Rectal cancer
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(1) The patient is a 75-year-old female who presented with left lower quadrant pain, decreased bowel movements, weight loss, and recent vomiting of coffee ground material. (2) Physical exam revealed abdominal tenderness and a palpable mass in the left lower quadrant. (3) Imaging showed features suggestive of a colorectal mass. (4) During surgery, a rectosigmoid mass was found involving nearby structures, consistent with stage IV rectal cancer. (5) The patient underwent a Hartmann's procedure and ileostomy for palliation of bowel obstruction from metastatic rectal cancer.
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Rectal cancer
- 1. “A BULK IN THE TUNNEL” Ron Christian Y. Calalang Deepak Singh Yadav Clinical Clerks
- 2. GENERAL DATA • O.N. • 75/F • Roman Catholic • 5/29/1944 • Minalabac, Camarines Sur • Chief Complaint: Vomiting • Informant: Daughter and Patient Herself • Reliability: 90%
- 3. HPI 3 mos PTA -left lower quadrant pain, colicky, mild to moderate in intensity accompanied with bloating. -No associated fever or vomiting. No consult done. No medications taken. Interim -same pain felt intermittently, with noted decrease in caliber of stools and progressive episodes of constipation. - No consult done. No meds taken. 1 day PTA -pain increased in intensity radiating to the umbilical and right quadrant (+) pelvic pain and urge to defecate but cannot pass stool (+) 4 bouts of coffee-ground vomitus: about ¼- ½ cup each bout. Persistence of symptoms- Consult
- 4. PAST MEDICAL HISTORY • (+) Hypertension, ~10 years, on Losartan, fairly compliant to meds • (-) Diabetes Mellitus • (-) Cardiac disease • (-) Previous surgery • (-) Allergies
- 5. OBSTETRIC HISTORY • G9 P9 (9009) – all delivered via normal spontaneous deliveries • Menopause: 48 years old
- 6. FAMILY HISTORY • (-) Hypertension • (-) Diabetes Mellitus • (-) Asthma • (-) Coronary Artery Disease • (-) Malignancies
- 7. PERSONAL SOCIAL HISTORY • (-) tobacco use • (-) alcoholic drinker • Patient’s usual diet includes fish and vegetables. Denies frequent intake of processed foods.
- 8. REVIEW OF SYSTEMS • General: (+) weight loss (-) fatigue (-) fever • Skin: (-) rashes (-) sores (-) lumps • HEENT: (-) headache (-)head injury (-)tinnitus (-) vertigo (-) discharge • Respiratory: (+) cough (-) difficulty of breathing • Cardiovascular: (+) easy fatigability (-) palpitations (-)chest pain • Musculoskeletal: (+) joint pains (-) limitation of movement • Neurologic: (-) seizures (-) loss of consciousness • Hematologic: (-) easy bruising (-) prolonged bleeding • Endocrine: (-) heat/cold intolerance (-) polydipsia (-) polyphagia (-) polyuria
- 9. PHYSICAL EXAMINATION • General: conscious, coherent, stretcher-borne, not in cardiorespiratory distress • Vital Signs: BP: 160/90 HR: 84 RR: 19 T: 36.7 C O2 Sat: 99% • HEENT: pink palpebral conjunctivae, no lesions, no neck vein engorgement, no neck mass, no cervical lymphadenopathy • Chest: symmetrical chest expansion, clear breath sounds • Heart: adynamic precordium, normal rate regular rhythm, no murmurs • Abdomen: no surgical scars, flat, hyperactive bowel sounds, flabby, distended, with abdominal tenderness on both lower quadrants, palpable mass, left lower quadrant • Extremities: no edema, no pallor, with full equal pulses, capillary refill time < 2 secs • DRE: no external lesions, good sphincter tone, (+) mass, hard, 7-8 cm from the anal verge, no fecal material, no blood on examining finger
- 10. SALIENT FEATURES • 75 years old/ female • Left lower quadrant pain • Decrease in caliber of stools • Weight loss • Insidious onset (3 months PTA) • Difficulty in defecation • Vomiting • Palpable mass, LLQ and 7-8 cm from anal verge
