complications, adjuvant therapy approaches studied in trials such as ESPAC-1, and the role of chemoradiation following gemcitabine chemotherapy.
This document summarizes the management of pancreatic carcinoma. It discusses the anatomy, epidemiology, risk factors, hereditary syndromes, pathophysiology including pre-cancerous lesions, types of pancreatic cancer, staging, prognostic factors, diagnostic techniques, treatment including surgery, chemotherapy, targeted therapy, radiotherapy and historical prospective studies. It provides a comprehensive overview of pancreatic carcinoma covering all relevant aspects of the disease.
Preoperative chemoradiotherapy is commonly used to treat rectal cancer. It can reduce the tumor size and increase the likelihood of sphincter-sparing surgery. Studies have shown that preoperative chemoradiotherapy results in lower local recurrence rates compared to postoperative chemoradiotherapy or radiotherapy alone, without increasing distant metastases or mortality. Short-course radiotherapy followed by surgery within a week is also effective at reducing local recurrence compared to surgery alone, especially when combined with total mesorectal excision.
The document discusses the anatomy and diagnostic evaluation of prostate cancer. It describes the prostate as a walnut-sized gland located below the bladder and surrounding the urethra. The primary function is to produce seminal fluid. Diagnostic workup involves PSA levels, digital rectal exam, prostate biopsy and various imaging modalities like CT, MRI, bone scan and PSMA PET/CT to stage disease extent and metastasis. Gleason scoring is used to grade prostate cancer based on architectural patterns seen on biopsy.
Presentation at Chittaranjan Seva Sadan, Kolkata where Dr Dasgupta was invited as faculty in the CME organized by Medical Education and research Committee, Bengal Obstetrics and Gynaecological Society
Clinical presentation and investigations for breast carcinomaViswa Kumar
This document provides an overview of breast carcinoma, including:
1) The embryology, functional anatomy, blood supply, innervation, and lymphatics of the breast.
2) The epidemiology of breast cancer, noting it is the most common cancer in women worldwide.
3) Clinical presentations like palpable masses, pain, nipple discharge, and skin changes.
4) Recommendations for diagnostic tools like mammography, ultrasound, and MRI to evaluate symptoms based on patient age and risk factors.
5) The BI-RADS assessment system to categorize imaging findings and guide next steps.
This document summarizes information about sentinel lymph node biopsy for breast cancer. It discusses the history and technique of sentinel lymph node biopsy. It describes that the sentinel lymph node is the first lymph node to receive drainage from the primary tumor site, usually in the axilla. The document outlines the procedure for sentinel lymph node biopsy and evaluating biopsy specimens. It discusses studies that have shown sentinel lymph node biopsy is an accurate method for staging breast cancer and that completion axillary lymph node dissection may not be needed in all cases with limited sentinel lymph node involvement.
This document summarizes the surgical anatomy of the prostate gland. It describes the prostate's location and relations to surrounding structures like the bladder, urethra, and rectum. It details the prostate's blood supply from branches of the internal iliac artery, innervation from pelvic splanchic and pudendal nerves, and lymphatic drainage routes. The document also outlines important surgical structures like the prostatic capsule, neurovascular bundle, and surrounding fascial planes important for nerve-sparing prostatectomy.
This document discusses adnexal masses in reproductive age women. It provides clinical background and epidemiology of adnexal masses. It discusses ultrasound techniques for evaluating adnexal masses such as 2D ultrasound, Doppler ultrasound, 3D and power Doppler ultrasound. Pattern recognition of benign disease using ultrasound is covered. The document also discusses predicting malignancy using systems like IOTA simple rules and pattern recognition. Characterization of adnexal masses and predicting histopathology and management are key focuses.
The document discusses the lymphatic drainage patterns of the vulva and vagina and describes vulval cancer. It notes that the vulva has dense lymphatic plexuses that drain to the superficial and deep inguinal lymph nodes and external iliac nodes. Vulval cancer is rare and usually occurs in postmenopausal women. Risk factors include conditions like lichen sclerosus. Diagnosis is by biopsy and treatment involves radical vulvectomy with bilateral lymph node dissection or radiotherapy depending on the stage of cancer. Prognosis depends on lymph node involvement, with 5-year survival rates ranging from 90-100% without node involvement to below 20% with positive pelvic nodes.
The document discusses the approach to diagnosing a breast lump. It outlines the triple assessment strategy which involves clinical examination, imaging, and tissue biopsy. This is currently the gold standard for diagnosis and can achieve nearly 100% diagnostic accuracy. The first step is confirming the presence of a discrete mass through physical examination. Next, imaging such as mammography or ultrasound is used to distinguish simple cysts from solid lesions. Tissue sampling of solid lesions through fine needle aspiration or core biopsy provides a histological diagnosis and guides management, which could include surgery for malignant masses or follow up for benign lesions.
Laparoscopic anatomy of inguinal herniaDONY DEVASIA
This document provides an overview of the anatomy relevant to laparoscopic inguinal hernia repair. It describes key anatomic spaces such as the retzius space and bogros space. It also outlines important landmarks including the triangle of doom, triangle of pain, and cooper's ligament. Surgeons are advised to understand the laparoscopic views of the anatomy before performing these hernia repair procedures.
This document discusses the management of endometrial carcinoma. It covers diagnosis through clinical examinations and investigations. Surgical staging is now standard practice to better guide adjuvant therapy. Prognostic factors include stage, grade, depth of invasion and nodal involvement. Treatment involves surgery, with radiation therapy and chemotherapy used for more advanced or high risk cases. Ongoing follow up is also recommended.
1) Carcinoma of the rectum arises from the adenoma-carcinoma sequence and risk factors include red meat, alcohol, smoking, and inflammatory bowel disease.
2) Evaluation involves digital rectal exam, rigid proctoscopy, colonoscopy, CT, MRI, and lab tests to stage the tumor and check for metastases.
3) Treatment depends on tumor stage but commonly includes total mesorectal excision surgery with clear margins and may involve radiation or chemoradiation to downstage the tumor preoperatively.
Cervical cancer is caused by HPV infection and is the leading cause of cancer deaths in many developing countries. HPV is present in over 99% of cervical cancers. Risk factors include young age of first sexual activity, multiple partners, early pregnancy, and smoking. Precancerous lesions usually develop over 10-15 years. Cervical cancer spreads locally through the cervix and vagina, and can metastasize to nearby lymph nodes and distant sites like the lungs and liver. Diagnosis involves identifying dysplastic cervical cells, and treatment depends on the cancer stage.
Peritoneal Carcinomatosis : Dr Amit DangiDr Amit Dangi
Here are the key steps:
1. The left subphrenic space is entered by incising the peritoneum overlying the left hemidiaphragm.
2. The peritoneum is dissected off the left hemidiaphragm in a cephalad direction towards the diaphragmatic crus.
3. The peritoneum is then stripped down the left paracolic gutter towards the pelvis, removing all peritoneal surfaces.
4. The left subphrenic peritonectomy is then completed, exposing the left hemidiaphragm and removing all peritoneal surfaces in the left subphrenic space.
This document provides information about cancer of the anal canal, including its anatomy, risk factors, staging, classification, and treatment. It notes that anal canal cancer is uncommon but increasing in incidence. The anal canal is approximately 4 cm long and lines by squamous epithelium. Risk factors include HPV infection and immunosuppression. Treatment typically involves chemoradiotherapy to preserve the sphincter, which provides high survival and local control rates of 60-90%. Combined modality therapy with 5-FU and mitomycin C or cisplatin is the standard of care.
