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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
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Oncologic resections.
Emergency
Right-sided tumor: definitive surgical treatment as above, primary ileocolonic anastomosis.
Left-sided tumor:
– Resection with on-table lavage and primary anastomosis.
– Stent placement for decompression of LBO bridging to (semi-)elective resection with primary anastomosis.
– More extensive resection to allow ileocolonic anastomosis: subtotal colectomy with primary ileosigmoidal or
ileorectal anastomosis.
– Two-stage procedure: (a) Hartmann type resection (
elective Hartmann reversal), (b) primary anastomosis
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with proximal diversion ( elective ostomy takedown), (c) proximal diversion ( elective resection and ostomy
takedown)
– Three-stage procedure (largely abandoned): proximal diversion (transverse colostomy)
elective resection
and anastomosis (with maintained diversion)
elective ostomy takedown.
Palliation
Segmental wedge resection.
Proximal diversion only.
Internal bypassing of obstructed segment.
Stenting.
Outcome
Five-year survival: all stages 65%; stage I 90–93%, stage II 80–85%, stage III 60–65%, stage IV 5–8%. Prognostic
factors: see Table 4–5.
Table 4–5. Prognostic Factors for Resected Colorectal Cancer.
Category Parameter
Stage Tumor penetration through the bowel wall (T4 tumor stage)
Regional lymph node involvement (N1, N2)
4 positive regional lymph nodes (N2)
Surgeon/pathologist Tumor involvement of surgical margins
12 lymph nodes removed (surgeon) or examined/reported (pathologist)
Tumor complication Bowel obstruction
Bowel perforation (particularly if perforation at tumor site)
Histopathology Poorly differentiated histology
Lymphovascular invasion
Perineural invasion
Marker Preoperative CEA > 5.0
Microsatellite-stable tumors
Specific chromosomal deletions (eg, chromosome18q loss of heterozygosity)
CEA, carcinoembryonic antigen.
Mortality of elective oncologic resection: 1–3%.
Rate of permanent stoma: minimal in specialized colorectal centers, higher in nonspecialized units: 20–40% of "temporary"
stomas (eg, Hartmann resection) never reversed.
Complications: bleeding, wound infections (5–10% elective, 15–40% fecal peritonitis), anastomotic leak (1–2%), abscess
formation, enterocutaneous fistula, splenic injury, pancreas injury, ureteral injury.
Follow-Up
Emergency intervention: planning of necessary subsequent surgeries after adequate physical/nutritional recovery.
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Adjuvant chemotherapy: for all stage III tumors and for selected stage II tumors.
Palliative chemotherapy: for stage IV tumors.
Oncologic follow-up: colonoscopy after 1 year, subsequently depending on findings. Clinical examination and blood work
(including CEA) every 3–6 months. Imaging (CT abdomen/pelvis, chest x-ray/-CT annually).
Surgical reintervention:
Metastatic disease: sandwich approach (resection of primary tumor, chemotherapy, resection of metastases).
Recurrent disease: re-resection if localized.
Carcinomatosis: one exploration often justified, subsequently individualized.
Cross-Reference
Colorectal cancer screening/surveillance (Ch. 2)
Colonoscopy (Ch. 2)
Carcinogenesis (Ch. 3)
Polyps (211.3) (Ch. 4)
Polyposis syndromes (211.3, 235.2) (Ch. 4)
Colorectal cancer—rectal cancer (154.1) (Ch. 4)
Colorectal cancer—liver metastases (197.7) (Ch. 4)
Colorectal cancer—lung metastases (197.3) (Ch. 4)
Right hemicolectomy (open) (Ch. 5)
(Sub-)total colectomy, ileorectal anastomosis (open) (Ch. 5)
Sigmoid resection (open, anastomosis vs Hartmann) (Ch. 5)
Colonoscopic stent placement (Ch. 5)
On-table lavage for primary anastomosis in LBO (Ch. 5)
Chemoprevention of colorectal cancer (Ch. 6)
Chemotherapy protocols—curative intent (colorectal cancer) (Ch. 6)
Follow-up for colorectal cancer (Ch. 6)
CEA monitoring for colorectal cancer (Ch. 6)
Amsterdam II criteria for HNPCC (App. 2)
Bethesda criteria for MSI testing (App. 2)
Tumor staging in TNM system (App. 2)
COLORECTAL CANCER—RECTAL CANCER (154.1)
Overview
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Colon and rectal cancer share the majority of baseline features (eg, etiopathogenesis, symptoms, pathology). However,
rectal cancer—unlike colon cancer—is more complex and carries an increased risk of local recurrences. Higher complexity is
related to intricate rectal anatomy with bony pelvic confinement, proximity to other organs, proximity to sphincter and pelvic
floor muscles; various levels of blood supply; multidirectional lymphovascular drainage within a defined fascial compartment.
