powerpoint: colorectal polyps and colorectal carcinoma
TRANSCRIPT
COLORECTAL POLYPS COLORECTAL POLYPS AND COLORECTAL AND COLORECTAL
CARCINOMACARCINOMA
COLORECTAL POLYPSCOLORECTAL POLYPS
Swelling arising from the colonic mucosa Swelling arising from the colonic mucosa Common finding in the large bowelCommon finding in the large bowel Prone to malignant changesProne to malignant changes Any colorectal polyp must be considered Any colorectal polyp must be considered
malignant until proved otherwisemalignant until proved otherwise Typically present with rectal bleeding or Typically present with rectal bleeding or
anemia due to occult blood lossanemia due to occult blood loss Many polyps cause no symptoms and Many polyps cause no symptoms and
found incidentally on barium enema found incidentally on barium enema examination or colonoscopyexamination or colonoscopy
COLORECTAL POLYPSCOLORECTAL POLYPS
Histopathologically- three patterns of Histopathologically- three patterns of growth:growth:
• tubular adenomas,tubular adenomas,
• villous adenomas,villous adenomas,
• tubulo-villous adenomastubulo-villous adenomas
TUBULAR ADENOMASTUBULAR ADENOMAS
Small pedunculated or sessile lesionsSmall pedunculated or sessile lesions
The least potential for malignant The least potential for malignant changeschanges
High risk in a rare familial disorder of High risk in a rare familial disorder of polyposis coli (adenomatous polyposis)polyposis coli (adenomatous polyposis)
VILLOUS ADENOMASVILLOUS ADENOMAS
Usually sessile and frond-like lesionsUsually sessile and frond-like lesions Tend to secrete mucusTend to secrete mucus Main complaint- passing stool with Main complaint- passing stool with
mucusmucus Symptomatic hypoK- emia may Symptomatic hypoK- emia may
developdevelop Great potential for malignant changeGreat potential for malignant change
TUBULO-VILLOUS ADENOMASTUBULO-VILLOUS ADENOMAS
Intermediate forms between the first twoIntermediate forms between the first two Include the majority of colonic polypsInclude the majority of colonic polyps Most are pedunculated, the stalk 1-10 Most are pedunculated, the stalk 1-10
cm.cm. Early malignant change- invasion Early malignant change- invasion
through the basement membrane into through the basement membrane into the muscularis mucosathe muscularis mucosa
Careful histological examination is Careful histological examination is essentialessential
COLONIC POLYPSCOLONIC POLYPS
May occur in any part of the colonMay occur in any part of the colon Majority of them arise in the rectum and Majority of them arise in the rectum and
sigmoid colonsigmoid colon They tend to cause rectal bleeding (visible They tend to cause rectal bleeding (visible
or occult) and may undergo malignant or occult) and may undergo malignant changechange
If rectal polyps are found, the entire colon If rectal polyps are found, the entire colon must be investigated- total colonoscopymust be investigated- total colonoscopy
The larger the lesion the more likely it is to The larger the lesion the more likely it is to be malignantbe malignant
COLORECTAL POLYPSCOLORECTAL POLYPSDIAGNOSIS DIAGNOSIS
RectoscopyRectoscopy
SigmoidoscopySigmoidoscopy
ColonoscopyColonoscopy
Barium enemaBarium enema
COLORECTAL POLYPSCOLORECTAL POLYPSMANAGEMENTMANAGEMENT
Polyps can be excised using diatermy Polyps can be excised using diatermy snare endoscopicallysnare endoscopically
Pedunculated lesions<2 cm. can be Pedunculated lesions<2 cm. can be removed with easeremoved with ease
Larger polyps or sessile require Larger polyps or sessile require snaring in several piecessnaring in several pieces
If a malignant polyp has been If a malignant polyp has been incompletely removed then bowel incompletely removed then bowel excision is requiredexcision is required
COLONIC POLYPSCOLONIC POLYPS
PEDUNCULATED COLONIC PEDUNCULATED COLONIC POLYPPOLYP
SESSILE POLYPSESSILE POLYP
PEDUNCULATED POLYP PEDUNCULATED POLYP ADENOCARCINOMA IN SITUADENOCARCINOMA IN SITU
COLONIC POLYPCOLONIC POLYPADENOCARCINOMA IN SITUADENOCARCINOMA IN SITU
MULTIPLE COLONIC POLYPSMULTIPLE COLONIC POLYPS
BLEEDING COLONIC POLYPBLEEDING COLONIC POLYP
SNARE POLYPECTOMYSNARE POLYPECTOMY
BLEEDING POSTPOLYPECTOMYBLEEDING POSTPOLYPECTOMY
ENDOSCOPIC VIEWENDOSCOPIC VIEW
Inflammatory pseudopolypsInflammatory pseudopolyps
Can occur as a complication of Can occur as a complication of ulcerative colitis or or Crohn's disease of the colon. of the colon.
