byUKShrivastavaProf &Head Surgery DepartmentAIMST UniversityMalaysia
Definition------- Uncontrolled cell growth in         the lining of bowel, colon and rectum         if remain untreated, g...
Age ---Seen in people above 50years of agePolyp– majority start in polyp, which develop in       lining of bowel mucosaGen...
Diet----- High animal fat & low fiber diet  Smoking-- Studies shows high incidence  Obesity---- High incidence  Physical a...
Change in bowel habitsBlood in stoolsConstipation & feeling of incompletedeificationGeneral Abdominal DiscomfortWeight los...
1 Faecal Occult blood---Either by Guaic test or                 Immunochemical reaction                  Usually 50 to 70 ...
4 Virtual Colonoscopy--- super x-ray of colon                   air is pumped to colon to                    expand CT pic...
Stage I----- Growth invades inner mucosa &              Sub mucosa NO lymph nodeStage II----- Penetrates to mesorectal tis...
CRITERIA’S      Tumor small chance of metastasizing       due to paucity of lymphatics in        colorectal mucosa      Th...
Presentations ------    A Polypoidal carcinoma    B Large pedunculated or sessile Adenoma    C Small ulcerated adeno carci...
Screening for all rectal bleedingOn colonoscopy-irregularity of mucosa they  look like              mucosal pinkness      ...
Magnifying colonoscopy is helpfulEndo rectal ultra sonography is helpful          Very sensitive Invx for Ti & Tii tumor  ...
It must include---- Accurate histology                Safe oncologic procedure                High chance of cure         ...
Options            Pathological stage 1 Standard polypectomy -- Pedunculated                         adenoma & ERC Ti 2 En...
Park’s per anal exicision— ideal for tumor at 6-10cm from anal verge assessed with fibro optic anal retractor posterior tu...
Anterior Resection---Required for high risk ERC patientERC with sub mucosal level ii and iii invasionFor poorly differenti...
Management depends on histology of tumorImportant to handle the excised tumor with careShould be submitted fresh with all ...
Adenoma-- Pedunculated 42to85% cases             Sessile 15to58% of cases All ERC are T1 tumor ( TNM) classificationHaggit...
Size---- < 5mm never found to have Ca         > 1cm have Ca focus in 40% of cases          those above 42mm of size Ca in ...
Many studies claim benefit chemo radiation  for growth upto7cm anal verge resectable  ERC with complete response 5 FU, leu...
ERC which has high histological grade that is    All sm3 and sm2 with invasion with, neural     and lymphatic invasionTumo...
Regular endoscopic surveillance for recurrenceEndorectal ultrasonograph- at each follow upDigital rectal examination, and ...
Recurrence totally depends on Histology and  molecular biology of the ERCOverall recurrence after local excision 10%Oxford...
Early diagnosisand treatment of ERC improves the outcomeMass screening programmer are MUSTImproved histological staging is...
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Early rectal cancer by Dr. U.K.Shrivastava (MS,FAIS,DHA), Prof. & Head of Surgery, AIMST University, Malaysia

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Early rectal cancer by Dr. U.K.Shrivastava (MS,FAIS,DHA), Prof. & Head of Surgery, AIMST University, Malaysia

