Please find the power point on Carcinoma of rectum. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references.

1. 1
Sunil Kumar Daha
CARCINOMA RECTUM

2.  Colorectal carcinoma is second most common
causes of malignancy
 Rectum is most frequent site involved
 Origin:
Arises from adenoma in stepwise progression
(the adenoma-carcinoma sequence)
Usually present as an ulcer, but polyploid and
infiltrating types also common
2
Introduction

3. Distribution
3

4. Adenoma-Carcinoma Sequence
4

5. 5

6. 1. Local spread
 Occurs circumferentially rather than
longitudinally
 Anterior penetration
Prostate, Seminal vesicles, Bladder in male
Vagina or uterus in female
 Lateral penetration
Ureter
 Posterior penetration
Sacrum and sacral plexus
Types of Carcinoma Spread
6

7. 2. Lymphatic spread
 Exclusively in an upward direction
 Metastatic at higher level than superior rectal
artery in late disease
3. Venous spread
 Principal sites are:
Liver (34%)
Lungs (22%)
Adrenal (11%)
Remaining spread to other locations including
brain
Types of Carcinoma Spread
4. Peritoneal Dissemination
 High lying rectal
carcinoma
7

8. 1. Duke’s staging
3 stages
Stage A
Growth limited to the rectal wall (15%): Prognosis excellent (90%
year survival)
Stage B
Growth extended to extrarectal tissue but no matastasis to regional
lymph nodes (35%: Prognosis reasonable (70% year survival)
Stage C
Secondary deposits in regional lymph nodes
C1: Local pararectal lymph node alone involved
C2: Nodes accompanying supplying blood vessels involved
Stage D
Not described by Duke’s
Signifies presence of widespread metastasis usually hepatic
Stages of Progression
8

9. Duke’s staging
9

10. T represents the extent of local spread and there are four
grades:
T1 = Invasion through the muscularis mucosae, but not into the
muscularis propria
T2 = Invasion into, but not through the muscularis propria
T3 = Invasion through the muscularis propria, but not through
the serosa (on surfaces covered by peritoneum) or
mesorectal fascia
T4 = Invasion through the serosa or mesorectal fascia
N describes nodal involvement:
N0 = No lymph node involvement
N1 = Between one and three involved lymph nodes
N2 = Four or more involved lymph nodes.
M indicates the presence of distant metastases:
M0 = No distant metastases
M1 = Distant metastases.
TNM staging
10

11.  In majority of cases Ca Rectum is columnar cell
adenocarcinoma
a. Low grade:
 Well-differentiated 11 per cent prognosis
good;
b. Average grade,
 64 per cent prognosis fair
c. High grade
 Undifferentiated tumours 25 per cent
prognosis poor
Histological grading
11

12.  Age of presentation usually > 55 yrs
 Bleeding per recctum
 Sense of incomplete defaecation (Tenesmus)
 Alteration of bowel habits- Early morning
diarrhoea
 Pain: Colicky, late symptom
 Weight loss and anorexia
Clinical Features
12

13. All patients with suspected rectal cancer should
undergo:
 Digital rectal examination
 Sigmoidoscopy and biopsy
 Colonoscopy if possible (or CT colonography or
barium
 enema)
All patients with proven rectal cancer require staging
by:
 Imaging of the liver and chest, preferably by CT
 Local pelvic imaging by magnetic resonance
imaging and/ or endoluminal ultrasound
Diagnosis
13

14.  Radical excision of rectum , together with
mesorectum and associated lymph nodes choice of
treatment in most cases.
 When tumor is locally advanced:
Course of neoadjuvant (preoperative)
chemoradiotherapy over approx. 6 weeks may
reduce its size and make curative surgery
possible.
 When rectal excision possible, aim should be to
restore gastrointestinal continuity and continence
by preserving anal sphincter
Treatment
14

15. 1. Local operation
 For small low grade T1 tumors
 Done via the anus and TEM (Transanal Endoscopic
Microsurgies) techniuqes
2. Anterior resection
 Anterior proctosigmoidscopy with colorectal
anastomosis
 For removing the portion of bowel containing the cancer
and the mesorectum completely, containing lymphatic
channels draining tumoe bed
 Lower anterior resection: Resection of rectum below
peritoneal reflection
 Intestinal continuity reestablished by anastomosis
between descending colon and rectum
Treatment
15

16. Low anterior resection by the double stapling method 16

17. J pouchingColo-anal anastomosis
17

18. 3. Hartmann’s operation
 Excellent procedure in
elderly, not fit for major
surgery
 Through an abdominal
incision
Rectum excised,
Anorectal stump
transected
End colostomy formed
Treatment
18

19. End Colostomy
19

20. 4. Abdominoperineal excision of rectum
 For the tumors of lower third of rectum
(Unsuitable for sphincter saving procedure)
Complete excision of rectum and anus by
concomitant dissection through abdomen
and perineum
Suture closure of perineum
Creation of permanent colostomy
Treatment
20

21. 5. Endoluminal stenting
 Done endoscopically often with fluoroscopic
guidance
 Used as palliative procedure or to relieve
obstruction
 Only colonic or upper rectal tumors suitable for
stenting
6. Palliative colostomy
 In cases with intestinal obstruction or gross
infiltration of neoplasm
Treatment
21

22.  Other palliative procedures
Neodymium:Yttrium–Aluminium–garnet (Nd:
YAG) laser can be used to deal with an
obstructing or bleeding
 Extensive operations
Cystectomy, Hysterectomy etc
 Pelvic exenteration ( Brunschwig’s operation)
Removal all the pelvic organs together with
internal illiac and obturator group of nodes
 Liver resection
Well localised metastasis
Treatment
22

23. Radiotherapy
 Provided an adequate dose, neoadjuvant
radiotherapy can reduce incidence of local
recurrence
 Long term survival not affected
 Radiotherapy + Chemotherapy: shrink extensive
tumor prior to surgery
Chemotherapy
 5-Flurouracil alone or in combination with
Oxaliplatin improve survival by 10-15 % in node
positive patient
Treatment
23The end

24.  Bailey and Love’s Short Practice of Surgery; 26th
Edition
 SRB’s manual of surgery; 5th edition
References
24