Download carcinoma of rectum

ETIOLOGY
PATHOGENESIS
CLINICAL FEATURES
BY
ALBIN JOSE,2002 MBBS
ANATOMY OF RECTUM



FROM
RECTOSIGMOID
JUNCTION
END AT ANORECTAL
JUNCTION
18-20 cm IN LENGTH
ANATOMY CONTD.

RECTUM HAS THREE
LATERAL CURVATURES
.UPPER AND
LOWER CONVEX TO
THE RIGHT
.MIDDLE
CONVEX TO THE LEFT
* ON THE MUCOSAL
ASPECT –
SEMICIRCULAR FOLDS
- HOUSTON'S VALVES
ANATOMY CONTD.

THE PART BELOW MIDDLE VALVE AMPULLA OF RECTUM
ANATOMY CONTD.

PERITONEAL RELATIONS
UPPER THIRD – IN FRONT AND ON THE
LATERAL ASPECTS
 MIDDLE THIRD – ANTERIOR SURFACE
 LOWER THIRD – NO PERITONEAL
COVERING

ANATOMY CONTD.

ARTERIAL SUPPLY
SUPERIOR RECTAL
ARTERY
MIDDLE RECTAL
ARTERY
INFERIOR RECTAL
ARTERY
ANATOMY CONTD.

VENOUS DRAINAGE
SUPERIOR HAEMORRHOIDAL VEINS →
RECTAL VEINS → SUPERIOR RECTAL
VEIN → INFERIOR MESENTERIC VEIN
→ PORTAL VEIN
 MIDDLE RECTAL VEIN

ANATOMY CONTD.

LYMPHATIC DRAINAGE
UPPER HALF – PARARECTAL AND
SIGMOID NODES → INFERIOR
MESENTERIC NODES
 LOWER HALF – ALONG MIDDLE
RECTAL VESSELS TO INTERNAL ILLIAC
NODES

ANATOMY CONTD.

NERVE SUPPLY

SYMPATHETIC ( L 1,L 2)
VASOCONSTRICTORS
INHIBITORY TO MUSCLES
MOTOR TO INTERNAL SPHINCTER
PAIN SENSATION
ANTOMY CONTD.

NERVE SUPPLY

PARASYMPATHETIC (S2, S3, S4)
MOTOR TO MUSCELES
INHIBITORY TO INTERNAL
SPHINCTER
SENSATION OF DISTENTION
ANATOMY CONTD.
RELATIONS (males)
.BLADDER
.SEMINALVESICLES
.PROSTATE
.URETERS
.PELVIC MUSCLES
.SACRUM COCCYX
ANATOMY CONTD.
RELATIONS
(females)
 POUCH OF
DOUGLAS
 UTERUS
 CERVIX
 POST. VAGINAL
WALL
 SACRUM
COCCYX
CARCINOMA OF RECTUM
CARCINOMA OF RECTUM
SECOND COMMENEST VICSERAL
TUMOUR OF THE BODY
 COMMON ABOVE 50 yrs
 YOUNGER AGE – BAD PROGNOSIS
 MALE : FEMALE – 1.2 : 1

AETIOLOGY
GE0GRAPHIC VARIATION
 DIETERY FACTORS
 PRE EXISTING DISEASES
 ADENOMA – CARCINOMA SEQUENCE
 HNPCC
 ALCOHOLISM, CIGARETTE SMOCKING
 PELVIC RADIOTHERAPY
 ACROMEGALY

GEOGRAPHIC VARIATION
DIETERY FACTORS





EXCESS CALORIE
INTAKE
LOW CONTENT OF
UNABSORBABLE
VEGETABLE FIBRE
HIGH CONTENT OF
REFINED
CARBOHYDRATES
INTAKE OF RED MEAT
DECREASED INTAKE
OF PROTECTIVE
MICRONUTRIENTS
PREEXCISTING DISEASES

INFLAMMATORY
BOWELDISEASE
ULCERATIVE COLITIS
1% PER YEAR AFTER 10 yrs
10% RISK AFTER 20 yrs
CROHNS DISEASE
7% RISK AFTER 20 yrs
COLONIC STRICTURESADENO CARCINOMA AT THE SITE
OF FIBROTIC NARROWING
EXCLUDED SEGMENTS
AFTER SEGMENTAL BYPASS
PREEXCISTING DISEASES CONTD.

DIVERTICULAR DISEASE FOR LONG
DURATION
HNPCC
 HEREDITERY
NON POLYPOSIS
COLON CANCERS
4 – 6 % RECTAL MALIGNANCIES
 LYNCH SYNDROME 1
.AUTOSOMAL DOMINANT
.SITE SPECIFIC WITHIN FAMILY
.4% MAY DEVELOP CARCINOMA

HNPCC
LYNCH SYNDROME 2
 AUTOSOMAL DOMINANT
 DELETION OF MISMATCH REPAIR
GENE


COLORECTAL,ENDOMETRIAL,
GASTRIC AND OTHER TYPES OF
CANCERS
ADENOMA – CARCINOMA
SEQUENCE
PROPOSED BY VOGELSTIEN
 ADENOCARCINOMA DEVELOP FROM
PREEXCISTING ADENOMA

ADENOMA – CARCINOMA SEQUENCE CONTD.