They are completely harmless and They are completely harmless and carry no risk of cancer but they can carry no risk of cancer but they can be confused with adenomatous be confused with adenomatous polyps on examination. polyps on examination.
Peutz-Jeghers syndromePeutz-Jeghers syndrome
It is an autosomal dominant inherited disorder It is an autosomal dominant inherited disorder characterized by intestinal hamartomatous polyps characterized by intestinal hamartomatous polyps in association with mucocutaneous melanocytic in association with mucocutaneous melanocytic macules. macules.
Patients with Peutz-Jeghers syndrome (PJS) have Patients with Peutz-Jeghers syndrome (PJS) have a 15-fold increased risk of developing intestinal a 15-fold increased risk of developing intestinal cancer compared with that of the general cancer compared with that of the general population. population.
Such cancer locations includes gastrointestinal Such cancer locations includes gastrointestinal and extraintestinal sites.and extraintestinal sites.
Facial Facial photograph of a photograph of a patient with patient with Peutz-Jeghers Peutz-Jeghers syndrome. syndrome.
Note the Note the mucocutaneous mucocutaneous pigmentationpigmentation
Photo of oral Photo of oral pigmented lesion pigmented lesion from a patient from a patient with Peutz-with Peutz-Jeghers Jeghers syndrome.syndrome.
Peuts-Jeghers syndrome Peuts-Jeghers syndrome gastroscopygastroscopy
The gastrointestinal polyps found The gastrointestinal polyps found in Peutz-Jeghers syndrome are in Peutz-Jeghers syndrome are typical hamartomas. typical hamartomas.
Their histology is characterized by Their histology is characterized by extensive smooth muscle extensive smooth muscle arborization throughout the polyp. arborization throughout the polyp.
Nevertheless, cancer may develop Nevertheless, cancer may develop in the gastrointestinal tract of in the gastrointestinal tract of patients with Peutz-Jeghers patients with Peutz-Jeghers syndrome (PJS) with a higher syndrome (PJS) with a higher frequency than in the general frequency than in the general populationpopulation
COCAINE COLITIS.COCAINE COLITIS.44 year-old man, a frequent user of cocaine, who presented with 44 year-old man, a frequent user of cocaine, who presented with
bloody diarrhea. Colonoscopy revealed a range of findings from areas bloody diarrhea. Colonoscopy revealed a range of findings from areas of congestion to sessile polyps to lesions resembling pedunculated of congestion to sessile polyps to lesions resembling pedunculated polyps. Stool cultures were all negative. Biopsies revealed mucosal polyps. Stool cultures were all negative. Biopsies revealed mucosal
congestion and inflammation. congestion and inflammation.
