Download Antar Labeeb EL Sheikh Aly Prof. Dr. / Ibrahim Mohamed El Ghazawy

Recent Trends
In
Management of Colorectal
Carcinoma
An essay
Submitted for Partial Fulfillment of Master Degree in
General surgery
Presented by
Antar Labeeb EL Sheikh Aly
M. B., B. Ch.
Under supervision of
Prof. Dr. / Ibrahim Mohamed
El Ghazawy
Professor of General Surgery
Faculty of medicine-Ain Shams Universty
Dr. /Mohamed Mahfouz Mohamed
Lecturer of General Surgery
Faculty of medicine – Ain Shams University
Faculty of Medicine
Ain Shams University
2009
Acknowledgement
Thanks to GOD who have lightened my path to become
a humble student of a noble profession, and granted me the
ability to accomplish this work.
I would like to express my deepest gratitude and
profound respect to Prof. Dr. Ibrahim Mohamed El Ghazawy,
Professor doctor of general surgery, Faculty of medicine - Ain
shams university, for his kind continuous encouragement,
cooperation and valuable suggestions. It was a great honor to
work under his guidance and supervision.
I am also deeply grateful and would like to express my
sincere thanks to Dr. Mohamed Mahfouz Mohamed, Lecturer
of general surgery, Faculty of medicine - Ain shams university,
for his great help and his efforts that made this work come to
light.
Lastly but not least ,my thanks to my mother, my
brothers and my wife whom suffer a lot to put me in a such
position.
Antar Labeeb
2010
‫ﺍﻻﺗﺠﺎﻫﺎﺕ ﺍﻟﺤﺪﻳﺜﺔ‬
‫ﻓﻰ‬
‫ﻣﻌﺎﻟﺠﺔ ﺳﺮﻁﺎﻥ ﺍﻟﻘﻮﻟﻮﻥ ﻭ ﺍﻟﻤﺴﺘﻘﻴﻢ‬
‫ﺭﺳﺎﻟﺔ‬
‫ﺘوطﺌﻪ ﻟﻠﺤﺼوﻝ ﻋﻠﻰ درﺠﺔ اﻟﻤﺎﺠﺴﺘﻴر ﻓﻲ اﻟﺠراﺤﺔ اﻟﻌﺎﻤﺔ‬
‫ﻣﻘﺩﻣﺔ ﻣﻥ‬
‫اﻟطﺒﻴب ‪ /‬ﻋﻨﺘر ﻟﺒﻴب اﻟﺸﻴﺦ ﻋﻠﻰ‬
‫ﺗﺣﺕ ﺇﺷﺭﺍﻑ‬
‫ﺍﻷﺳﺘﺎﺫ ﺍﻟﺪﻛﺘﻮﺭ ‪ /‬ﺍﺑﺮﺍﻫﻴﻢ ﻣﺤﻤﺪ ﺍﻟﻐﺰﺍﻭﻯ‬
‫أﺴﺘﺎذ اﻟﺠراﺤﺔ اﻟﻌﺎﻤﺔ‬
‫كﻠ�ﺔ اﻟطب – ﺠﺎﻤﻌﺔ ﻋﻴن ﺸﻤس‬
‫ﺍﻟﺪﻛﺘﻮﺭ‪ /‬ﻣﺤﻤﺪ ﻣﺤﻔﻮﻅ ﻣﺤﻤﺪ‬
‫ﻤدرس اﻟﺠراﺤﺔ اﻟﻌﺎﻤﺔ‬
‫كﻠ�ﺔ اﻟطب – ﺠﺎﻤﻌﺔ ﻋﻴن ﺸﻤس‬
‫ﻛﻠﻴﺔ ﺍﻟﻄﺐ‬
‫ﺟﺎﻣﻌﺔ ﻋﻴﻦ ﺷﻤﺲ‬
‫‪۲۰۰۹‬‬
Abbreviations
Abbreviation
Name
AJCC
American Joint Committee on Cancer
ANP
Autonomic nerve preserving
APC
APR
CEA
CRT
CT
ERUS
FOBT
FS
adenomatous polyposis coli
Abdominoperineal resection
Carcinoembryonic antigen
Chemoradiation Therapy
computer-assisted tomography
Endorectal ultrasound
Fecal occult blood test
Flexible sigmoidscopy
FU
HNPCC
Fluorouracil
Hereditary nonpolyposis colorectal
cancer
Intraoperative radiation therapy
low anterior resection
magnetic resonance imaging
Transanal endoscopic microsurgery
Total mesorectal excision
IORT
LAR
MRI
TEM
TME
List of Contents
List of Contents
Page
Acknowledgement .................................................................... I
List of Contents ...................................................................... II
List of Abbreviations ............................................................. III
List of Tables ......................................................................... IV
List of Figures ..........................................................................V
Introduction ............................................................................ 1
Aim of the work ....................................................................... 4
Review of Literature
Embryology & Anatomy of the colon and rectum.. ........... 5
Pathology and Pathogenesis of colorectal carcinoma ...... 31
Prognostic Factors……..………………………………....49
Diagnosis of colorectal carcinoma ................................... 57
Screening of colorectal carcinoma ................................... 73
Management of colorectal carcinoma .............................. 78
Results and survival of patient……………………….…119
Summary ............................................................................ 125
References .......................................................................... 129
Arabic Summary ………………………………………….