HIGH PREVELENCE
ADENOMA HAS HIGH
PREVELENCE OF
CARCINOMA
DISTRIBUTI0N OF
ADENOMA WITHIN THE
RECTUM IS
COMPARABLE TO THAT
OF CARCINOMA
IN CASE OF EARLY
INVASIVE Ca ,
SORROUNDING TISSUE
SHOWS PRECEDING
CHANGES OF
EVOLUTION
ADENOMA –CARCINOMA SEQUENCE CONTD.


PEAK INCIDENCE
OF ADENOMA
ANTEDATES BY
SOME YEARS THE
PEAK OF Ca
RECTUM
RISK OF Ca
DECLINES WITH
REMOVAL OF ALL
IDENTIFIED
ADENOMAS
ADENOMA –CARCINOMA SEQUENCE CONTD.

RISK OF DELOPING CARCIN0OMA
NUMBER
 SIZE – LARGE
 TYPE – VILLOUS COMPONENT

AETIOLOGY CONTD.

ALCOHOLISM

CIGARETTE SMOCKING
MOLECULAR CARCINOGENESIS
 APC/β-CATENIN

PATHWAY
MICROSATELLITE INSTABILITY
MECHANISM
APC/β-CATENIN PATHWAY






LOSS OF APC TUMOUR SUPPRESSOR GENE
LONG ARM OF CHROMOSOME 5
80% OF SPORADIC CASES
ACCUMULATED β-CATENIN TRANSLOCATES
TO THE NUCLEUS
TRANSCRIPTION OF MYC & CYCLIN D
PROMOTE CELLULAR PROLIFERATIONADENOMAS DEVELOP
APC/β-CATENIN PATHWAY CONTD.
 POINT
MUTATION IN K-RAS GENE
EXCESSIVE ACTIVATION OF THIS
GENE
 PROMOTES MITOSIS AND PREVENTS
APOPTOSIS
 50 % OF ALL RECTAL CARCINOMAS

APC/β-CATENIN PATHWAY CONTD.

18 q21 DELETION

CANCER SUPPRESSOR GENE LOST IN 6070 % OF CANCERS
DCC GENE
DPC 4 , SMAD 4
SMD 2
ENCODE FOR TGF-β REGULATOR OF CELL
CYCLE




APC/β-CATENIN PATHWAY CONTD.


LOSS OF TP 53
GENE
IN 70-80% OF
CANCERS
APC/β-CATENIN PATHWAY CONTD.
MICROSATELLITE INSTABILITY







10-15% OF RECTAL CANCERS
NO MORPHOLOGICALLY IDENTIFIABLE CHANGES
LOSS OF DNA REPAIR GENES
REPETITIVE DNA SEQUENCES BECOME UNSTABLE
DURING REPLICATION
TGF-β GENE
BAX GENE
LOSS OF MLH 1GENE
LOSS OF THESE RESULTS IN LOSS OF
APOPTOSIS AND A DYSREGULATED GROWTH
MICROSATELLITE INSTABILITY
PATHOLOGY

MACROSCOPICAL

ANNULAR ENCIRCLING
LESIONS
NAPKIN RING
CONSTRICTIONS
CENTRAL
ULCERATIONS WITH
ELEVATED MARGINS
PAPILLEFEROUS
INFILTRATING TYPE
EARLY LESIONS ARE
SMALL BUTTON LIKE
AREAS OF ELEVATION




MICROSCOPICAL

95% ARE
ADENOCARCINOMAS
MICROSCOPICAL

10% OF THESE ARE
COLLOID
CARCINOMAS
MICROSCOPICAL

5 % ARE
UNDIFFERENTIATED CARCINOMA
SIGNET CELL CARCINOMA
ADENO-SQUAMOS
HISTOLOGICAL
WELLDIFFERENTIATED
 MODERATELY DIFFERENTIATED
 POORLY DIFFERENTIATEDANAPLASTIC

SPREAD OF THE CARCINOMA




LOCAL SPREAD
LYMPHATIC
HAEMATOGENOUS
SPREAD
PERITONEAL
DISSEMINATION
LOCAL SPREAD


CIRCUMFERENTIAL
SORROUNDING
MESORECTUM
LOCAL SPREAD
ANTERIOR IN MALES
PROSTATE,BLADDER&
SEMINAL VESICLES.