COLORECTAL CANCERCOLORECTAL CANCERPATHOLOGYPATHOLOGY
Adenocarcinoma of the colon is Adenocarcinoma of the colon is growing outside from the mucosa growing outside from the mucosa and later ulcerate and invade the and later ulcerate and invade the muscular layermuscular layer
Next invades the serosa and Next invades the serosa and surrounding structuressurrounding structures
Stromal fibrosis causes narrowing- Stromal fibrosis causes narrowing- bowel obstructionbowel obstruction
COLORECTAL CANCERCOLORECTAL CANCERPATHOLOGYPATHOLOGY
Lymphatic spread is sequential first to Lymphatic spread is sequential first to mesenteric nodes and then paraaortic nodesmesenteric nodes and then paraaortic nodes
Large paraaortic nodes- duodenal obstructionLarge paraaortic nodes- duodenal obstruction Large nodes compressing porta hepatis- Large nodes compressing porta hepatis-
jaundicejaundice Hematogenous spread- to the liver, usually Hematogenous spread- to the liver, usually
follows lymphatic spreadfollows lymphatic spread By the time of diagnosis 25% of pts. already By the time of diagnosis 25% of pts. already
have widespread metastaseshave widespread metastases
COLORECTAL CANCERCOLORECTAL CANCERCLINICAL PRESENTATIONCLINICAL PRESENTATION
Cecal cancer- occult bleeding- iron Cecal cancer- occult bleeding- iron defficiency anemia, palpable mass in defficiency anemia, palpable mass in RIFRIF
Colorectal cancers ulcerate earlier- Colorectal cancers ulcerate earlier- lower digestive bleeding- hematochezialower digestive bleeding- hematochezia
Bowel obstruction, partial or total in Bowel obstruction, partial or total in stenotic lesions, usually in the left colonstenotic lesions, usually in the left colon
Bowel perforation- fecal peritonitisBowel perforation- fecal peritonitis Malignant fistula into the: stomach, Malignant fistula into the: stomach,
bladder, uterus, vagina, skin bladder, uterus, vagina, skin
COLORECTAL CANCERCOLORECTAL CANCERSYMPTOMS AND SIGNSSYMPTOMS AND SIGNS
Cecal tumor: anemia, diarrhea, palpable Cecal tumor: anemia, diarrhea, palpable massmass
Descending colon: rectal bleeding, change in Descending colon: rectal bleeding, change in bowel habit, colicky pain, perforationbowel habit, colicky pain, perforation
Rectal tumor: rectal bleeding, tenesmus, Rectal tumor: rectal bleeding, tenesmus, mucus diarrheamucus diarrhea
Compressing symptoms: jaundice, duodenal Compressing symptoms: jaundice, duodenal obstruction, ureterohydronephrosisobstruction, ureterohydronephrosis
Systemic effects: malaise, anorexia, weight Systemic effects: malaise, anorexia, weight lossloss
COLORECTAL CANCERCOLORECTAL CANCER
Premalignant conditionsPremalignant conditions
• Poliposis coli- genetic familial disorderPoliposis coli- genetic familial disorder
• Ulcerative colitis- inflammatory bowel Ulcerative colitis- inflammatory bowel diseasedisease
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
General examination- features General examination- features suggesting malignant disease:suggesting malignant disease:• Obvious weight lossObvious weight loss• Palor of the skinPalor of the skin• Abdominal distentionAbdominal distention• HepatomegalyHepatomegaly• Abdominal massAbdominal mass
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
Rectal examination:Rectal examination:• Finger can reach lesions as far as the its Finger can reach lesions as far as the its
length 7-9 cmlength 7-9 cm• Palpable fixed mass in Douglas pouch-Palpable fixed mass in Douglas pouch-
sigmoid tumor dropped retrorectallysigmoid tumor dropped retrorectally• The glove inspected for blood and The glove inspected for blood and
mucusmucus
COLORECTAL CANCERCOLORECTAL CANCERINVESTIGATIONSINVESTIGATIONS
Rectosigmoidoscopy- about 50% of Rectosigmoidoscopy- about 50% of colorectal cancer lie within reach of the colorectal cancer lie within reach of the rigid sigmoidoscope- biopsyrigid sigmoidoscope- biopsy
Barium enema- synchronous tumorsBarium enema- synchronous tumors ColonoscopyColonoscopy Abdominal CT- stagingAbdominal CT- staging Urography- ureterohydronephrososUrography- ureterohydronephrosos Barium meal- duodenal compressionBarium meal- duodenal compression Plain abdominal X ray- bowel obstructionPlain abdominal X ray- bowel obstruction
RESECTED ILEOCOLONRESECTED ILEOCOLONCECAL CANCERCECAL CANCER
COLONIC CANCERCOLONIC CANCER
ULCERATED COLON ULCERATED COLON CANCERCANCER
STENOTIC COLON CANCERSTENOTIC COLON CANCER
ULCERATED RECTAL ULCERATED RECTAL CANCERCANCER
BARIUM ENEMABARIUM ENEMATRANSVERSE COLON CANCERTRANSVERSE COLON CANCER
BARIUM ENEMABARIUM ENEMACECAL CANCERCECAL CANCER
BARIUM ENEMABARIUM ENEMARECTAL CANCERRECTAL CANCER
RECTAL CANCERRECTAL CANCER
ENDOSCOPIC ULTRASOUNDENDOSCOPIC ULTRASOUND
RECTAL CANCERRECTAL CANCER