Treatment of rectal cancer has therefore evolved from a surgery-only to a multi-modality approach. While spectrum of
treatment options continue to expand (radical vs local, sphincter-preserving vs APR, open vs laparoscopic, etc), the
surgeon's experience and surgical technique as well as pretreatment assessment of tumor extension are of utmost
importance for outcome.
Except for very early stages of rectal cancer, preoperative or postoperative radiotherapy, generally in combination with
chemotherapy, is indicated per NCI guidelines to improve local tumor control, even though overall survival is not necessarily
prolonged. Quality-of-life issues (eg, sphincter preservation, ostomy, urogenital function) are much more relevant in the
decision-making process for rectal than for colon cancer.
Definition of proximal beginning of rectum:
1. Anatomic/intraoperative: confluence of tenia.
2. Endoscopic (most relevant because of neoadjuvant treatment): 15 cm above anal verge as measured by rigid
sigmoidoscope.
Obsolete definitions (because too variable): peritoneal reflection, sacral promontory.
Epidemiology
Annual incidence in US: 42,000 new rectal cancers, 15,000 rectal cancer deaths. Increasing incidence after age 50, peak in
the 7th decade, but 5–10% of patients are younger than 50 years.
Symptoms
Asymptomatic detection during routine exam.
Bleeding (most common), change in bowel habits (frequency, consistency, diameter), constipation, abdominal pain,
tenesmus. Rectal/pelvic pain is uncommon and an ominous sign.
Complications: massive bleeding, obstruction, invasion of other organs, perforation, formation of fistula (rectovaginal,
perirectal, rectourinary).
Differential Diagnosis
Anal cancer: based on location, most commonly squamous cell cancer (caveat: adenocarcinoma arising from anal canal
glands).
Adenocarcinoma of other primary origin: prostate cancer, ovarian and endometrial cancer. Tumor (also adenocarcinoma) may
invade through rectal wall
overall presentation, histology, and immunohistochemistry needed for differentiation.
Rare anorectal tumors: carcinoid, lymphoma, GIST, melanoma, presacral mass (chordoma, teratoma, etc).
Premalignant polyps: particularly villous polyps may involve large and circumferential area.
Benign conditions: rectal prolapse/intussusception, solitary rectal ulcer syndrome, endometriosis, inflammatory conditions
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(radiation proctitis, IBD, etc).
Pathology
MACROSCOPIC
Polypoid friable mass vs ulcerating crater with elevated edges, variable size, and involvement of the circumference.
Pattern of metastatic dissemination: (1) lymphovascular lymph nodes: perirectal (mesorectum), lateral pelvic
sidewall, retroperitoneal; (2) hematogenous
portal system liver metastases lung metastases. (3) hematogenous
vena cava lung metastases.
MICROSCOPIC
Adenocarcinoma in the overwhelming majority of cases (> 95%). Rare subforms: mucinous or signet ring cell
carcinoma, adenosquamous carcinoma. Small cell carcinoma (1%): dismal prognosis!
Intramucosal carcinoma (T
is
) = carcinoma in situ = high-grade dysplasia: cancer not penetrating through muscularis
mucosa. Invasive cancer: invasion of muscularis propria and beyond.
Negative prognostic growth patterns: lymphovascular invasion, perineural invasion, extranodal tumor deposits.
Minimum of 12–15 lymph nodes necessary for adequate oncologic staging of the specimen, but decreased number
after radiation.
Additional secondary postchemoradiation changes include tissue fibrosis, residual mucinous lakes, endangitis
obliterans of arterioles.