The anal canal is approximately 4 cm in length extending from the anorectal junction to the anal verge. Anal cancers are rare and mostly squamous cell carcinomas arising from the anal transitional zone. Risk factors include HPV infection and immunosuppression. Combined chemoradiotherapy is the standard first-line treatment and results in high response rates and organ preservation compared to radiation alone. Salvage surgery may be considered for select cases after failed nonsurgical treatment or as primary treatment for those who cannot tolerate chemoradiotherapy. Prognosis depends on tumor stage, with 5-year survival rates ranging from 45-86% depending on depth of invasion and nodal involvement.
Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface MalignanciesMary Ondinee Manalo Igot
Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is emerging as a new standard treatment for peritoneal surface malignancies. Traditionally, peritoneal carcinomatosis was considered incurable and treated only with palliative chemotherapy. However, CRS-HIPEC aims to remove all visible tumor deposits surgically and then uses heated chemotherapy in the abdominal cavity to target any remaining microscopic disease. Studies show CRS-HIPEC provides significantly longer survival times compared to intravenous chemotherapy alone, with median overall survivals of 16-36 months. Experts indicate CRS-HIPEC should now be considered the standard of care for select patients with peritoneal metastases from conditions like ovarian
Peritoneal carcinomatosis refers to the spread of cancer to the peritoneal cavity. It has traditionally had a poor prognosis with best supportive care or chemotherapy alone. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) or early postoperative intraperitoneal chemotherapy (EPIC) has emerged as a treatment approach that can provide long-term survival or cure in properly selected patients. Key factors in patient selection include ensuring no distant metastases, thorough staging to determine peritoneal cancer index and completeness of cytoreduction, and histology of primary tumor. The goal of CRS is to remove all visible tumor nodules followed by HIPEC or EPIC to treat any remaining microscopic
The document discusses carcinoma of the pancreas. It covers the anatomy, epidemiology, risk factors, genetics, screening, staging, pathologic conditions, clinical presentation, evaluation, management approaches for resectable, borderline resectable, and unresectable disease, surgical procedures including Whipple procedure and distal pancreatectomy, complications, adjuvant therapy approaches studied in trials such as ESPAC-1, and the role of chemoradiation following gemcitabine chemotherapy.
This document summarizes the management of pancreatic carcinoma. It discusses the anatomy, epidemiology, risk factors, hereditary syndromes, pathophysiology including pre-cancerous lesions, types of pancreatic cancer, staging, prognostic factors, diagnostic techniques, treatment including surgery, chemotherapy, targeted therapy, radiotherapy and historical prospective studies. It provides a comprehensive overview of pancreatic carcinoma covering all relevant aspects of the disease.
Preoperative chemoradiotherapy is commonly used to treat rectal cancer. It can reduce the tumor size and increase the likelihood of sphincter-sparing surgery. Studies have shown that preoperative chemoradiotherapy results in lower local recurrence rates compared to postoperative chemoradiotherapy or radiotherapy alone, without increasing distant metastases or mortality. Short-course radiotherapy followed by surgery within a week is also effective at reducing local recurrence compared to surgery alone, especially when combined with total mesorectal excision.
The document discusses the anatomy and diagnostic evaluation of prostate cancer. It describes the prostate as a walnut-sized gland located below the bladder and surrounding the urethra. The primary function is to produce seminal fluid. Diagnostic workup involves PSA levels, digital rectal exam, prostate biopsy and various imaging modalities like CT, MRI, bone scan and PSMA PET/CT to stage disease extent and metastasis. Gleason scoring is used to grade prostate cancer based on architectural patterns seen on biopsy.
Presentation at Chittaranjan Seva Sadan, Kolkata where Dr Dasgupta was invited as faculty in the CME organized by Medical Education and research Committee, Bengal Obstetrics and Gynaecological Society
Clinical presentation and investigations for breast carcinomaViswa Kumar
This document provides an overview of breast carcinoma, including:
1) The embryology, functional anatomy, blood supply, innervation, and lymphatics of the breast.
2) The epidemiology of breast cancer, noting it is the most common cancer in women worldwide.
3) Clinical presentations like palpable masses, pain, nipple discharge, and skin changes.
4) Recommendations for diagnostic tools like mammography, ultrasound, and MRI to evaluate symptoms based on patient age and risk factors.
5) The BI-RADS assessment system to categorize imaging findings and guide next steps.
This document summarizes information about sentinel lymph node biopsy for breast cancer. It discusses the history and technique of sentinel lymph node biopsy. It describes that the sentinel lymph node is the first lymph node to receive drainage from the primary tumor site, usually in the axilla. The document outlines the procedure for sentinel lymph node biopsy and evaluating biopsy specimens. It discusses studies that have shown sentinel lymph node biopsy is an accurate method for staging breast cancer and that completion axillary lymph node dissection may not be needed in all cases with limited sentinel lymph node involvement.
This document summarizes the surgical anatomy of the prostate gland. It describes the prostate's location and relations to surrounding structures like the bladder, urethra, and rectum. It details the prostate's blood supply from branches of the internal iliac artery, innervation from pelvic splanchic and pudendal nerves, and lymphatic drainage routes. The document also outlines important surgical structures like the prostatic capsule, neurovascular bundle, and surrounding fascial planes important for nerve-sparing prostatectomy.
This document discusses adnexal masses in reproductive age women. It provides clinical background and epidemiology of adnexal masses. It discusses ultrasound techniques for evaluating adnexal masses such as 2D ultrasound, Doppler ultrasound, 3D and power Doppler ultrasound. Pattern recognition of benign disease using ultrasound is covered. The document also discusses predicting malignancy using systems like IOTA simple rules and pattern recognition. Characterization of adnexal masses and predicting histopathology and management are key focuses.
The document discusses the lymphatic drainage patterns of the vulva and vagina and describes vulval cancer. It notes that the vulva has dense lymphatic plexuses that drain to the superficial and deep inguinal lymph nodes and external iliac nodes. Vulval cancer is rare and usually occurs in postmenopausal women. Risk factors include conditions like lichen sclerosus. Diagnosis is by biopsy and treatment involves radical vulvectomy with bilateral lymph node dissection or radiotherapy depending on the stage of cancer. Prognosis depends on lymph node involvement, with 5-year survival rates ranging from 90-100% without node involvement to below 20% with positive pelvic nodes.
The document discusses the approach to diagnosing a breast lump. It outlines the triple assessment strategy which involves clinical examination, imaging, and tissue biopsy. This is currently the gold standard for diagnosis and can achieve nearly 100% diagnostic accuracy. The first step is confirming the presence of a discrete mass through physical examination. Next, imaging such as mammography or ultrasound is used to distinguish simple cysts from solid lesions. Tissue sampling of solid lesions through fine needle aspiration or core biopsy provides a histological diagnosis and guides management, which could include surgery for malignant masses or follow up for benign lesions.
Laparoscopic anatomy of inguinal herniaDONY DEVASIA
This document provides an overview of the anatomy relevant to laparoscopic inguinal hernia repair. It describes key anatomic spaces such as the retzius space and bogros space. It also outlines important landmarks including the triangle of doom, triangle of pain, and cooper's ligament. Surgeons are advised to understand the laparoscopic views of the anatomy before performing these hernia repair procedures.