STENOTIC COLON CANCERSTENOTIC COLON CANCER
SIGMOID STENOTIC CANCERSIGMOID STENOTIC CANCERLIVER AND PERITONEAL MTSLIVER AND PERITONEAL MTS
COLORECTAL CANCERCOLORECTAL CANCERMANAGEMENTMANAGEMENT
Surgical resection is the only curative Surgical resection is the only curative therapeutic modalitytherapeutic modality
Radio/chemotherapy- neoadjuvant or Radio/chemotherapy- neoadjuvant or adjuvant treatmentadjuvant treatment
Radio/chemo neoadjuvant therapy- Radio/chemo neoadjuvant therapy- decreases locoregional recurrences decreases locoregional recurrences in rectal cancerin rectal cancer
Adjuvant chemotherapy- useful for Adjuvant chemotherapy- useful for colon cancercolon cancer
COLORECTAL CANCERCOLORECTAL CANCERMANAGEMENTMANAGEMENT
Loco-regional recurrence= tumor re-Loco-regional recurrence= tumor re-growth at the anastomosis or within growth at the anastomosis or within operative areaoperative area
Loco-regional recurrence may Loco-regional recurrence may develop from either retained develop from either retained microscopic tissue in the lateral microscopic tissue in the lateral margins of resection or microscopic margins of resection or microscopic positive nodes left in the positive nodes left in the mesorectummesorectum
COLORECTAL CANCERCOLORECTAL CANCERPROGNOSTIC FACTORSPROGNOSTIC FACTORS
Age (young or very old)Age (young or very old) Histological type (coloid type is Histological type (coloid type is
worse)worse) Vascular and lymphatic invasionVascular and lymphatic invasion Histological grade (poor Histological grade (poor
differentiated)differentiated) The degree of wall invasion (Dukes The degree of wall invasion (Dukes
classification)classification)
STAGING- DUKES STAGING- DUKES CLASSIFICATIONCLASSIFICATION
After histological examination of the After histological examination of the resected specimenresected specimen
Dukes A- tu.confined to the bowel wallDukes A- tu.confined to the bowel wall Dukes B- tu. spread into the extrarectal Dukes B- tu. spread into the extrarectal
or extracolic tissues, no+ lymph nodesor extracolic tissues, no+ lymph nodes Dukes C- tu. spread extrarectally or Dukes C- tu. spread extrarectally or
extracolic with + lymph nodesextracolic with + lymph nodes Dukes D- distant metastasesDukes D- distant metastases
SURVIVAL RATESSURVIVAL RATES
½ of the pts. are incurable at ½ of the pts. are incurable at presentationpresentation
¼ of the pts. with radical surgery are ¼ of the pts. with radical surgery are alive and well at 5 yearsalive and well at 5 years
Very few pts. surviving 5 years die Very few pts. surviving 5 years die later of recurrent diseaselater of recurrent disease
COLORECTAL CANCERCOLORECTAL CANCEROPERATIONSOPERATIONS
The principles of tumor resection:The principles of tumor resection:• The affected segment of bowel resected The affected segment of bowel resected
with a margin of normal tissuewith a margin of normal tissue• The precise lines of resection are The precise lines of resection are
determined by the distribution of determined by the distribution of mesenteric blood vesselsmesenteric blood vessels
• No touch, isolation techniqueNo touch, isolation technique• The mesentry resected with its lymph nodesThe mesentry resected with its lymph nodes• The cut ends of bowel can be rejoined at The cut ends of bowel can be rejoined at
the same operationthe same operation
COLORECTAL CANCERCOLORECTAL CANCEROPERATIONSOPERATIONS
Right colon tu.- right colectomy with ileocolic Right colon tu.- right colectomy with ileocolic anastomosisanastomosis
Transverse colon tu. Segmental colectomy with Transverse colon tu. Segmental colectomy with colo-colic anastomosiscolo-colic anastomosis
Left colon tu.- left colectomy with colorectal Left colon tu.- left colectomy with colorectal anastomosisanastomosis
Upper rectal tu.- anterior resection of the rectum Upper rectal tu.- anterior resection of the rectum with colorectal anastomosiswith colorectal anastomosis
Low rectal tu.- abdominoperineal resection of the Low rectal tu.- abdominoperineal resection of the rectum with definitive left colostomyrectum with definitive left colostomy
Stenotic recto-sigmoid tu.-Hartmann op.= Stenotic recto-sigmoid tu.-Hartmann op.= rectosigmoidectomy, closure of the rectal stump, rectosigmoidectomy, closure of the rectal stump, left colostomyleft colostomy
ADVANCED DISEASEADVANCED DISEASE Palliative resection when distant metastases are Palliative resection when distant metastases are
present- survival within 1 yearpresent- survival within 1 year If liver metastases are confined in a lobe- If liver metastases are confined in a lobe-
lobectomy can be associated to bowel resection if lobectomy can be associated to bowel resection if the pt. is relatively fit.the pt. is relatively fit.