- 11. DIFFERENTIAL DIAGNOSES Differential Dx Rule In Rule Out Colorectal mass Obstructive symptoms Age Insidious onset Weight loss Palpable mass, 7-8 cm from anal verge Volvulus Palpable mass LLQ Obstructive symptoms Age (+) Weight loss (+) insidious onset Palpable rectal mass
- 12. CASE DISCUSSION KRISTINE FAITH TABLIZO Post-Graduate Intern
- 13. I. DIAGNOSTICS II. ANATOMY III. MANAGEMENT
- 14. DIAGNOSTICS
- 15. LABORATORY/ ANCILLARY TESTS • CBC- to detect anemia; can reflect infection • Blood typing- in anticipation for possible blood transfusion • Na, K, BUN, Creatinine- baseline; detect electrolyte imbalance or elevated creatinine or BUN; prep for contrast studies • Protime- to screen for bleeding problem • CEA- baseline level for post treatment surveillance • Urinalysis-to detect for infection, blood in the urine, etc
- 16. LABORATORY TESTS • CBC • Blood typing • Na, K, BUN, Creatinine • Protime • Urinalysis Sodium 135.74 L Potassium 3.88 BUN 5.54 Creatinine 39.90 L Protime 11 secsBT O+ Color: Dark yellow Blood (-) WBC 7.30/ul Character: Clear Bilirubin (-) RBC 28.50/ul ↑ pH 5.5 Urobilinogen Normal Specific gravity1.027 Ketone (-), CHON (-), Glucose (-) Bacteria 173.30 13.3 3 120 0.35 4 85.8 339 CEA 73.9
- 17. IMAGING • Chest X-ray- detect for pneumonia or other pulmonary problems and cardiac enlargement, • Abdominal X-ray, upright and supine- detect free intra- abdominal air, bowel-gas patterns • WAB CT-Scan with Triple contrast- provide more detailed information on abdominal structures specially those that are inconclusive in standard x- rays • However, a standard CT scan is relatively insensitive for the detection of intraluminal lesions specially in assessing bulky rectal tumors and perirectal adenopathy.
- 18. • Chest X-ray • Abdominal X-ray, upright and supine • WAB CT-Scan with Triple contrast
- 20. ANATOMY OF THE RECTUM • 5 in (12 cm) in length • Begins anterior to the third segment of the sacrum or at the rectosigmoid junction • Ends at the level of the lower quarter of the vagina, (or at the apex of the prostate) where it leads into the anal canal
- 21. ANATOMY OF THE RECTUM • Rectosigmoid Junction- narrowest portion of LI where the 3 taenia coli fuse together
- 22. ANATOMY OF THE RECTUM • Curved antero- posteriorly and laterally • Antero-posterior flexures • Sacral- ff the curve of the coccyx • Perineal-terminal part of rectum
- 23. •Has NO: taenia coli, omental appendices, haustrations, •Has 3 transverse folds (valves of Houston) •Rectal ampulla- largest portion of rectum storing the feces
- 27. • ■ ■
- 28. ANATOMY
- 29. IMAGING
- 34. MANAGEMENT
- 35. PATIENT’S SUMMARY • Patient came in with features of bowel obstruction, and was admitted with consent at the ward. • Diagnostics were facilitated. • Hooked to IVF. NGT and IFC inserted. Replaced NGT loses with IVF volume per volume. • Initial plan: Explore Laparotomy • Seen by IMCP, Anesthesia • Referred to and Co-Managed by IM-Onco and IM-Gastro • Initially for EGD, Colonoscopy but was deferred due to abdominal distension, generalized abdominal tenderness. • Planned for Ex-Lap, rectosigmoidectomy Hartmann’s procedure.
- 36. PATIENT’S SUMMARY • Intra-op findings: • Closed-loop obstruction at rectosigmoid area with mass involving the left ovary and ileum 80 cm from the ileocecal valve with noted swelling near right reproductive tube • Biopsy was then obtained. • Ileostomy done over resected area of the ileum. Jackson-Pratt drain placement done. • JP drain monitoring done. Progressive diet. Colostomy care. Daily wound care. Chest physiotherapy. • Discharged stable with no signs of surgical complication. • To follow up at Onco Center, Cardio OPD and Surgery OPD.