Evaluation
REQUIRED MINIMAL STANDARD
History: specific symptoms—bleeding, constipation, change in bowel habits, pain, weight loss, urinary/vaginal symptoms,
preexisting sexual or anal sphincter dysfunction; family history; comorbidities.
Clinical examination:
1. Digital rectal exam:
a. Exact description of tumor location:
(1) Radial: anterior, posterior, lateral, or circumferential.
(2) Axial: distance of most distal tumor edge from anal verge and from puborectalis muscle, relation to
level of the prostate, proximal end reachable? For very distal tumors: assessment of distance to
intersphincteric groove, assessment of baseline sphincter strength.
b. Clinical impression of stage: mobile, tethered, fixed tumor, nearly obstructing.
2. Rigid sigmoidoscopy/proctoscopy: sufficient to establish diagnosis (and perform biopsy), should be repeated prior to
elective surgery, particularly after neoadjuvant treatment
assessment of distance from anal verge to bottom of
tumor, location, circumferential extent, length and patency of tumor-involved segment, condition of noninvolved
rectum.
3. Abdominal exam: habitus, organomegaly, etc.
4. Inguinal lymph node palpation: mandatory for very low rectal and anal tumors; ominous sign if found to be
enlarged.
Biopsy: histologic confirmation of clinical suspicion, basis for treatment planning.
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Full colonic evaluation (preferably colonoscopy) mandatory prior to elective surgery: rule out synchronous cancers or
polyps, rule out underlying colonic disease.
Evaluation of local extension and tumor staging:
Local evaluation:
– ERUS: assessment of T stage (80–95% accuracy), N stage (65–81% accuracy), not reliable for
circumferential/lateral margins (fascia propria of the rectum).
– MRI: evaluation of circumferential margins (60–90% accuracy), but less reliable for T stage (75–85%).
Systemic evaluation:
– CT scan of abdomen/pelvis: evaluation of distant metastases (liver, retroperitoneal lymph nodes), evidence of
urinary tract involvement (hydronephrosis/-ureter? blurring of rectoprostatic plane?).
– Chest x-ray (or chest CT): metastatic disease, operability?
ADDITIONAL TESTS (OPTIONAL)
Tumor marker: CEA.
Blood work: anemia, liver function (albumin, PTT, PT), kidney function.
PET (?): if suspicion of distant tumor manifestations.
CT scan of chest: not routinely, required by some study protocols.
Urologic exam, GYN exam: if specific symptoms or findings.
Classification
Based on location: low (0–5 cm), mid (5–10 cm), or upper rectum (10–15 cm).
Based on stage: localized, locally advanced (size, infiltration of other structures), metastatic.
Based on TNM stage.
Early favorable tumor: uT1-2N0, < 40% of circumference involved, < 3–4 cm, well-differentiated adenocarcinoma,
absence of lymphovascular or peri-neural invasion.
Nonoperative Treatment
Inoperable patients due to comorbidities or metastatic liver replacement > 50%.
Inoperable/incurable due to extent of local tumor
symptom control.
Neoadjuvant chemoradiation (combined modality treatment) to achieve local tumor control:
2500 cGy short-term radiation over 1 week, followed by radical surgery after 1 week.
5040 cGy radiation over 6 weeks, followed by radical surgery after 6–12 week interval.
15–25% complete clinical and endosonographic response: while surgery is still considered standard of care,
nonoperative/expectant approach to be offered to patient
clinical, endoscopic, and endosonographic reevaluation
within short intervals, salvage surgery if evidence of recurrence.
Small cell cancer: systemic disease, dismal prognosis
chemoradiation, but most commonly no role for surgery.
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Operative Treatment
INDICATIONS
Any rectal cancer (unless prohibitive contraindications), with/without neoadjuvant chemoradiation.
Even in presence of systemic tumor manifestations, achieving local tumor control still desirable, potentially later
metastasectomy in curative intent possible.
OPERATIVE APPROACH
Curative Intent (Local Tumor Control, Overall Intent to Cure)
Local excision: option for early and favorable tumors transanal local excision or transanal microscopic excision
(TEM).
