Slide 1

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 2

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 3

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 4

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 5

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 6

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 7

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 8

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 9

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 10

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 11

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 12

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 13

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 14

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 15

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 16

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 17

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 18

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 19

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 20

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 21

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 22

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 23

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 24

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 25

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 26

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 27

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 28

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 29

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 30

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 31

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 32

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 33

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 34

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 35

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 36

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 37

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 38

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 39

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 40

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 41

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 42

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 43

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 44

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 45

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 46

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 47

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 48

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 49

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma


Slide 50

RECTAL
PROLAPSE

Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse (procidentia) when the
mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.

Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of age
and elderly people. More common in female
than male.

In children:

Aetiology

the predisposing causes are:-

 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.

In adult:

the predisposing causes depend
on type of the prolapse.

Partial prolapse





Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.

Complete prolapse

is generally regarded
as sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
from pregnancy, obesity.

 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to

incontinence.

Examining for rectal prolapse
 Most NOT evident in lying position as rest
 Ask patient to bear down – most still not
evident
 Need to examine after straining on the
toilet for 1-2 minutes – lean forward –
observe from behind – estimate in
centimetres - ? full thickness
circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination
 Resting tone (low = IAS problem)
 Squeeze pressure (low = EAS problem)
 Co-ordination
 Sensation (? Neurological dysfunction)
 Assessment stops here for MOST patients

Radiologic
examination

Complications of rectal prolapse:






Irreducibility (table sugar!)
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene

the prolapse tends
to disappear spontaneously by the age
of 5 years. So conservative measures
are sufficient.

Prolapse in children:

 Conservative treatment: constipation
and straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.

 Perirectal injection of alcohol/phenol
may be used to fix the lax mucosa to
underlying tissue.

Partial prolapse:

 Injections of 5% phenol in oil in
submucosa.
10-15ml total.
 Electrical stimulation with sphincteric
exercises.

Complete prolapse:

Surgery always necessary, none are
ideal.







Thiersch’s operation
Rectopexy
Rectosigmoidectomy
Ivalon sponge rectopexy
Ripstein operation
Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths*
Lung and bronchus 31%

15% Breast

Prostate

10%

10% Colon and rectum

Colon and rectum

10%

 6% Ovary

Pancreas

5%

 6% Pancreas

Leukemia

4%

 4% Leukemia

Esophagus

4%

 3% Non-Hodgkin
lymphoma

Liver and intrahepatic 3%
bile duct
Non-Hodgkin
Lymphoma

3%

 3% Uterine corpus
 2% Multiple myeloma

Urinary bladder

3%

 2% Brain/ONS

Kidney

3%

22% All other sites

All other sites

24%

27% Lung and bronchus

Decreasing mortality of CRC
5-year Survival
1960-70

1980-90

Colon cancer

40-45%

60%

Rectal cancer

35-40%

58%

Anatomic Location of CRC
 Cecum

14 %

 Ascending colon

10 %

 Transverse colon

12 %

 Descending colon

7 %

 Sigmoid colon

25 %

 Rectosigmoid junct.9 %
 Rectum

23 %

70%

Epidemiology
 Increasing Incidence of CRC

 Incidence 30-40 / 100000 / year
 >70 y. of age 300 / 100000 / year
 third most common malignant disease
 second most common cause of cancer
death

Epidemiology
 70% of CRC are resectable at
diagnosis
 Mortality has decreased

Ethiology
 Diet: fibers, vit E, vit C
 Polips (adenomatous)
 IBD – more then 10 years of progression
 Smoking
 Cyclooxigenase inhibitors
 Genetic cancer

WHO Classification of CRC










Adenocarcinoma in situ / severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma

Anal Cancer
Anal cancer

Middle rectal cancer

Symptoms
Bleeding per anum
Sensation of incomplete bladder empting
Tenesmus
Abdominal pain
Palpable rectal tumor

 Pacienţi în stadii avansate: pierdere ponderală,
hepatomegalie, icter, anemie.
 Examenul fizic include: aprecierea stării generale, a
prezenţei adenopatiilor periferice şi a hepatomegaliei.

!!! RECTAL EXAMINATION

Investigations
 Staging:
- Recto- and colonoscopy
- Barium enema
- CT
- MRI
- EUS

 RECTOSCOPY
 COLONOSCOPY

+ BIOPSY

Indications
- Suggestive

images on barium enema
- Suggestive symptoms of colonic cancer
- Screening
-After polipectomy

EUS

 Accuracy 81-93%
 More difficult to interpret
Limited value in evaluation of LN
invasion

Requires contact with tumor and a
lumen in which to be inserted.