II
List of Tables
List of Tables
No.
Comment
Page
1
Primary Tumor(T):TNM classification
42
2
Regional Lymph Nodes (N): TNM
classification
43
3
Distant Metastasis (M): TNM classification
43
4
Anatomic Stage/Prognostic Groups
44
5
Screening Guidelines for Colorectal Cancer
75
6
Advantages and Disadvantages of Screening Modalities
for Asymptomatic Individuals
76
7
SURGICAL OPTIONS FOR COLORECTAL
CANCER.
81
8
Standard Resections of the Colon
86
9
Characteristics of Tumors Amenable to Local
Excision.
94
10
TNM Staging of Colorectal Carcinoma and 5Year Survival
122
11
Staging Systems for Colon and Rectal Cancer,
A.JCC
122
IV
List of Figures
List of Figures
NO
Comment
Page
1
Anatomy of colon
7
2
Right & Left Colic flexures
13
3
Structures posterior to sigmoid colon
16
4
The marginal artery
22
5
The arterial supply of the rectum.
25
6
The lymph vessels and nodes during the large
intestine
29
7
Gross appearance of a colectomy specimen
40
8
Schematic discreption of the staging system
with respect to the depth of invasion
45
9
Barium enema of an invasive sigmoid
carcinoma, feature of apple core appearance
present
66
10
CT Colonography
69
11
Endorectal ultrasonography showing a T3
rectal carcinoma
71
12
Kraske approach to a posterior lesion
96
13
Rectal cancer.
98
V
Introduction
INTRODUCTION
Colorectal carcinoma is the fourth most common internal
malignancy; it is second only to carcinoma of the lung as a
cause of carcinoma death. (Jemal et al., 2005).
The large intestine is divided into five segments. From
proximal to distal, these segments are: right colon, transverse
colon, left colon, sigmoid colon, and rectum. (Rolandelli &
Roslyn , 2001).
The majority of colorectal cancers are in the rectum (38%),
the sigmoid colon (21%) and the rectosigmoid junction (7%).
The descending colon (4%) and the transverse colon (5.5%) are
less common sites of tumor formation, whereas in the
ascending colon (5%) and the caecum (12%) the incidence is
slightly higher. The incidence in the appendix is about 0.5%; in
the hepatic flexure is 2%; in the splenic flexure is 3%; and in
the anus is 2 %. (Mortensen & Jones, 2004)
The etiology of colorectal cancer can be seen as an
interaction between genetic factors but the basic underlying
cause appears to be an accumulation of genetic mutation, which
leads to the development of benign adenomas with subsequent
-۱-
Introduction
transformation to invasive malignancy (the adenocarcinoma
sequence). (Cuschieri & Robert, 2001)
Both ulcerative colitis and Crohn's disease carry an
increased risk of developing colorectal cancer. Established risk
factors for cancer among patients with inflammatory bowel
disease (IBD) include the younger age at diagnosis, greater
extent, and duration of disease, increased severity of
inflammation and family history of colorectal cancer. Recent
evidence suggests that current medical therapies and surgical
techniques for inflammatory bowel disease may be reducing the
incidence of colorectal cancer. (Zisman & Rubine, 2008).