- 37. • Dx: Partial Intestinal Obstruction secondary to Rectosigmoid Cancer stage IV (T4bN2bM1)
- 39. COLORECTAL CANCER • Colorectal carcinoma is the most common malignancy of the gastrointestinal tract. • 3rd most common cancer and the 3rd leading cause of cancer deaths in the Philippines • Risk factors: aging, hereditary factors, dietary factors, consumption of processed meat, Inflammatory Bowel disease, Obesity and sedentary lifestyle, smoking, diabetes mellitus
- 42. RECTAL CA • anatomy of the pelvis and proximity of other structures (ureters, bladder, prostate, vagina, iliac vessels, and sacrum) make resection more challenging and often require a different approach than for colonic adenocarcinoma. • it is more difficult to achieve negative radial margins in rectal cancers that extend through the bowel wall because of the anatomic limitations of the pelvis. • local recurrence is higher • relative paucity of small bowel and other radiation- sensitive structures in the pelvis makes it easier to treat rectal tumors with radiation.
- 43. • Survival extremely limited in stage IV rectal carcinoma. • highly selected patients with isolated, resectable metastases may benefit from resection (metastasectomy). • Liver- most common site of metastasis (15%); 2nd– lungs; others– retroperitoneum, ovary • Of these, 20% are potentially resectable for cure.--survival improved (20% –40% 5-year survival) • Hepatic resection of synchronous metastases from colorectal carcinoma may be performed as a combined procedure or in two stages. • The remainder of patients with stage IV disease cannot be cured surgically, and therefore, the focus of treatment should be palliation. • diverting stoma or bypass procedure may be appropriate in patients with stage IV disease who develop obstruction.
- 44. • Stage IV: Distant Metastasis (Tany, Nany, M1). • Isolated hepatic and/or pulmonary metastases are rare, but present may be resected for cure in selected patients. • Some patients will require palliative procedures. • Radical resection may be required to control pain, bleeding, or tenesmus, • Local therapy using cautery, endocavitary radiation, or laser ablation may be adequate to control • bleeding or prevent obstruction. • proximal diverting colostomy may be required to alleviate obstruction • It is critical that the morbidity of any procedure be realistically weighed against potential benefit in these patients with limited
- 49. Sources: • Schwartz’s Principles of Surgery, 10th Edition • NCCN Clinical Practice Guidelines in Oncology, 2017 • Ellis’ Applied Anatomy for Students and Junior Doctors, 11th Edition • Moore’s Clinically Oriented Anatomy, 7th Edition • Gray’s Anatomy for Students, 2nd Edition • Netter’s Atlas of Human Anatomy, 6th Edition • Google Images THANK YOU
Editor's Notes
- CEA-still the most widely used tumor marker for gastrointestinal cancer, originally thought to be a specific marker for colorectal cancer but turned out to be a nonspecific marker on further studies. -- can be elevated in breast, lung, and liver cancers --used to follow patients during therapy and to detect recurrence after successful surgery. marker for monitoring colorectal cancer The association between highly elevated serum tumor marker concentration and metastases and poor prognosis was also discovered through CEA studies. Elevated CEA levels before resection of colon cancer may suggest a worse prognosis. However, a low positive predictive value for diagnosis in asymptomatic patients limits its widespread use in screening.
- Normal CEA 3 ng/mL
- Plain X-rays of the abdomen are useful for detecting free intra-abdominal air, bowel gas patterns suggestive of small or large bowel obstruction Triple contrast- oral, IV and rectal contrast medium To find pathology by enhancing the contrast between a lesion and normal tissue detection of extraluminal disease, such as intra-abdominal abscesses and pericolic inflammation, sensitivity in detection of hepatic metastases However, a standard CT scan is relatively insensitive for the detection of intraluminal lesions specially in assessing bulky rectal tumors and perirectal adenopathy. Extravasation of oral or rectal contrast- perforation Nonspecific findings such as bowel wall thickening or mesenteric stranding may suggest inflammatory bowel disease, enteritis/colitis, or ischemia.
- A chest xray of a 75 year old female taken on PA view. With good visualization (entire thoracic cage) With good inspiratory effort (> 8 intercostal spaces, 6-8 ant. Ribs, 9-11 post ribs) Wth good exposure No obliquity (+) poorly defined densities on the upper lobes, more on the right- consider PTB (+) atheromatous aorta Normal heart size. No blunting of costophrenic angle With thoracic dextroscoliosis.
- Understanding thorough anatomy is key in surgical mgt
- rectum is straight in lower mammals (hence its name) but
- rectum is straight in lower mammals (hence its name) but
- rectum is straight in lower mammals (hence its name) but
- Valves of Houston: Thought to serve as support to fecal mass to avoid distention of rectal ampulla Rectal ampulla-lies immediately above the pelvic diaphragm and stores the feces.