This document discusses the management of endometrial carcinoma. It covers diagnosis through clinical examinations and investigations. Surgical staging is now standard practice to better guide adjuvant therapy. Prognostic factors include stage, grade, depth of invasion and nodal involvement. Treatment involves surgery, with radiation therapy and chemotherapy used for more advanced or high risk cases. Ongoing follow up is also recommended.
1) Carcinoma of the rectum arises from the adenoma-carcinoma sequence and risk factors include red meat, alcohol, smoking, and inflammatory bowel disease.
2) Evaluation involves digital rectal exam, rigid proctoscopy, colonoscopy, CT, MRI, and lab tests to stage the tumor and check for metastases.
3) Treatment depends on tumor stage but commonly includes total mesorectal excision surgery with clear margins and may involve radiation or chemoradiation to downstage the tumor preoperatively.
Cervical cancer is caused by HPV infection and is the leading cause of cancer deaths in many developing countries. HPV is present in over 99% of cervical cancers. Risk factors include young age of first sexual activity, multiple partners, early pregnancy, and smoking. Precancerous lesions usually develop over 10-15 years. Cervical cancer spreads locally through the cervix and vagina, and can metastasize to nearby lymph nodes and distant sites like the lungs and liver. Diagnosis involves identifying dysplastic cervical cells, and treatment depends on the cancer stage.
Peritoneal Carcinomatosis : Dr Amit DangiDr Amit Dangi
Here are the key steps:
1. The left subphrenic space is entered by incising the peritoneum overlying the left hemidiaphragm.
2. The peritoneum is dissected off the left hemidiaphragm in a cephalad direction towards the diaphragmatic crus.
3. The peritoneum is then stripped down the left paracolic gutter towards the pelvis, removing all peritoneal surfaces.
4. The left subphrenic peritonectomy is then completed, exposing the left hemidiaphragm and removing all peritoneal surfaces in the left subphrenic space.
This document provides information about cancer of the anal canal, including its anatomy, risk factors, staging, classification, and treatment. It notes that anal canal cancer is uncommon but increasing in incidence. The anal canal is approximately 4 cm long and lines by squamous epithelium. Risk factors include HPV infection and immunosuppression. Treatment typically involves chemoradiotherapy to preserve the sphincter, which provides high survival and local control rates of 60-90%. Combined modality therapy with 5-FU and mitomycin C or cisplatin is the standard of care.
This document summarizes information about anal canal cancer, including:
- It accounts for 1-2% of large bowel malignancies and is increasing in incidence. Risk factors include HPV infection and HIV infection.
- Screening high-risk groups like HIV+ individuals can detect early anal intraepithelial neoplasia, as HPV vaccines may help prevent cancers.
- Most anal canal cancers are squamous cell carcinomas. Clinical staging evaluates tumor extent, node involvement, and distant spread through digital exam, imaging and biopsy.
Dr. Naina Kumar Agarwal's document discusses carcinoma of the anal canal. It covers the anatomy of the anal canal, epidemiology and risk factors for anal carcinoma including HPV infection and immunosuppression. It discusses screening and prevention strategies as well as the pathology, signs and symptoms, staging, and treatment of anal carcinoma. Definitive chemoradiation is the standard of care for localized squamous cell carcinoma of the anal canal, with the addition of chemotherapy to radiation therapy improving local control rates and survival compared to radiation alone. Prognostic factors include tumor size, lymph node involvement, and gender.
Vulvar cancer is a rare malignancy that constitutes about 5% of female genital tract cancers. It most commonly affects older women around age 68. About 40% of cases are linked to HPV infection. Sentinel lymph node biopsy is an important diagnostic technique to detect early metastatic spread. Studies have found the sentinel lymph node to be accurate in detecting metastases in over 90% of cases, with a low false negative rate of around 3-8%. Positive sentinel nodes are associated with higher rates of recurrence and worse survival outcomes. Sentinel lymph node biopsy provides valuable staging information with less morbidity compared to traditional inguinal lymphadenectomy.
Anal carcinoma rates have been increasing in the United States, especially in those over age 50. Risk factors include HPV infection, receptive anal intercourse, immunosuppression, smoking, and certain autoimmune diseases. High-grade anal intraepithelial neoplasia can be treated to prevent anal cancer from developing. Vaccination and screening are recommended for high-risk groups. Treatment typically involves chemo-radiation, with surgery as an option for recurrent or persistent disease.
1) Squamous cell carcinoma of the head and neck (SCCHN) is the sixth most common cancer worldwide, with 500,000 new cases expected each year. Approximately 2/3 of patients present with locally advanced disease.
2) Risk factors for head and neck cancer include tobacco products, alcohol, chemicals such as asbestos and formaldehyde, and viruses such as HPV. HPV-positive oropharyngeal cancer is an emerging issue.
3) Treatment depends on disease stage, with surgery or radiation used for early stage and multimodality treatment for advanced stages. Outcomes are generally poor with high mortality and recurrence rates. However, HPV-positive cancers have a better prognosis compared to HPV-negative cancers
1. Carcinoma of the vagina is a rare cancer representing 1-2% of gynecologic malignancies. The majority are squamous cell carcinomas.
2. Risk factors include HPV infection, previous pelvic radiation, and in-utero exposure to DES which can cause clear cell adenocarcinoma.
3. Treatment depends on stage but commonly involves radiation therapy with brachytherapy. Surgery may be used for early stage lesions or failures of radiation therapy. Chemotherapy combined with radiation may improve outcomes for advanced stages.
ETIOPATHOGENESIS AND STAGING OF CA PENIS (1).pptxDebashis Routray
This document discusses the etiopathogenesis and staging of penile cancer. It begins with an introduction and describes carcinoma in situ (Tis) and its subtypes. It then covers premalignant lesions such as condylomata acuminata and lichen sclerosus. Risk factors, natural history, clinical presentation, diagnosis, and histological subtypes are summarized. Grading of penile cancer is described based on histologic features.
This document discusses squamous cell carcinoma of the anal canal. It describes the anatomy of the anal canal and defines the anal canal, transitional zone, and anal margin. Risk factors for anal cancer include HPV infection and HIV/AIDS. Combined modality treatment including chemotherapy with mitomycin and 5-fluorouracil alongside radiation therapy is an effective standard of care based on clinical trials showing improved local control and survival compared to radiation alone.
Management of anal canal tumors with emphasis on treatment(1)SabaMajid5
This document discusses the management of anal canal tumors with an emphasis on radiation therapy planning. It provides details on:
1) The anatomy of the anal canal and blood supply, lymphatic drainage, and nerve innervation.
2) Risk factors, staging, and patterns of spread for anal canal cancer.
3) The standard of care for anal canal cancer, which is concurrent chemoradiation therapy using radiation doses between 50-59 Gy along with chemotherapy drugs like 5-FU and mitomycin.
4) Techniques for radiation therapy planning including target volume delineation, field arrangements, and dose guidelines to maximize tumor coverage while minimizing dose to surrounding organs.
1) Anal cancer is uncommon, comprising 2.4% of digestive system cancers in the US, with an estimated 7,060 new cases and 880 deaths in 2013.
2) The median age at diagnosis of anal cancer is 60, younger than the median age of 66 for all cancers.
3) The majority of anal cancers are squamous cell carcinomas caused by HPV infection, while adenocarcinomas are rare. Treatment typically involves chemotherapy and radiation.
4) Five-year survival rates range from 71-78% for early stage anal cancer to 20-24% for late stage or metastatic disease. Combined chemoradiation provides local control in 85-90% of cases.
