This document discusses carcinoma of the rectum, including its etiology, pathology, staging, clinical features, investigations, differential diagnosis, and treatment options. Some key points: - Carcinoma of the rectum is more common in females and usually originates from pre-existing adenomas or polyps. Risk factors include diet high in red meat/saturated fat and low in fiber, as well as smoking, alcohol, family history, and certain medical conditions. - Pathologically, most are adenocarcinomas that may be well, moderately, or undifferentiated. Staging systems include Duke's and TNM classification. Clinical features include bleeding, anemia, and symptoms of bowel obstruction.

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CARCINOMA
RECTUM

2. CARCINOMA
RECTUM

3. CARCINOMARECTUM
• It is common in females.
• In 3% of cases, it occurs in
multiple sites(syn
chronous).
• Usually originates froma
pre-existing adenoma or
papilloma (tubular polyp).
• Any tumour within15 cm
proximal to the anal margin
is called as rectal
tumour/cancer.
• More than 95%are
adenocarcinoma.
• It is characterizedby
chromosomal instability.
Microsatelliteinstability
(MSI) is rare in rectal cancer.

4. AETIOLOGY
• Red meat and saturated
fattyacids increase the risk.
• Highfibre diet reduces the
risk.
• Alcohol and smoking
increases the risk.
• FAP and adenomas are
more prone to carcinomas.
• Villous adenoma has 40%
chance of turning
malignancy, size more than
2 cm is at high-risk.
• Ulcerative colitis; Crohn‘s
disease;
• HNPCCcarries higher
incidence of carcinoma of
rectum.
• Family history of rectal
cancer—anyfirst degree
relative of a person with
rectal cancer will showtwo
times increased riskof
carcinoma rectum.

5. • Risk of developing other
cancers like of
endometrium(40%);
stomach(20%); biliary tree
(20%); ovary (10%) in the
same patient also increases.
• ‘Adenoma—carcinoma
sequence’ like in carcinoma
of colon is knowncommon
methodof occurrence
PATHOLOGY
Gross:
• Ulcerative ™
• Papilliferous ™
• Infiltrative ™
• Annular: It is common in
rectosigmoid junction. ™
• Diffuse type: Often
observedin patients with
ulcerative colitis which
carries poor prognosis

7. Histologically:
• It is adenocarcinoma which
may be: ™
• Well-differentiated—10%™
• Moderatelydifferentiated—
65%™
• Undifferentiated—25%
Colloid carcinoma of the rectum
• It is 12%commonin young
people
• Types ™
• Primary
• secondary ™
• Secondarycolloid
carcinoma is commontype
and is due to mucoid
degenerationof
adenocarcinoma itself
• Primary is mucus within
the cell with displaced
nucleus (signet ring).
• Primary type has got
poorer prognosis
compared to secondary.

8. SPREAD
Local spread:
• Initially, it spreads, locally
circumferentially (takes 12–
18 months to completethe
circumference of the bowel).
• Laterspreads out to the
muscular coat and peri-
rectal tissue.
• Then to prostate, bladder,
seminal vesicles in males,
and uterus and vagina in
females.
• Posteriorly intothe sacrum
and sacral plexus, laterally
into the ureters.
STAGING
Duke’s staging of carcinoma
rectum
• A. Confinedto bowel wall,
mucosa and submucosa
• B. Extends acrossthe
bowel wall to the
muscularis propriawithno
lymph nodes involved
• C. Lymph nodes are
involved

9. Modified Duke’s staging
• A. Growthlimited to
rectal wall
• B. Growthextending into
extra-rectal tissues but no
lymph nodespread
B1: Invading muscularis
mucosa B2: Invading in to or
through the serosa
• C. Lymph node
secondaries
• D. Distant spreadto liver,
lungs, bone, brain
TNMCLASSIFICATION
Tumour: T
• Tx—Primary not assessed
• T0—No primary tumour
• Tis—Carcinoma in situ:
intraepithelial or invasion of
lamina propria
• T1—Submucosa
• T2—Muscularis propria
T3—Subserosa/perirectal
tissue; T3a <1 mm; T3b 1–5
mm; T3c 5–15 mm; T3d 15+
mm

10. • T4—Perforation into
visceral peritoneum(a) or
invasion to other organs (b)
Nodes: N
• N1—1–3 regional nodes
involved; N1a –one LN; N1b
–2–3 LN; N1c Small deposits
in the fat
• N2—4 or more regional
nodes involved; N2a—-4–6
LN; N2b—7 or more LN.
Metastasis: M
• M0—Nodistant
metastases
• M1—Distant metastases;
M1a One distant organ or
set of lymph node; M1b
More than one organ or to
the peritoneum