Most patients with colorectal polyps and early colorectal
cancer are asymptomatic. Patients with advanced cancers may
present with abdominal symptoms such as pain, persistent
changes in bowel habits or bleeding from the rectum. General
symptoms and signs can include loss of appetite, weight loss,
nausea and vomiting, or unexplained iron deficiency anemia.
General examination may reveal signs of advanced disease such
as abdominal mass. The draft National Health and Medical
Research Council guidelines for the prevention, early detection
and management of colorectal cancer recommend a thorough
-۲-
Introduction
examination of the anus, rectum and colon for all symptomatic
patients. The use of sigmoidoscopy at the time of the digital
rectal examination is recommended to detect anal abnormalities
such as hemorrhoids and fissures at the initial examination. The
draft guidelines recommend colonoscopy as the most accurate
investigation for assessing the colon and rectum. (Alfered &
Arden , 2006).
Surgical options for colorectal cancer depend on the
location of the primary tumor. Before surgical resection,
evaluation for sites of metastatic disease is important. A careful
physical examination determines the presence of hepatomegaly,
ascites, or adenopathy (Alfered & Arden , 2006).
In particular, colon cancer can often be prevented entirely
by removing polyps before they become malignant. Therefore,
current guidelines recommend screening of adults who are at
average risk for colorectal cancer (Smith et al, 2005)
-۳-
Introduction
AIM OF THE WORK
The aim of this essay is to identify the new
modalities and recent updates in diagnosis and
treatment of colorectal carcinoma.
Introduction
CHAPTER 1:
EMBRYOLOGY & SURGICAL
ANATOMY
-٥-
Chapter 1:Anatomy
I-EMBRYOLOGY
The colon is produced by both the midgut and the hindgut.
The midgut is responsible for the genesis of the cecum, the
ascending colon, and the proximal ⅔ of the transverse colon.
The hindgut is responsible for the remainder of the colon, the
rectum, and the proximal part of the anus. To be more specific,
the distal ⅓ of the transverse colon, the descending colon, the
sigmoid colon, the rectum and the proximal part of the anal
canal develop from the hindgut. (Skandalakis et al ,2004)
II-Surgical Anatomy of The Colon & Rectum
The colon extends from the end of the ileum to the rectum.
The cecum, ascending colon, hepatic flexure, and proximal
transverse colon comprise the right colon. The distal transverse
colon, splenic flexure, descending colon, sigmoid colon, and
rectosigmoid comprise the left colon (Yeatman & Bland,1989 )
(Fig-1).
-٦-
Chapter 1:Anatomy
(Fig-1): Anatomy of the colon (Yeatman and Bland , 1989).
The ascending and descending portions are fixed in the
retroperitoneal space; the transverse colon and sigmoid colon
are suspended in the peritoneal cavity by their mesocolons. The
caliber of the lumen is greatest at the cecum and diminishes
distally (George et al, 2003).
Anatomic differences between the small and large
intestines include position, caliber, degree of fixation, and, in
the colon, the presence of three distinct characteristics: the
taeniae coli, the haustra, and the appendices epiploicae. The
three taeniae coli, anterior (taenia libera), posteromedial (taenia
mesocolica), and posterolateral (taenia omentalis), represent
-۷-
Chapter 1:Anatomy
bands of the outer longitudinal coat of muscle that traverse the
colon from the base of the appendix to the rectosigmoid
junction, where they merge. The muscular longitudinal layer is
actually a complete coat around the colon, although it is
considerably thicker at the taeniae (Fraser et al, 1981).
The haustra are separated by the plicae semilunares or
crescentic folds of the bowel wall, which give the colon its
characteristic radiographic appearance when filled with air or
barium. The appendices epiploicae are small appendages of fat
that protrude from the serosal aspect of the colon (Marcio,
2005).
Parts of large intestine
1-Cecum and appendix:
The cecum is the saccular commencement of the colon. It is
located in the right iliac fossa, where it lies on the iliacus
muscle cranial to the lateral half of the inguinal ligament. At
times, it may cross the pelvic brim to lie in the true pelvis.
Anteriorly, it usually is in contact with the anterior abdominal
wall. Superiorly, it is continuous with the ascending colon, and
at some point along its medial border, the ileum enters it at the
ileocecal ostium. This opening is surrounded by two flaps that
protrude into the lumen and contain circular muscle derived
-۸-