Etiopathogenesis and natural history of ca cervixNiranjan Chavan
CERVICAL CANCER , the 2nd most common cancer in India can be easily prevented with proper adequate screening and awareness.
Adequate sex education is necessary to inculcate safe sexual practices to prevent HPV infection.
Etiopathogenesis and natural history of ca cervixNiranjan Chavan
CERVICAL CANCER , the 2nd most common cancer in India can be easily prevented with proper adequate screening and awareness.
Adequate sex education is necessary to inculcate safe sexual practices to prevent HPV infection.
This document discusses HPV infection and oropharyngeal cancer. It notes that HPV is a common virus, and certain HPV types can cause cancers like oropharyngeal, cervical, anal and others. HPV-positive oropharyngeal cancer rates have been rising dramatically and now account for most oropharynx cancers. HPV-positive cancers often present with neck masses and occult primaries, and have better survival rates than HPV-negative cancers. Ongoing trials are exploring de-escalated treatment approaches for HPV-positive patients given their superior outcomes with standard chemoradiation. The document reviews staging, symptoms, imaging, treatment and outcomes for HPV-positive oropharyngeal cancer.
1) Cancers of the penis are rare but devastating, accounting for 0.4-0.6% of cancers in men in the US and Europe but up to 10% in some other regions.
2) Risk factors include poor hygiene, phimosis, HPV infection, and lack of circumcision. Over 95% are squamous cell carcinoma.
3) Staging involves physical exam, biopsy, and imaging of lymph nodes and distant organs. Treatment may include organ-sparing surgery or penile amputation depending on size, grade, and extent of invasion.
Cervical cancer occurs in the cervix and is mainly caused by HPV infection. Examination includes speculum exam to visualize lesions and biopsy for diagnosis. Risk factors include multiple sexual partners and smoking. Early symptoms may include abnormal bleeding but it can also be asymptomatic. Treatment depends on stage but may include surgery, radiation, chemotherapy, or a combination. Regular pap smears can help detect early changes. Vaccination and safe sex practices can help prevent HPV infection and therefore reduce cervical cancer risk.
ca cervix.ppt.pptx cancer cancer of femaleswatisheth8
The transformation zone of the cervix undergoes metaplasia throughout life in response to changes in the environment. Cervical cancer develops from precancerous lesions in this zone and is strongly associated with HPV infection. Screening allows for early detection and treatment of precancers and early cancers. Treatment options depend on the stage of cancer, with local excision for early stages and surgery or chemoradiation for more advanced stages.
This document provides background information on ovarian cancer, including its pathophysiology, etiology, epidemiology, clinical presentation, diagnosis, and screening. It states that ovarian cancer typically spreads within the peritoneal cavity. Several risk factors are identified, including genetic and reproductive factors. Epithelial ovarian cancer represents the most common histology and has a poor prognosis when diagnosed at advanced stages, due to nonspecific symptoms. No approved screening methods exist for ovarian cancer detection.
This document provides tips and instructions for using a PowerPoint presentation (ppt) on anal cancer:
1. The ppt can be freely downloaded, edited, and modified. It contains blank slides for notes that students can fill in.
2. The instructor should show blank slides, ask students what they know, and then show slides with information to fill gaps in an active learning session repeated three times.
3. The ppt is also useful for self-study with notes and bibliography provided.
Chapter 39 role of radiotherapy in benign diseases.pptx [read only]Nilesh Kucha
This document discusses the role of radiotherapy in treating non-malignant diseases. It begins by classifying non-malignant diseases and outlining some common indications for radiotherapy, such as invasive growth, functional impairment, or pain. It then discusses specific disorders like desmoids, keloids, and Peyronie's disease. For each condition, it describes non-radiotherapy treatments, radiotherapy dose and techniques, and expected clinical outcomes. Throughout, it emphasizes the need for a risk-benefit analysis and informed consent when using radiotherapy for benign rather than malignant purposes.
Chapter 39 role of radiotherapy in benign diseasesNilesh Kucha
Surgery is the last resort
RADIOTHERAPEUTIC TREATMENT
Indications:
- Painful degenerative changes with no or minimal joint space narrowing
- Inflammatory synovitis
- Postoperative pain relief
- As an adjunct to conservative measures
Technique:
- Low energy X-rays or electrons
- Small field sizes (2-4 cm)
- Total dose 6-10 Gy in 3-5 fractions over 1-2 weeks
- Joint immobilization
Results:
- Pain relief in 60-80% patients lasting 3-6 months
- No disease modification
- Repeat treatment possible if pain recurs
Chapter 39 role of radiotherapy in benign diseasesNilesh Kucha
Radiotherapy can successfully treat some non-malignant diseases by reducing inflammation, inhibiting fibroblast proliferation, and preventing mitotic cell proliferation. It may be indicated for aggressive growths, functional impairment, or pain when other methods have failed. Risks include potential long-term induction of tumors. Treatment requires a risk-benefit analysis and informed consent. Doses and techniques vary depending on the condition but are typically fractionated over several days to weeks with total doses of 8-65Gy. Outcomes include improved symptoms for some connective tissue disorders and skin conditions.
Chapter 38 role of surgery in cancer preventionNilesh Kucha
The document discusses the role of surgery in preventing cancers caused by hereditary genetic mutations. It focuses on several high-risk cancer syndromes including BRCA1/2 mutations which increase breast and ovarian cancer risk, CDH1 mutations which increase stomach cancer risk, and APC mutations which cause Familial Adenomatous Polyposis (FAP) and increase colon cancer risk. For each, it describes the associated cancer risks, genetic testing recommendations, surveillance guidelines, and risk-reducing surgical options such as prophylactic mastectomies, salpingo-oophorectomies, and gastrectomies. The timing of such surgeries is based on the earliest age of cancer onset in the
Superior vena cava (SVC) syndrome results from obstruction of blood flow through the SVC, which can be caused by external compression or invasion by adjacent tumors or thrombosis within the SVC. The most common causes are lung cancer, lymphoma, and thrombosis related to intravenous devices. Obstruction of the SVC increases venous blood pressure as collateral veins form, potentially causing symptoms like head and neck swelling, dyspnea, and cough. SVC syndrome is diagnosed based on symptoms and imaging evidence of SVC obstruction.
Regulatory T-cells (Tregs) help maintain self-tolerance and prevent autoimmunity by suppressing immune responses. They express FOXP3 and CD25 and function through various mechanisms like secreting inhibitory cytokines or metabolizing IL-2. Tregs are implicated in tumor immune escape by suppressing anti-tumor immunity. While Tregs are normally beneficial, in cancer high levels associate with poor prognosis by hindering immune response. Emerging immunotherapies aim to deplete or modulate Tregs to enhance anti-tumor immunity.
Tumor lysis syndrome is an oncologic emergency caused by massive tumor cell lysis and release of potassium, phosphate, and nucleic acids into circulation. It often occurs after initiation of cytotoxic therapy in patients with high-grade lymphomas or ALL who have a large tumor burden or high proliferative rate. This can result in hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia, and acute kidney injury due to uric acid precipitation in renal tubules. Aggressive hydration, allopurinol or rasburicase to reduce uric acid, phosphate binders, and renal replacement therapy if needed are used to treat and prevent tumor lysis syndrome.