- Has a peritoneal covering on its anterior, right, and left sides for the proximal third; only on its front for the middle third; and no covering for the distal third.
- Receives blood from the superior, middle, and inferior rectal arteries and the middle sacral artery. (The superior rectal artery pierces the muscular wall and courses in the submucosal layer and anastomoses with branches of the inferior rectal artery. The middle rectal artery supplies the posterior part of the rectum.)
- Posteriorly lie sacrum and coccyx and the middle sacral artery, which are separated from it by extraperitoneal connective tissue containing the rectal vessels and lymphatics. The lower sacral nerves, emerging from the anterior sacral foramina, may be involved by growth spreading posteriorly from the rectum, resulting in severe sciatic pain. A layer of fascia (Denonvilliers) separates the rectum from the anterior structures and forms the plane of dissection which must be sought after in excision of the rectum. Laterally, the rectum is supported by the levator ani. pudendal nerve is formed from the sacral plexus – a network of nerve fibres located on the posterior pelvic wall. ... It then crosses the sacrospinous ligament (close to its insertion to the ischial spine), and then re-enters the pelvis through the lesser sciatic foramen.
- Has venous blood that returns to the portal venous system via the superior rectal vein and to the caval (systemic) system via the middle and inferior rectal veins. (The middle rectal vein drains primarily the muscular layer of the lower part of the rectum and upper part of the anal canal.) Anastomoses occur between SUPERIOR RECAL VEIN (PORTAL) and SYSTEMIC VEINS– PORTOSYSTEMIC Shunt--- increase in portal pressure may lead to rectal varices
- Abdominal xrays of the same pt. taken on AP supine and standing views. With good visualization, exposure, no obliquity. With notable gas-dilated bowels with multiple air fluid levels- indication bowel obstruction In the upright projection, there is lack of noticeable gas in the lower abdomen. No sign of intraperitoneal free air
- Had the patient come in at a different time or condition, for example, without obstructive symptoms, *pT1 tumours are those that invade into the subepithelial connective tissue or lamina propria
- The amount of serosanguineous fluid should decrease each day and the color of the fluid will turn light pink or light yellow. Your surgeon will usually remove the bulb when drainage is below 25 ml per day for two days in a row. On average, JP drains can continue to drain for 1 to 5 weeks. Complications of ileostomy: Stoma necrosis = early postoperative period; usually caused by skeletonizing the distal small bowel and/or creating an overly tight fascial defect. Limited mucosal necrosis above the fascia may be treated expectantly, but necrosis below the level of the fascia requires surgical revision. Stoma retraction= may occur early or late and may be exacerbated by obesity. Local revision may be necessary. dehydration with fluid and electrolyte abnormalities= creation of an ileostomy bypasses the fluidabsorbing capability of the colon Ideally, ileostomy output should be maintained at less than 1500 mL/d to avoid this problem. Bulk agents and opioids (Lomotil, Imodium, tincture of opium) are useful. The somatostatin analogue, octreotide, has been used with varying success in this setting. Skin irritation can also occur, especially if the stoma appliance fits poorly. Skin-protecting agents and custom pouches can help to solve this problem. Obstruction may occur intra-abdominally or at the site where the stoma exits the fascia. Parastomal hernia is less common after an ileostomy than after a colostomy but can cause poor appliance fitting, pain, obstruction, or strangulation. In general, symptomatic parastomal hernias should be repaired. A variety of techniques to repair these hernias have been described, including local repair (either with or without mesh), laparoscopic repair, and stoma resiting. Prolapse is a rare, late complication and is often associated with a parastomal hernia.
- P53- tumor suppressor K-ras= signals cell growth and multiplication
- Surgery is mainstay of treatment Pre-operative radiotherapy or chemoradiation for rectal CA Post-operative chemoTx and radioTx for stage II rectal CA Post-operative chemoTx for stage III colon CA
- Therapeutic decisions, therefore, are based on the location and depth of the tumor and its relationship to other structures in the pelvis.
- 5-FU acts in several ways, but principally as a thymidylate synthase (TS) inhibitor. Interrupting the action of this enzyme blocks synthe Leucovorin-used in combination with 5-fluorouracil to treat colorectal cancer, may be used to treat folate deficiency that results in anemiasis of the pyrimidine thymidine, which is a nucleoside required for DNA replication.