MRI – standard of care

Tumor markers
 CEA
 CA 19-9
– Dynamic may be significant for recurrence

Clinical Staging of CRC
TNM
stage

Primary
tumor

Lymph-node
metastasis

Distant
metastasis

Dukes
stage

Astler-Coller
modified
Dukes stage

Stage 0

Tis

N0

M0

A

A

Stage I

T1

N0

M0

A

A1

T2

N0

M0

A

B1

T3

N0

M0

B

B2

T4

N0

M0

B

B2

A

any T

N1

M0

C

C1/C2

B

any T

N2, N3

M0

C

C1/C2

Stage IV

any T

any N

M1

D

D

Stage II
Stage III

TNM Classification
Tis

T1

T2 T3

T4

Mucosa
Muscularis mucosae
Submucosa

Muscularis propria

Subserosa
Serosa
Extension
to an adjacent
organ

Stage and Prognosis
Stage

5-year Survival (%)

0,1

Tis,T1;No;Mo

> 90

I
II

T2;No;Mo
T3-4;No;Mo

80-85
70-75

III

T2;N1-3;Mo

70-75

III
III

T3;N1-3;Mo
T4;N1-2;Mo

50-65
25-45

IV

M1

<3

Purpose of Radio(chemo)therapy
in Rectal Cancer
 To lower local failure rates and improve survival in
resectable cancers
 to allow surgery in primarly inextirpable cancers
 to facilitate a sphincter-preserving procedure
 to cure patients without surgery: very small
cancer or very high surgical risk

Rectal Cancer
 Surgery is the mainstay of treatment of
RC
 After surgical resection, local failure is
common
 Local recurrence after conventional
surgery:
– 15%-45% (average of 28%)
 Radiotherapy significantly reduces the
number of local recurrences

Radiotherapy in the management of RC
– Preoperative RT (30+Gy): 57%

relative reduction of local failure
– Postoperative RT (35+Gy): 33%
relative reduction

ESMO Recommendations
 Resectable cases
– Surgical procedure: TME
– Preoperative RT: recommended
– Postoperative chemoradiotherapy: T3,4 or N+

 Non-resectable cases: local recurrences
– Preoperative RT with or without CT

Predicting risk of recurrence in RC
 Surgery-related

 Tumor-related

-Low anterior resection

-Anatomic location

-Excision of the mesorectum

-Histologic type

-Extent of lymphadenectomy

-Tumor grade

-postoperative anastomotic

-Pathologic stage

leakage
-Tumor perforation

-radial resection margin
-neural, venous, lymphatic
invasion

Total Mesorectal Excision (TME)
 Local recurrence rates after surgical
resection of RC have decreased from about
30% to < 10%
– 1. Radio(chemo)therapy
– 2. Importance of circumferential margin (TME)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection
MILES

Anterior resection and very low
anterior resection

Follow up!!

Epidermoid carcinoma
 75% of all malignancies of the area
– Early: verucous, nodular lesion
– Late: ulcerated, indurated, nodular nmass

 Palpable inguinal nodes
 May invade the rectum: false impression of
rectal carcinoma
 Lymphatic spread: like rectal + inguinal
nodes

Treatment
 External radiation + concomitant
chemotherapy
 Radical surgery in case of failure

Malignant melanoma
 Horrible prognosis
 Dark mass protruding from the anus
 50% pigmented
 Lymph node MTS early
 Treatment - not clear advantage of any
alternative

Bowen’s disease:
Squamous cell carcinoma in situ
 Like all other places of skin
 Plaque-like eczematoid lesion + pruritus
 Biopsy-carcioma in situ + hyperkeratosis
and giant cells
 Therapy: local excision with safety
margins

Basal cell carcinoma
 Ulcerating tumor (uncommon)
 “Rodent ulcer” like every other place of
skin exposed
 Doesn’t spread distantly
 Local excision

Paget’s disease
 Rare condition
 Pale plaquelike condition with induration +
nodular mass (not always)
 Nodular mass= coloid carcinoma from
glands or other skin appendages
 Local excision (without mass)
 Radical surgery + chemo + RT for coloid
carcinoma