This document provides an overview of different types of clinical study designs, including observational studies and experimental studies. It discusses the key aspects and objectives of different phases of clinical trials, including:
1. Phase I trials which aim to determine safety and maximum tolerated dose of new therapies.
2. Phase II trials which provide preliminary evidence of efficacy through surrogate endpoints and further evaluate safety.
3. Phase III trials which are comparative effectiveness trials that use clinical outcomes like survival to compare new treatments to standard of care through randomized controlled designs.
ITC, or isolated tumor cells, refer to small clusters of cancer cells that break off from the primary tumor and circulate in the bloodstream. While only 0.05% of circulating tumor cells survive to form metastases, detection of ITC can provide prognostic information. ITC can be detected using morphological or non-morphological methods like immunohistochemistry and PCR, but non-morphological methods have a higher false positive rate. The presence of ITC may have prognostic value and inform more aggressive treatment, but the evidence for their clinical significance is equivocal for many cancer types. ITC detection is most clearly prognostic in breast cancer, while data is mixed for colorectal cancer.
The document summarizes the process of cancer metastasis through the invasion-metastasis cascade. It involves 6 key steps: 1) Localized invasion of primary tumor cells aided by loss of cell adhesion molecules and matrix metalloproteinases. 2) Intravasation of tumor cells into blood vessels assisted by tumor-associated macrophages. 3) Transport of circulating tumor cells protected by platelet emboli. 4) Extravasation of tumor cells from vessels into distant tissues. 5) Formation of dormant micrometastases. 6) Rare colonization of micrometastases into macroscopic tumors limited by the foreign tissue environment. Metastasis suppressor genes and strategies targeting multiple steps simultaneously show promise for preventing cancer spread.
This document discusses the components of a cancer genetic counseling session. It describes the process of obtaining a family history, assessing cancer risks, discussing genetic testing options and implications for family members. Key parts of the session include getting informed consent, choosing an appropriate candidate for testing, determining cancer risks, implications for relatives, and making management recommendations even if testing is declined.
This document provides guidelines for the management of febrile neutropenia in cancer patients. It defines febrile neutropenia and outlines risks for serious infection. Initial assessment involves evaluating risk of complications to determine treatment approach. Empiric broad-spectrum antibacterial therapy should be initiated within 60 minutes of presentation to cover likely pathogens. The regimen may be modified based on infection source or persistence of fever. Early antifungal therapy should also be considered for high-risk patients.
Dendritic cells are bone marrow-derived antigen-presenting cells that initiate adaptive immune responses. They capture antigens through processes like endocytosis and present them on MHC molecules to activate T cells. Dendritic cells exist in immature and mature forms, and upon maturation they migrate from tissues to lymph nodes to activate T cells. As the most potent antigen-presenting cells, dendritic cells play a key role in anti-cancer immunity by presenting tumor antigens, activating T cells, and generating an immune response against cancer cells.
This document provides an overview of clinical trials and their various phases. It discusses how clinical trials are used to test potential interventions in humans to determine if they should be adopted for general use. The different phases of clinical trials are described, including phase I-IV. Key aspects of clinical trial design such as randomization, blinding, and placebos are explained. Hypothesis testing and its role in statistical analysis is also summarized.
Chapter 27 chemotherapy side effects dr lmsNilesh Kucha
The era of modern chemotherapy began in the early 1940s when Goodman and Gilman first administered nitrogen mustard to lymphoma patients. Although nitrogen mustard was originally developed as a chemical weapon, its toxic effects on the lymphatic system led to clinical trials of its use in cancer treatment. This marked the beginning of chemotherapy as an active field of cancer research and therapy development.
Chemoprevention seeks to use natural, synthetic, or biological agents to prevent cancer development and progression. It can involve blocking cancer initiation through agents that prevent DNA damage from carcinogens. It can also suppress promotion and progression of initiated cells through inhibition of signal transduction pathways. The FDA has approved selective estrogen receptor modulators like tamoxifen and raloxifene for breast cancer chemoprevention and aspirin use has been associated with reduced colorectal cancer risk. However, some agents like beta-carotene and retinoids have been found to increase cancer risk in smokers.
Chapter 25 assessment of clincal responsesNilesh Kucha
The document discusses guidelines for assessing clinical response in cancer patients based on tumor size changes. The RECIST (Response Evaluation Criteria in Solid Tumors) criteria provide a standardized approach for measuring lesions and determining objective tumor responses. Key points include defining measurable vs. non-measurable lesions, methods for measurement and assessment, and criteria for complete response, partial response, stable disease and progressive disease based on tumor burden changes. The guidelines aim to improve consistency in evaluating clinical trial outcomes.
Metronomic chemotherapy involves the chronic administration of chemotherapy drugs at low, minimally toxic doses on a frequent schedule with no prolonged breaks. This strategy aims to control cancer by targeting tumor vasculature and is an attractive option in resource-limited areas due to its low cost, oral administration, and minimal side effects compared to conventional chemotherapy. Combining metronomic chemotherapy with drug repositioning and targeted therapies may lead to improved cancer control through multi-pronged effects on cancer cells, vasculature, and the immune system. However, determining the optimal biological dose and identifying surrogate markers pose challenges to realizing the full potential of this approach.
Chapter 24.2 lmwh in cancer asso thrombosisNilesh Kucha
The document discusses cancer-associated thrombosis (CAT). It notes that cancer increases the risk of venous thromboembolism (VTE) due to alterations in the coagulation system and inflammatory response to cancer that result in a hypercoagulable state. Several risk assessment scores are used to stratify cancer patients' risk of VTE, with the goal of identifying those who could benefit from thromboprophylaxis. The pathophysiology of CAT involves Virchow's triad of stasis, vessel injury, and hypercoagulability due to factors from cancer cells and cytokines that promote coagulation and clot formation.
Chapter 24.1 kinase inhibitors and monoclonal antibodiesNilesh Kucha
Tyrosine kinases are enzymes that help transfer phosphate groups and play a role in cell signaling. There are two types: receptor tyrosine kinases which are transmembrane proteins, and non-receptor tyrosine kinases which act as intracellular signal transducers. When tyrosine kinases are mutated or overexpressed, they can lead to uncontrolled cell growth and survival contributing to cancer. Tyrosine kinase inhibitors are small molecule drugs that target the intracellular tyrosine kinase domain to inhibit phosphorylation and downstream signaling, thereby inhibiting cancer cell growth and survival. Examples of tyrosine kinase inhibitors discussed in the document include imatinib, gefitinib, lapatinib, crizotinib, sorafenib, sunitin
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
2. U.S. GI Intergroup
Compared mitomycin vs cisplatin
The rate of colostomy at 5 years was
significantly lower in the mitomycin, 5-FU,
radiation arm (10 vs. 19%; P = .04).
Disease-free and overall survival rates were
similar in each group.
Grade 3-4 hematologic toxicity was higher in
those who received mitomycin (60% vs.
42%) but other acute toxicity levels were
similar.
The combination of 5-FU, mitomycin, and
radiation was recommended as the
preferred standard of care.
3. The combination of radiation, 5-
FU, and mitomycin
5-year survival rates local control rates
80% for (T1)
70% for (T2)
45% to 55% for larger or
deeply invasive cancers
(T3 or T4)
65% to 75% overall
90% to 100% - (T1)
65% to 75% - (T2)
40% to 55% - (T3 or
T4)
60% overall.
Up to 5% of patients
overall lost anorectal
function because of
treatment-related
morbidity
4. Timing of delivery of
chemotherapy
The importance of timing relative to
radiation each day is not known.
