byUKShrivastavaProf &Head Surgery DepartmentAIMST UniversityMalaysia

Definition------- Uncontrolled cell growth inthe lining of bowel, colon and rectumif remain untreated, grows into themuscular layer and then to out side

All such growth confined to mucosa only are early cancer and curable. That is T I tumor

Considered to be 4th most commonlydiagnosed cancer in the world & 2nd

most frequent cause of cancer death

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

Diet----- High animal fat & low fiber dietSmoking-- Studies shows high incidenceObesity---- High incidencePhysical activity---Sedentary life style raises Non Steroidal Anti inflammatory Drugs---

Studies says it reduces the incidence So better food with fruits, green vegetablesExercise, non smoking Reduces the

incidence

Change in bowel habitsBlood in stoolsConstipation & feeling of incompletedeificationGeneral Abdominal DiscomfortWeight loss, Poor appetiteContinued TirednessVomiting, Anemia

1 Faecal Occult blood---Either by Guaic test orImmunochemical reaction Usually 50 to 70 yrsHigh risk 40 years

2 Flexible sigmoidoscopy-- low risk 5 yearsHigh risk 2 years

3 Colonoscopy----- low risk 10 yearsHigh risk 5 yearsIf required get Bx

4 Virtual Colonoscopy--- super x-ray of colonair is pumped to colon to expand CT pictures are takenBx can not be taken

5 Double Contrast Barium Enema 6 Digital rectal examination7 Endoscopic rectal ultrasound8 Abdominal U/S , X-ray chest MRI pelvis,CT

scan andPositron Emission Tomography PET scan

9 CEA estimation-- Tumor marker for follow up

Stage I----- Growth invades inner mucosa &Sub mucosa NO lymph node

Stage II----- Penetrates to mesorectal tissuesNO lymph node

Stage III------ Regardless to penetration theLymph nodes are involved

Stage IV ------ Evidence of cancer in otherparts of body ( metastatic)

CRITERIA’STumor small chance of metastasizing

due to paucity of lymphatic's incolorectal mucosa

These tumors are usually well tomoderately differentiated,

Absence of lympho vascular & neuralInvasion

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

Presentations ------A Polypoidal carcinomaB Large pedunculated or sessile AdenomaC Small ulcerated adeno carcinoma

TO DETECT SUCH EARLY LESIONS SCREENINGIS ALWAYS REQUIRED AND CURE IS POSSIBLE

BYTRANS ANAL ENDOSCOPIC MICROSURGERY

Screening for all rectal bleedingOn colonoscopy-irregularity of mucosa they

look likemucosal pinknesssuperficial granularity,nodularitymucosal fading, or depressionhemorrhagic spots

What to do? Spray the mucosa with indigo carmine make it visualize & Bx

Magnifying colonoscopy is helpfulEndo rectal ultra sonography is helpful

Very sensitive Invx for Ti & Tii tumorHelpful to find residual tumor afterpolypectomy

MRI--- This is helpful to find tumor invadingbeyond submucosa to muscularis coat

MRI & Ultrasound both good for L.N. MetsPET is used only see the pelvic recurrenceSLN bx after isosulfan blue dye injection

It must include---- Accurate histologySafe oncologic procedureHigh chance of cureMinimum morbidity

PROCEDURE DESTROYING HISTOGY NOT GOOD

a Electro coagulationb Endocavitory Radiationc Laser and Cryotherapy

Options Pathological stage1 Standard polypectomy -- Pedunculated

adenoma & ERC Ti2 Endoscopic mucosal - Flat &depressed

resections adenoma >3cm3 TEM Large adenoma

Ti smi smii smiii& Tii4 Anterior Resection T I smiii Tii with poor

differetiation, vascular invasion & incomplete

excision

Park’s per anal exicision—ideal for tumor at 6-10cm from anal vergeassessed with fibro optic anal retractorposterior tumor position Trendelenburganterior tumor jack-knife positionlateral tumor either left or right lateral positionfull thickness with 1cm margin removedunderlying mesorectal fat palpated ,for L.N.

Defect sutured or stappled, pt can eat ,dischargedcomplication few 5% bleed, R/V fistula, retention

Anterior Resection---Required for high risk ERC patientERC with sub mucosal level ii and iii invasionFor poorly differentiated growthEvidence of lymphovascular & neural

invasionWhenever the dissected margins are positiveInadequate tissues for histological assessment

RARE TO GO FOR A.P.R. IN ERC CASES

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, IsB Flat Type ---- flat elevated IIa, flat depression

IIa +IIc., flat elevated.anddepression,type

C Depressed TypeLaterally spreading Type laterally spreading

Adenoma-- Pedunculated 42to85% casesSessile 15to58% of cases

All ERC are T1 tumor ( TNM) classificationHaggitt described sub mucosal invasion in

polypat level 1,2,3, Invasive ca in sessile is L 4

Kikuchi classified the sessile lesionsm1a , sm1b , sm1c, sm2 sm31/4 1/2 >1/2 , in-between, mus.pro

Size---- < 5mm never found to have Ca> 1cm have Ca focus in 40% of casesthose 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 differentiatedAchieved by polypectomy or by TEM sm1 &T

High risk all Sm2 and sm3 growth with invasionOVERALL LYMPH NODE METS IN ERC T1 TUMOR IS

RARE 5to20%in sm2 and sm3 group

Many studies claim benefit chemo radiation for growth upto7cm anal verge resectable ERC

with complete response 5 FU, leucovorin # RT( 30% ) NO Further treatmentAll those with incomplete response- surgery

for removal of residual growthAdjuvant Chemoradiation – only for T2 rectal

Ca

ERC which has high histological grade that isAll sm3 and sm2 with invasion with, neuraland lymphatic invasion

Tumor 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

Regular endoscopic surveillance for recurrenceEndorectal ultrasonograph- at each follow upDigital rectal examination, and sigmoidoscopy

every 3 months for 3 years 6 months 2 yearsthen every year

CEA 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

Recurrence totally depends on Histology andmolecular biology of the ERC

Overall recurrence after local excision 10%Oxford study group 5 yr disease free survival

after TEM is 79% for ERCThe 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.

Early diagnosis and 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 function

High risk with TEM outcome NOT that good