  1. 1. byUKShrivastavaProf &Head Surgery DepartmentAIMST UniversityMalaysia
  2. 2. Definition------- Uncontrolled cell growth in the lining of bowel, colon and rectum if remain untreated, grows into the muscular layer and then to out sideAll such growth confined to mucosa onlyare early cancer and curable. That is T I tumor Considered to be 4th most commonly diagnosed cancer in the world & 2nd most frequent cause of cancer death
  3. 3. Age ---Seen in people above 50years of agePolyp– majority start in polyp, which develop in lining of bowel mucosaGenetics -HNPCC(lynch syndrome), FAP, Gardner SyndromeFamily History-- Raises two foldPersonal History—Either of polyp or any cancerI.B.D. ---- Ulcerative colitis, Crohn’s Disease
  4. 4. Diet----- High animal fat & low fiber diet Smoking-- Studies shows high incidence Obesity---- High incidence Physical activity---Sedentary life style raises Non Steroidal Anti inflammatory Drugs---Studies says it reduces the incidence So better food with fruits, green vegetables Exercise, non smoking Reduces theincidence
  5. 5. Change in bowel habitsBlood in stoolsConstipation & feeling of incompletedeificationGeneral Abdominal DiscomfortWeight loss, Poor appetiteContinued TirednessVomiting, Anemia
  6. 6. 1 Faecal Occult blood---Either by Guaic test or Immunochemical reaction Usually 50 to 70 yrs High risk 40 years2 Flexible sigmoidoscopy-- low risk 5 years High risk 2 years3 Colonoscopy----- low risk 10 years High risk 5 years If required get Bx
  7. 7. 4 Virtual Colonoscopy--- super x-ray of colon air is pumped to colon to expand CT pictures are taken Bx can not be taken5 Double Contrast Barium Enema6 Digital rectal examination7 Endoscopic rectal ultrasound8 Abdominal U/S , X-ray chest MRI pelvis,CT scan and Positron Emission Tomography PET scan9 CEA estimation-- Tumor marker for follow up
  8. 8. Stage I----- Growth invades inner mucosa & Sub mucosa NO lymph nodeStage II----- Penetrates to mesorectal tissues NO lymph nodeStage III------ Regardless to penetration the Lymph nodes are involvedStage IV ------ Evidence of cancer in other parts of body ( metastatic)
  9. 9. CRITERIA’S Tumor small chance of metastasizing due to paucity of lymphatics in colorectal mucosa These tumors are usually well to moderately differentiated, Absence of lympho vascular & neural Invasion ALL such lesions if with in 8 to 10 cm from anal verge& the tumor is of size 3 to 4 cm occupying 1/3 of circumference of rectal wall are best treated BY TRANS ANAL EXCISION
  10. 10. Presentations ------ A Polypoidal carcinoma B Large pedunculated or sessile Adenoma C Small ulcerated adeno carcinoma TO DETECT SUCH EARLY LESIONS SCREENING IS ALWAYS REQUIRED AND CURE IS POSSIBLE BY TRANS ANAL ENDOSCOPIC MICROSURGERY
  11. 11. Screening for all rectal bleedingOn colonoscopy-irregularity of mucosa they look like mucosal pinkness superficial granularity,nodularity mucosal fading, or depression hemorrhagic spotsWhat to do? Spray the mucosa with indigo carmine make it visualize & Bx
  12. 12. Magnifying colonoscopy is helpfulEndo rectal ultra sonography is helpful Very sensitive Invx for Ti & Tii tumor Helpful to find residual tumor after polypectomyMRI--- This is helpful to find tumor invading beyond submucosa to muscularis coat MRI & Ultrasound both good for L.N. Mets PET is used only see the pelvic recurrence SLN bx after isosulfan blue dye injection
  13. 13. It must include---- Accurate histology Safe oncologic procedure High chance of cure Minimum morbidity PROCEDURE DESTROYING HISTOGY NOT GOOD a Electro coagulation b Endocavitory Radiation c Laser and Cryotherapy
  14. 14. Options Pathological stage 1 Standard polypectomy -- Pedunculated adenoma & ERC Ti 2 Endoscopic mucosal - Flat &depressed resections adenoma >3cm3 TEM Large adenoma Ti smi smii smiii& Tii 4 Anterior Resection T I smiii Tii with poor differetiation, vascular invasion & incomplete excision
  15. 15. Park’s per anal exicision— ideal for tumor at 6-10cm from anal verge assessed with fibro optic anal retractor posterior tumor position Trendelenburg anterior tumor jack-knife position lateral tumor either left or right lateral position full thickness with 1cm margin removed underlying mesorectal fat palpated ,for L.N.Defect sutured or stappled, pt can eat ,discharged complication few 5% bleed, R/V fistula, retention
  16. 16. Anterior Resection---Required for high risk ERC patientERC with sub mucosal level ii and iii invasionFor poorly differentiated growth Evidence of lymphovascular & neuralinvasion Whenever the dissected margins are positiveInadequate tissues for histologicalassessment RARE TO GO FOR A.P.R. IN ERC CASES
  17. 17. Management depends on histology of tumorImportant to handle the excised tumor with careShould be submitted fresh with all treatmement details. A Pedunculated Type– Ip, Ips, Is B Flat Type ---- flat elevated IIa, flat depression IIa +IIc., flat elevated.and depression,type C Depressed Type Laterally spreading Type laterally spreading
  18. 18. Adenoma-- Pedunculated 42to85% cases Sessile 15to58% of cases All ERC are T1 tumor ( TNM) classificationHaggitt described sub mucosal invasion in polyp at level 1,2,3, Invasive ca in sessile is L 4Kikuchi classified the sessile lesion sm1a , sm1b , sm1c, sm2 sm3 1/4 1/2 >1/2 , in-between, mus.pro
  19. 19. Size---- < 5mm never found to have Ca > 1cm have Ca focus in 40% of cases those above 42mm of size Ca in 80%Villous adenoma highest risk in 30% of casesadenoma found in rectum high risk for Ca 24%adenoma in Rt colon 6% and lt Colon 8% casesLow-risk ERC completely excised, no lympho- vascular invasion and well differentiated Achieved by polypectomy or by TEM sm1 &THigh risk all Sm2 and sm3 growth with invasionOVERALL LYMPH NODE METS IN ERC T1 TUMOR IS RARE5to20%in sm2 and sm3 group
  20. 20. Many studies claim benefit chemo radiation for growth upto7cm anal verge resectable ERC with complete response 5 FU, leucovorin # RT ( 30% ) NO Further treatment All those with incomplete response- surgery for removal of residual growthAdjuvant Chemoradiation – only for T2 rectal Ca
  21. 21. ERC which has high histological grade that is All sm3 and sm2 with invasion with, neural and lymphatic invasionTumor those ulcerated or flat raised varietyTumor showing invasion to resected marginsTumor in rectum, recurrence is higher than other part of large bowelERC lying in lower third of rectum Six fold high risk than upper part Molecular Marker-cyclin dependent kinase inhibitor better prognosis and sucrose isomaltase higherrecurrence
  22. 22. Regular endoscopic surveillance for recurrenceEndorectal ultrasonograph- at each follow upDigital rectal examination, and sigmoidoscopy every 3 months for 3 years 6 months 2 years then every yearCEA estimation to be done each visit of patientMRI and PET if required to be doneAll those cases had RTH should have longer follow up recurrence make at longer gap
  23. 23. Recurrence totally depends on Histology and molecular biology of the ERCOverall recurrence after local excision 10%Oxford study group 5 yr disease free survival after TEM is 79% for ERC The U.S.National cancer studies low risk100% 5 yr DFS high risk 29% 10yrDFSThose having Chemoradition show better survivalIn case of LN mets DFS goes down to 36% only.
  24. 24. Early diagnosisand treatment of ERC improves the outcomeMass screening programmer are MUSTImproved histological staging is importantClassical surgery always afford better cureLow risk ERC with local excision and TEM do match the outcome , preserving rectal functionHigh risk with TEM outcome NOT that good

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