Mainly by analogy with the results of
trials already completed in more
common cancers, and by general
usage, the delivery of 96- to 120-hour
infusions of 5-FU, together with bolus
injections of cisplatin or mitomycin on
the first or second day of the 5-FU
infusion, is the schedule used most
widely.
5. Increasing the total radiation dose and
shortening the overall duration of the radiation
schedules
When combined with 5-FU and mitomycin –
- 30 Gy in 3 weeks eradicate up to about
90% ( < 3 cm in size).
- Higher doses, from 45 Gy in 5 weeks to 54
Gy in 6 weeks, sometimes supplemented by
additional radiation after an interval of 6 to 8
weeks - controlled 65% to 75% larger than
4 cm.70
Improved tumor control was observed .
Although the patients also received higher
total doses of chemotherapy, increase in
radiation dose was the more significant
factor.
6. INTRODUCTION
Cancer of the anal canal is an uncommon malignancy,
accounting for approximately 1.5% to 2% of all cancers
of the lower alimentary tract in the United States.
The risk of anal canal cancer has increased over the past
30 years with its association with HPV and HIV.
7. ANATOMY
The anal canal is a 4-cm-long structure that passes downward and
backward from the rectal ampulla (level of pelvic floor) to the anus (anal
verge).
The proximal border of the anal canal clinically corresponds to the anal
sphincter at the level of the puborectalis muscle (palpable as the anorectal
ring on digital rectal examination). This is where the rectum enters the
puborectalis sling, made by fibers from both sides.
The distal end of the anal canal is at the level of the anal verge, where the
groove between the internal sphincter and the subcutaneous part of the
external sphincter is palpable.
This also is the level of the squamous-mucocutaneous junction and the
perianal skin.
8.
9. It follows that two distinct categories of tumors arise in
the anal region.
Tumors that develop from mucosa (columnar,
transitional, or squamous) are true anal canal cancers
tumors
that arise from skin at or distal to the squamous-
mucocutaneous junction are termed anal margin
tumors
10.
11. definitions
Anal Canal= 4 cm mucosa
lined region from junction of the
puborectalis portion of the
levator ani muscle and the
external anal sphincter, and
extends distally to the anal
verge
Transitional zone- from
glandular (columnar) to
squamous mucosa- at dentate
line
Anal Margin- begins at the
anal verge. It represents the
transition from the squamous
mucosa to the epidermis-lined
perianal skin.
Rectal
glandular
mucosa
Transitional
Squamous
True Epidermis
12. epidemiology
Relatively uncommon.
Seen in middle age- median age at
diagnosis 61 years.
Slight female preponderance
Incidence is increasing possibly due to
association with hpv.
More common in men having anal
receptive intercourse and hiv +.
13. ETIOLOGY AND RISK
FACTORS
HPV infection
Immunosuppression- transplant
patients and those with HIV.
Cigarrete smoking- 5 FOLD increased
risk
14. Benign anal conditions -- fistulae,
fissures, and hemorrhoids -- do not
appear to predispose to cancer .
Fissures may facilitate the access of
high-risk HPV to basal epithelial cell
layers.
Any increased risk of cancer from
chronic IBD -
? Discontinued ( danish population
based study )
15. AIN
Presence of cellular and nuclear
abnormalities in the perianal and anal
epithelium without a breach of the
epithelial basement membrane.
Precursor to scc of anal canal.
16. Parallel observations in the cervix in
which HPV infection causes the
development of CIN, the precursor lesion
to invasive cervical cancer.
AIN = squamous intraepithelial lesion
(SIL)
Also called carcinoma in situ and
Bowen’s dz
AIN 1 = LSIL
AIN 2&3 = HSIL
17. AIN & HIV
Limited data for HIV negatve pts
AIN 1 (LSIL)
- LSIL progresses to HSIL in more than 50
percent of HIV-positive homosexual males
within two years.
AIN 2&3 (HSIL)
- risk for progression to invasive cancer
ranges from 10 to 50 percent among HIV
positive patients
Among HPV-infected individuals, the
prevalence of HSIL and anal carcinoma is
higher in those with concomitant HIV infection
compared to those who are HIV-negative.
18. HPV and AIN
HPV causes anal intraepithelial
neoplasia(AIN) which progresses from
low grade to high grade dysplasia and
ultimately to invasive cancer.
Hpv 16 & 18 are strongly implicated.
As anal lesions progress there is also
accumulation of mutant p53
expressions.
19. The high-risk HPV E6 and E7 proteins
are thought to contribute to the
induction of anogenital cancers by
interacting with and degrading the
function of p53 and pRb, respectively.
HPV DNA integration is needed for
transition from low- to high-grade AIN.
Loss of heterozygosity at 11q23 is the
most consistent event, and appears to
be independent of human
immunodeficiency virus (HIV) status.
20. Anal pap smears – sensitiivity 69 to
93% and specificity ranges from 32 to
59%.
Anoscopy, anal cytology, and high-
resolution anal colposcopy each play
a role in the assessment of AIN.
High-grade AIN recurs or persists after
treatment in less than 25% of those
who are HIV-negative, but in up to
80% of HIV-positive patients.
21. Management of AIN
Excision is for clinically definable lesions.
WLE guided by frozen sections.
1 cm margins
Large defects closed with local flaps
WLE is associated with high rates of disease recurrence
and anal incontinence/stenosis
Targeted destruction guided by high-resolution anoscopy
Decreased morbidity compared to WLE
High risk for persistent or recurrent disease among HIV+
Surveillance examinations performed at six-month
intervals as long as dysplasia is present
Treatment with imiquimod or 5-fluorouracil has initial 50-
90% response rates.
Recurrence limited with long duration therapy
Compliance limited by significant skin irritation
22. Photodynamic therapy.
Some authors recommend
observation only for wide-field low
grade AIN, and even for high-grade
AIN when there are no signs of
invasive cancer, if the risk of functional
damage due to ablative treatment is
considered too great.
23. WHO Classification of Anal
Cancer
Anal canal
Squamous cell carcinoma
- Keratinizing (below dentate)
- Nonkeratinizing (above dentate)
- Basaloid (transitional)
Adenocarcinoma
- Rectal type
- Of anal glands
- Within anorectal fistula
Small cell carcinoma
Undifferentiated
“Anal Cancer” = squamous cell
cancer arising in the mucosa of
the anal canal
Anal margin
Squamous cell carcinoma
Giant condyloma
Basal cell carcinoma
Others (Melanoma)
Bowen's disease (SCC in situ)
Paget's disease (Intraepithelial
adenocarcinoma)
Classification of tumor is
determined by the
pathology/histology of the
tumor not the anatomic
location as determined by the
surgeon or endoscopist.
24. NATURAL HISTORY
Anal cancer is predominantly a locoregional disease, with possible
direct extension to surrounding tissues and lymphatic dissemination
to inguinal and pelvic nodes; hematogenous distant metastasis is a
relatively rarer occurrence.
Anal canal cancers constitute 75% of all lesions, and only 25% are
anal margin tumors.
Local spread may be present in approximately 50% of cancers at
diagnosis with involvement of the anal sphincter or surrounding soft
tissues.
Extension to the rectum and perianal skin also may occur.
Invasion of the vaginal septum is more common than invasion of
the prostate gland because of the presence of Denonvillier’s fascia
in men, which acts as a barrier
25. Lymphatic drainage is dependent on the anatomic location of the primary
tumor.