IN
FEMALES
UTERUS ,CERVIX,
POSTERIOR WALL OF
VAGINA, POUCH OF
DOUGLAS
LOCAL SPREAD
POSTERIOR
SACRUM&SACRAL PLEXUS
 LATERAL- URETER
 DOWNWARD- ANAPLASTIC
CARCINOMA

LYMPHATIC




ABOVE THE PERITONEAL REFLECTION- TO
THE INFERIOR MESENTERIC NODES
BELOW THIS LEVEL TO ABOUT 1-2cm OF
THE ANAL ORIFICE IS ALSO TO THE
INFERIOR MESENTERIC NODES
IN THE FIELD OF MIDDLE RECTAL ARTERIES
SPREAD ALONG THESE VESSELS
PRE AORTIC,INTERNAL ILLIAC AND SACRAL
LYMPH NODES
HAEMATOGENOUS SPREAD



VIA THE VENOUS
SYSTEM
ANAPLASTIC AND
RAPIDLY GROWING
TUMOURS
SITES
.LIVER- 34%
.LUNGS- 22%
.ADRENALS- 11%
.BRAIN,BONE,OVARY33%
PERITONEAL DISSEMINATION

FOLLOW PENETRATION OF
PERITONEAL CAVITY BY A HIGH LYING
RECTAL CARCINOMA
CLINICAL FEATURES

BLEEDING

EARLIEST, COMMON
SYMPTOM
FRESH BLEEDING
BLOOD STAINING
STOOLS
BLOOD STAINING THE
UNDER CLOTHINGS



CLINICALFEATURES CONTD.

SENSE OF INCOMPLETE DEFECATION
TENESMUS - CANCERS OF LOWER
RECTUM
 SPURIOUS DIARRHOEA
 BLOODY SLIME

CLINICAL FEATURES CONTD.

ALTERATION IN BOWEL HABIT
EARLY MORNING BLOODY DIARRHOEA
 ANNULAR CARCINOMA- INCREASING
CONSTIPATIION
 GROWTH AT AMPULLA OF RECTUMEARLY MORNING DIARRHOEA

CLINICAL FEATURES CONTD.

PAIN
COLICKY TYPE- ADVANCED
GROWTH AT RECTOSIGMOID
JUNCTION
SEVERE – DEEP
CARCINOMATOUS ULCER
ERODES THE PROSTATE OR
BLADDER
PAIN IN BACK OR SCIATICA –
SACRAL PLEXUS
CLINICAL FEATURES CONTD.

WEIGHT LOSS

ANAEMIA
EXAMINATION

ABDOMINAL
EXAMINATION

NORMAL IN EARLY
LESIONS
ADVANCED GROWTHSSIGNS OF LARGE
INTESTINAL
OBSTRUCTION, COLON
LOADED WITH FAECES
MAY BE FELT
LIVER PALPATED FOR
METASTASIS
ASCITES



EXAMINATION CONTD.




PER RECTAL
EXAMINATION
EARLY CASES –
PLATEAU OR A
NODULE WITH AN
INDURATED BASE
CENTRE ULCERATION
– SHALLOW
DEPRESSION WITH
EVERTED RAISED
EDGES
FINGER SMEARED
WITH BLOOD OR
MUCOPURELENT
MATERIAL TINGED
WITH BLOOD
PER RECTAL EXAMINATION

CARCINOMA OF LOWER PART
AFFECTED LYMPH NODES MAY BE
FELT
EXAMINATION CONTD.

IN FEMALES VAGINAL EXAMINATION
SHOULD BE DONE
SUMMARY
STAGING OF CANCER

DUKES STAGING

A- GROWTH
LIMITED TO THE
RECTAL WALL
STAGING

B- THE GROWTH
EXTENDED TO THE
EXTRA RECTAL
TISSUE BUT NO
METASTASIS TO
REGIONAL LYMPH
NODES
STAGING

C- THERE ARE
SECONDARY
DEPOSITS IN THE
REGIONAL
LYMPHNODES
.C 1- LOCAL
PARARECTAL
LYMPHNODES ALONE
.C 2- NODES
ACCOMPANYING THE
SUPPLYING VESSELS
STAGING

D- PRESENCE OF
WIDE SPREAD
METASTASIS
STAGING
 ASTER
COLLER
STAGING

A- MUCOSA ONLY
ASTER-COLLER STAGING

B1- SUBMUCOSA
INVOLVED
ASTER-COLLER STAGING

B2- MUSCULARIS
INVOLVED
ASTER-COLLER STAGING

C1- INVOLVEMENT
OF MUSCULARIS
AND NODES
ASTER-COLLER STAGING

C2- INVOLVEMENT
OF SEROSA AND
NODES
ASTER-COLLER STAGING

D- DISTANT
METASTASIS
TNM STAGING






Tx – PRIMARY TUMOUR CANNOT BE
ASSESSED
Tis – CONFINED TO THE MUCOSA
T 1 - EXTEND UPTO SUBMUCOSA
T 2 – EXTENDS INTO THE MUSCULARIS
PROPRIA
T 3 – EXTENDS IN TO THE SUB SEROSA BUT
NOT TO ADJACENT STRUCTURES
T 4 – INVOLVES ADJACENT STRUCTURES
TNM STAGING
Nx – CANNOT BE ASSESSED
 N O – NO LYMPH NODE METS.
 N 1 – CANCER CELLS FOUND IN 1 TO 3
NEARBY NODES
 N 2 – CANCER CELLS IN 4 OR MORE
NODES
 N 3 – CANCER CELLS IN NODES
ALONG NAMED VESSELS

TNM STAGING
Mx – DISTANT METS. CANNOT BE
ASSESSED
 M 0 – NO DISTANT METS.
 M 1 – DISTANT METS. PRESENT