Bone metastases- local radiotherapyBone metastases- local radiotherapy Unresectable right colon cancer- ileotransverso. Unresectable right colon cancer- ileotransverso.
by-passby-pass Unresectable left colon cancer- transverso-Unresectable left colon cancer- transverso-
sigmoidostomysigmoidostomy Unresectable rectosigmoid cancer- loop Unresectable rectosigmoid cancer- loop
colostomy colostomy
FAMILIAL POLIPOSIS COLIFAMILIAL POLIPOSIS COLI
It is a rare autosomal dominant It is a rare autosomal dominant disorderdisorder
Multiple colorectal polypsMultiple colorectal polyps Rectal bleeding/ change in bowel habitRectal bleeding/ change in bowel habit The treatment- colorectal removal The treatment- colorectal removal
with ileoanal anastomosis, or with ileoanal anastomosis, or panproctocolectomy with definitive panproctocolectomy with definitive ileostomyileostomy
POLIPOSIS COLIPOLIPOSIS COLI
POLIPOSIS COLIPOLIPOSIS COLI
COMPLICATIONS OF LARGE COMPLICATIONS OF LARGE BOWEL SURGERYBOWEL SURGERY
Wound infection and dehiscenceWound infection and dehiscence Intraperitoneal abscessIntraperitoneal abscess PeritonitisPeritonitis
• Causes:- fecal spillage intraoperativeCauses:- fecal spillage intraoperative
- anastomotic leak- anastomotic leak
EARLY COMPLICATIONSEARLY COMPLICATIONS
Wound infectionWound infection Intra-abdominal abscessIntra-abdominal abscess Stoma problemsStoma problems
LATE COMPLICATIONSLATE COMPLICATIONS
Diarrhea due to short bowelDiarrhea due to short bowel Small bowel obstruction- adhesions, Small bowel obstruction- adhesions,
fibrous band, internal herniation, fibrous band, internal herniation, kinkingkinking
Abdominoperineal resection- Abdominoperineal resection- hypogastric plexus damaged- hypogastric plexus damaged- micturition problems and impotencemicturition problems and impotence
STOMASSTOMASINDICATIONSINDICATIONS
CANCER SURGERYCANCER SURGERY ULCERATIVE COLITISULCERATIVE COLITIS FAMILIAL POLIPOSISFAMILIAL POLIPOSIS DIVERTICULITISDIVERTICULITIS
STOMASSTOMAS
PERMANENT STOMASPERMANENT STOMAS
TEMPORARY STOMAS:TEMPORARY STOMAS:
- BOWEL - BOWEL OBSTRUCTION,OBSTRUCTION,
- PROTECTIVE STOMAS,- PROTECTIVE STOMAS,
- UNPREPARED BOWEL- UNPREPARED BOWEL
STOMA TYPESSTOMA TYPES
CECOSTOMYCECOSTOMY LOOP COLOSTOMYLOOP COLOSTOMY END COLOSTOMYEND COLOSTOMY