Tumors that arise distal to the dentate line drain to inguinal lymph nodes
(superficial and deep), and those above the dentate line spread primarily to
the internal iliac system, and with more proximal lesions, spread occurs to
the inferior mesenteric group.
The regional nodes are considered to be inguinal (superficial and deep
femoral), internal iliac, and perirectal (anorectal, perirectal, and lateral
sacral). All other nodal groups represent sites of distant disease.
The incidence of involvement of inguinal nodes is directly proportional to
the size and extent of the primary tumor. Overall, this risk may be
approximately 10% at diagnosis but may increase to 20% for tumors larger
than 4 cm, and with T4 disease, this may be as high as 60%.
26. Distant metastasis may occur to any organ, but the liver and
lungs are most frequently involved. Overall, distant
metastases are relatively rare.
At diagnosis, only 5% to 10% of patients will be found to
have distant disease.
After curative treatment, the risk of distant disease varies,
ranging between 10% and 30%, and depends on the initial
tumor (T) stage.
The risk of distant metastasis also increases with the number
of regional nodes involved
27. CLINICAL PRESENTATION
AND DIAGNOSIS
Most patients with anal cancer are first seen with rectal bleeding.
This occurs in approximately 50% of patients;
30% experience pain or the sensation of a rectal mass.
Pruritus in 30%
Altered bowel habbits -rare
A common concern with most anal neoplasms is the frequent delay
in diagnosis resulting from confusion with more common, benign
conditions. Thus, the clinician must maintain a high index of
suspicion when evaluating lesions of the anal canal and margin.
An interval of 4 to 6 months may ensue between onset of symptoms
and diagnosis in up to 50% of patients.
28. WORK UP
Physical examination
1. Regional lymph nodes
2. Adjacent organs for direct invasion
3. Anogenital areas for concurrent malignancies
Proctoscopy &Biopsy of primary tumor
Fine-needle aspiration biopsy or simple excision of enlarged
inguinal nodes
Chest radiograph
CT/MRI of abdomen and pelvis( mri preferrd as delineates soft
tissue planes better and also better to detect involvement of urethra
or vagina)
HIV antibody assay, if risk factors are present
29. EUS to evaluate for sphincter
involvement and perianal lymph
nodes.
Consider PET scan since 25% of
patients have metastatic disease by
PET not seen on CT and 20% of
inguinal nodes negative by CT are
PET positive.
30. STAGING
PRIMARY TUMOR (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor =2 cm in greatest dimension
T2 Tumor >2 cm but =5 cm in greatest dimension
T3 Tumor >5 cm in greatest dimension
T4 Tumor of any size invades adjacent organ(s) (e.g., vagina,
urethra, bladder)
Direct invasion of the rectal wall, perirectal skin, subcutaneous
tissue, or the sphincter muscle(s) is not classified as T4
31. REGIONAL LYMPH NODES (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in perirectal lymph node(s)
N2 Metastasis in unilateral internal iliac and/or inguinal lymph
node(s)
N3 Metastasis in perirectal and inguinal lymph nodes and/or
bilateral internal iliac and/or inguinal lymph node
32. AJCC stage groups
Stage I T1 N0 M0
Stage II T2 N0 M0
T3 N0 M0
Stage IIIA T1 N1 M0
T2 N1 M0
T3 N1 M0
T4 N0 M0
Stage IIIB T4 N1 M0
Any T N3 M0
Any T N2 M0
Stage IV Any T Any N M1
37. Molecular prognostic factors
High expression of p53 associated
with decreased DFS.
Also local control rates are lower with
increased p53 expression.
High level of Ki 67 – longer DFS.
39. Surgery
Surgical treatment was the primary therapy 20 to 35 years ago, but
it has been replaced by sphincter-sparing therapy with combination
chemoradiotherapy.
Surgical therapy is now used most often as a method of salvage.
Surgical treatment, when it was used as a primary therapy, required
an abdominoperineal resection (APR).
This consisted of wide local excision of the anus, to include the
levator ani muscles and contents of the ischiorectal fossa.
The operation results in a permanent colostomy, as well as loss of
sexual function, in most patients.
Overall, 5-year survival rates were approximately 50-70% in
different serieses.
40.
41.
42.
43. Radical resection
For intermediate-stage primary anal canal
cancer who -
- Cannot tolerate radiation therapy or
chemoradiation
- Incontinent because of irreversible damage of
the sphincters
- Anovaginal fistula
- Prior pelvic radiation treatment (most
frequently for carcinoma of the cervix)
- Active inflammatory bowel disease affecting
the rectum or anal region
- Failure of chemoradiation or radiation and less
frequently, complications of the initial treatment.
44. Residual cancer
Suspected residual cancer should be confirmed
by biopsy.
Random biopsies from the site of the primary
cancer in the absence of clinical features .
Residual masses after radiation or
chemoradiation may take several months to
regress fully.
Frequent examination by an experienced
observer is desirable, including, if necessary,
examination under anesthesia.
C/F - hard-edged ulcer
- an enlarging mass
- increasing pain
45. SALVAGE SURGERY
Locoregional failure in 30%
½ recurrence, ½ progression
Salvage APR is associated with five-
year survival rates from 24 to 58%
Salvage Surge
APR = abdominoperineal resection
Pelvic exenteration = multiviseral
resection
Urinary and fecal diversion
46. RECURRENCES
Strictly, all local recurrences are due to
residual cancer.
Salvage surgery offers a potential for
long-term local control and survival in
roughly one third to one half of the
patients fit for surgery who do not have
clearly unresectable cancer or known
extrapelvic disease.
Need reconstructive surgery to close
defects in irradiated pelvic tissues should
be considered.
47. Prognostic variables
Node positivity
Size of the resected tumor
Status of resection margins
An analysis of the pathologic data from
patients in the UKCCCR trial showed –
lateral excision margin free of
cancer
> 1 mm - recurrence occurred in
25%
< 1mm - recurrence occurred in
48. Problems in Surgery
Perineal wound healing skin
breakdown
fistula
formation,
Malnutrition
Debility due to pain
Flap reconstruction should be
considered
49. TREATMENT OF
LYMPHATICS
Lymphatic Drainage
Lymphatic drainage of anal cancers
depends on the location of the tumor in
relation to the dentate line.
Tumors below the dentate line drain to
the inguinal and femoral nodes.
Tumors above the dentate line drain to
the perirectal and paravertebral nodes, a
pattern similar to that seen with rectal
cancers.
Tumors in the most proximal portion of
the canal drain to the nodes of the inferior
mesenteric system.
50. Lymph Node Management
Chemoradiation is the treatment of choice for inguinal lymph
node disease
Cure rates approach 90 percent for synchronous disease
Bilateral groins should be incorporated into the radiation
fields with the addition of a boost for clinically positive lymph
nodes.
Metachronous lymph nodes + in 10 to 20%
Usually appearing w/in six months after treatment
Respond well to CRT
Formal node dissection is reserved for metastases residual
or recurrent after radiation-based treatment.
51. CLINICALLY NORMAL NODES
If dissected - significant postoperative wound healing
problems or chronic lymphedema.
Rate of late failure in clinically normal inguinal nodes not
treated prophylactically ranges from about 10% to 25%.
May prove uncontrollable in up to one half of the patients.
Because of the morbidity - elective lymphadenectomy of
clinically normal inguinal nodes is not recommended.