11. Stage grouping:
• I—1–2, N0, M0
• IIA—T3, N0, M0
• IIB—T4a, N0, M0
• IIC—T4b, N0, M0
• IIIA—T1–2, N1/N1c, M0;
T1, N2a, M0
• IIIB—T3–T4a, N1/N1c,
M0; T2–T3, N2a, M0; T1–2,
N2b, M0
• IIIC—T4a, N2a, M0; T3–
4a, N2b, M0; T4b, N1–2,
M0
• IVA—T1–4, N1–2, M1a
• IVBT1–4, N1-2, M1b
CLINICALFEATURES
• Bleeding per rectum/anum
(may mimichaemor
rhoids)—earliest
symptom.
• Bloody slime: Mucus with
blood in stool.
• Sense of incomplete
evacuation, constipation
• Anaemia, malnutrition,
loss of appetite and weight.
• Alteredbowel habits.
• Urinary symptoms are due
to infiltrationof bladder or
prostate.

12. • Spurious diarrhoea:
• It occurs in early morning
due to overnight mucus
accumulation in the rectum
• causing urgencyfor
defecation, but resultsin
spurious diarrhoea with
incomplete evacuation.
• Tenesmus:It is painful
incomplete defecation with
bleeding.
• Presenting as piles due to
proximal venous congestion
by tumour or as fistula in
perianal region(whichitself is
tumour extension intothe
anal canal).
• Backpain, due to invasion
of sacral plexus.
• Ascites, liver secondaries,
urinary symptoms

13. INVESTIGATION
• Proctoscopy.
• Sigmoidoscopy
• Biopsy using Yeoman’s
forceps.
• Bariumenema in case of
FAP and synchronous
growths.
• Colonoscopy is ideal to rule
out presence of any
synchronous growths
proximally(5%) or polyps.
• Eventhough colonoscopyis
done rigid
proctosigmoidoscopy is a
must to identify the precise
location of the tumour and
to measurethe tumour
distance fromanal sphincter
accurately.

14. • Ultrasoundabdomen—to
look for secondaries in liver,
ascites.
• CT scanto see operability,
local extension, size, nodal
status, ureteral involvement,
presence of perforationor
fistula. CT is very useful to
assess nodal status.
• Endorectal
ultrasonography—very
useful to assess the local
extent of the tumour.
Transrectal ultrasound
(TRUS)/endorectal
ultrasound gives more
accuratepicture of primary
tumour, layers, perirectal
tissues and nodes.

15. • Endorectal coil MRI (EC
MRI) is veryuseful as it gives
larger field of viewcompared
to TRUS
• Fluorine—18
fluorodeoxyflucosePET scan
is useful to detect recurrent
local tumours; metastatic
disease; to detectpathologic
responsein preoperative
chemoradiation.
• PET is not accuratefor nodal
spread. Blood tests like
haematocrit; CEA; blood urea
and serumcreatinine; serum
electrolytes and proteins for
management purpose. CEA
estimation—it is raisedin
metastaticdisease. It is
importantduring follow-up
after treatment.

16. DIFFERENTIAL DIAGNOSIS
• Inflammatory stricture ™
• Amoebicgranuloma™
• Tuberculosis™
• Carcinoid™
• Solitary ulcer syndrome
SURGERY
• Surgeryis the main method
of treatment.
• Preoperative
chemoradiotherapyis often
usedif growth is invading
into adjacent tissues (T4)
• Adjuvant chemotherapyand
radiotherapy is a must.
• Genetic, morphologic,
biologicfeatures of rectal
cancers are similar to colonic
cancers.

17. • But anatomical factors
make it more complex than
coloniccancers, like its
location deep in the pelvis,
relationto important
structures likeureters,
bladder, genital, autonomic
nerves and anal sphincters.
So surgical approachis very
difficult
TREATMENT
Abdominoperineal resection
(APR)
• is the gold standard.
• But if tumour is well-
differentiated and if there is
adequatemargin abovethe
anal canal

18. • Total mesorectal excision
(TME)
• mesorectumcontains nodes
and lymphatics
• clearance - gives better
result
• Circumferential resected
margin—CRM(radial
margin)
Anterior resection (Abdominal
radical restorative operation)
• is done in growths located
in the mid and upper part
of the rectum
Hartmann’s operation
• is an excellent palliative
procedure—done in
elderlypeople
Pelvicevisceration (Brunschwig’s
operation)
• It is removal of rectumwith
the tumour, all the lymph
nodes, urinarybladder, fat,
fascia, uterus, vagina, with
colostomyand urinary
diversion

19. Palliative colostomy
• is done in advancedun
resectable growthwhich
presents with intestinal
obstruction.
Radiotherapy
• It is beneficial in carcinoma
rectumshowing increased
survival rate.
Chemotherapy
• It is very useful
adjuvant therapy.
• To prevent
recurrence after
anterior resection
REFERENCE
1. SRB's Manual of Surgery
by SriramBhat M
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das

20. A
Special Thanks
To A Very
Special Doctor