Elective irradiation of clinically normal inguinal node areas
- little morbidity
- reduces the risk of late node failure in the volume
irradiated to less than 5%
52. Sentinel Lymph Node Bx
SLNB identifies inguinal metastases in
10–40% of anal cancer patients with
limited morbidity ranging between 3%
and 7%.
The clinical impact of this procedure
on the therapeutic approach is
unclear as long as the inguinal nodes
are included in the radiation field.
55. The Technique
Set-up
Extended Lloyd-Davies position
Good assistance
Long midline incision
Wide retraction
Small bowel packed out of the way
Full laparotomy (liver etc)
57. TME
Principle is that the sharp
dissection(diathermy/ scissors) should
only proceed in the areolar tissue
plane(holy plane) within and thus
sparing the autonomic nerve plexuses,
the non visceral presacral fat pad, the
parietal sidewall fascia of the pelvis, the
hypogastric plexus, vesicles and
prostate in males and vagina in
females.
58.
59. The sigmoid is grasped with toothed
forceps and reflected medially The
adjacent adhesive bands are divided
with long curves scissors, and the
peritoneal reflection is retracted
laterally with forceps. Following this
procedure, the sigmoid is usually
mobilized easily toward the midline.
The peritoneal surface on the left
side of the colon is picked up with
forceps and divided with long,
curved, blunt-nosed Metzenbaum
scissors, which are gently
introduced downward beneath the
peritoneum to separate the
underlying structures, such as the
left spermatic, or ovarian, vessels or
ureter, from the peritoneum to avoid
their accidental injury. The
peritoneum is incised down to the
cul-de-sac on the left side
63. The inferior mesenteric vein is often
divided above the left colic branch and
a mobilization of the splenic flexure is
performed so as to allow creation of
the descending colostomy without
tension. The blood supply to the
descending colon is now derived from
the middle colic artery via the marginal
artery of Drummond.
65. Although involved lymph nodes may not be
evident in the mesentery over the bifurcation
of the aorta, it is desirable to ligate the inferior
mesenteric artery just distal to the origin of
the left colic artery . The contents of the
proximal clamps are tied, and the ligation is
reinforced by a transfixing suture.
Some prefer to ligate the inferior mesenteric
artery as near its point of origin from the aorta
as possible. Usually, this level is near the
ligament of Treitz. The blood supply to the
sigmoid to be used as a colostomy is now
derived from the middle artery through the
marginal artery of Drummond.
68. The peritoneum
along the right side
of the rectosigmoid
junction is incised
lateral to the
inferior mesenteric
and superior
hemorrhoidal
vessels .
69. This incision extends down to the
pouch of Douglas. The right ureter is
identified beneath the residual
peritoneum, and its course over the
iliac vessels is exposed with blunt
gauze dissection. The proximal
bowel is retracted anteriorly and
laterally. The superior hypogastric
nerves are visualized just below the
iliac vessels and the ureters. The
dissection proceeds behind the
superior hemorrhoidal vessels
toward the entrance of the presacral
space behind the sacral promontory.
Division of the retrosacral fascia or
ligament just below the sacral
curvature at about S2 is done
sharply in the midline with scissors
or electrocautery.
70. The peritoneal reflection in
the pouch of Douglas is
incised about 1 cm up its
anterior reflection over the
bladder in men (shown in
this illustration) or behind
the uterus in women. The
bladder or uterus is
retracted anteriorly using a
fiberoptic lighted deep
pelvic retractor. The sharp
dissection proceeds
anterior to Denonvilliers'
fascia until the prostate and
seminal vessels or the
rectovaginal septum is
seen.
71. The paths of the
anterior and
posterior
dissections (Figure
9) show the close
adherence to the
presacral fascia
posteriorly and to
the actual prostate
and seminal
vesicles anteriorly.
72. The two lateral dissections in the TME are time-
consuming, as the surgeon carefully proceeds to
expose the parietal fascia over the lateral pelvic wall
structures.
The fiberoptic lighted deep pelvic retractors are
essential for clear visualization during lateral retraction
of the rectum and anterior elevation of the bladder or
the uterus and vagina.
The preservation of the pelvic autonomic nerve plexus
and the anterior roots of sacral nerves S2, S3, and S4
is essential for anal continence and sexual function. The
plexus is seen as a dense plaque of nerve tissue that
comes close to the rectum at the level of the prostate or
upper vagina
73. . The TME does not encounter "lateral
suspensory ligaments" but rather a fusion of
the lateral mesorectum with tissue that may
contain the middle hemorrhoidal arteries as
the dissection heads toward the autonomic
nerve plexus.
This tissue is divided with electrocautery, and
the middle hemorrhoidal vessels may require
a ligature. The course of the ureters and the
autonomic plexus is noted as the dissection
is carried down to the levators
88. The skin in the
region of the anal
orifice is seized
with several Allis
forceps, and the
incision is made
through the skin
and subcutaneous
tissue at least 2 cm
away from the
closed anal orifice
89. All blood vessels
are clamped and
tied to prevent
further loss of
blood as the
operation
progresses
90. he posterior portion of
the incision is extended
backward over the
coccyx, and the anus is
tipped upward to enable
its attachments to the
coccyx to be severed
more readily. After the
anococcygeal raphe is
severed and the
presacral space is
entered, the
accumulated blood from
above is suctioned out.
91. The levator muscle is
exposed on one side
and, with the finger held
beneath it, is divided
between paired clamps
as far from the rectum
as possible.Following
the ligation of all
bleeding points on one
side, a similar division of
the levator ani muscles
is carried out on the
opposite side.
Alternatively, the levator
muscles may be
transected with
electrocautery.
92. Palpation of the inlying
urethral catheter will
facilitate the procedure by
localizing the urethra and
preventing accidental injury
to the prostate, urethra.
The skin and subcutaneous
tissue of the perineum are
retracted upward, while the
anus is pulled downward
and backward to assist in
the exposure. The rectum
is pulled down, the
remaining attachments of
the levator ani muscles and
transversus perinea are
divided, and all bleeding
points are ligated
93. . In the female the
dissection between the
rectum and vagina is
more easily
accomplished if
counterresistance is
applied to the posterior
vaginal wall by the
surgeon's fingers. In the
presence of extensive
infiltrating growths it may
be necessary to excise
the perineal body as well
as a portion of the
posterior vaginal wall.
98. Anal Margin Cancers
Anal margin -distal end of the anal canal to a 5-
cm margin surrounding the verge.
Treat similar to skin cancer.
WLE for T1 and early T2 lesions that can be
excised with a 1-cm margin.
Larger T2 cancers -add prophylactic radiation to
the inguinal lymph nodes along with radiation or
excision of the primary tumor.
T3 and T4 lesions- radiation to both inguinal
regions and the pelvis, along with 5-FU and
mitomycin C.
APR for bulky tumors extending into the
sphincter or surrounding structures.
99. When possible, initial surgical
management is preferred to radiation-
based treatment of perianal cancers
because of the frequent morbidity from
long-term changes in the perianal skin
after irradiation.
100. The regional nodes for the perianal skin are the
inguinal nodes.
Perirectal or pelvic node metastases are very
uncommon.
The risk of inguinal node metastases is about
10%, associated mainly with category T3 or T4
tumors, or poorly differentiated cancers.
Elective inguinal nodal irradiation has been
suggested for those categories only.
The management of abnormal inguinal nodes is
similar to that of anal canal cancer.