Radical excision (oncologic resection with lymphadenectomy): total/partial mesorectal excision (TME),
abdominoperineal resection (APR) vs sphincter-salvaging operation with primary anastomosis (one/two stage).
Pelvic exenteration.
Rare approaches: Kraske (posterior proctotomy), York-Mason (posterior anoproctotomy).
Emergency
Temporizing measures: stent placement vs proximal diversion.
Definitive surgical treatment: as above for elective, or Hartmann-type resection.
Palliation
Proximal diversion.
Stenting.
Local destruction: electrocoagulation, laser, endocavitary radiation therapy.
Outcome
Benchmark of radical surgical technique: local recurrence rate < 10% without neo-/adjuvant treatment.
Local recurrence rates for transanal excision: 20–30%.
Five-year survival: all stages 65%, stages I 90–93%, stage II 80–85%, stage III 60–65%, stage IV 5–8%.
Mortality of elective oncologic resection: 3–5%.
Rate of permanent stoma: 5% in specialized colorectal centers, 20–25% in nonspecialized units.
Complications: bleeding 4–10% (presacral veins), wound infections 5–10%, leak with/without pelvic sepsis 5–15%
(particularly after neoadjuvant radiation), abscess formation, fistula (perirectal, rectovaginal), ileostomy-related
complications, SBO. Sexual and urinary dysfunction.
Follow-Up
Emergency surgery: planning of subsequent surgeries after complete physical/nutritional recovery, and potential
chemoradiation treatment.
Elective surgery:
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Ileostomy takedown > 6 weeks if clinically and radiologically no evidence for leak, often delayed until full course of
adjuvant chemotherapy delivered (eg, 6 months).
Local excision: final pathology T1 surgery only, T2 chemoradiation or radical surgery, T3 radical surgery.
Long-term: oncologic follow-up, possible complemented with ERUS. Management of recurrent rectal cancer.
Cross-Reference
Colorectal cancer screening/surveillance (Ch. 2)
Colonoscopy (Ch. 2)
Carcinogenesis (Ch. 3)
Polyps (211.3) (Ch. 4)
Polyposis syndromes (211.3, 235.2) (Ch. 4)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Recurrent rectal cancer (789.3, 154.1) (Ch. 4)
Colorectal cancer—liver metastases (197.7) (Ch. 4)
Colorectal cancer—lung metastases (197.3) (Ch. 4)
Low anterior resection (LAR)/total mesorectal excision (TME) (Ch. 5)
Transanal excision (polyp, cancer) (Ch. 5)
Transanal endoscopic microsurgery (TEM) (Ch. 5)
Chemoprevention of colorectal cancer (Ch. 6)
Chemotherapy protocols—curative intent (colorectal cancer) (Ch. 6)
Radiation therapy (Ch. 6)
Intensity-modulated radiation therapy (IMRT) (Ch. 6)
Follow-up for colorectal cancer (Ch. 6)
Amsterdam II criteria for HNPCC (App. 2)
Bethesda criteria for MSI testing (App. 2)
Tumor staging in TNM system (App. 2)
RECURRENT RECTAL CANCER (789.3, 154.1)
Overview
Recurrent rectal cancer is a challenge to management and surgical skills. Nihilistic approach is counterproductive, as there is
a good chance for cancer cure or at least best local palliation. Local tumor recurrence is the endpoint of failure in primary
treatment of rectal cancer. The most effective way to manage recurrent disease is to avoid it.
Several factors contribute to primary local tumor control:
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Primary prevention.
Tumor-related: tumor stage, localization of the primary tumor and/or its lymph node metastases, pathologic and
molecular features.
Treatment-related: surgical technique, neo-/adjuvant chemoradiation.
Secondary prevention: follow-up and surveillance detection of loco-regional or distant recurrence, or metachronous
lesions.
Natural course of locally advanced, unresectable rectal cancer: shortened median survival time (7–8 months without any
treatment), accumulation of severe disabling local problems.
Recurrent rectal cancer remains confined to pelvis in ~25–50% and hence justifies an aggressive surgical approach. Even in
the presence of distant metastases, an aggressive local approach may achieve the best and fastest palliation, but other
treatment options have to be considered.
Epidemiology
Benchmark: local recurrence rate to be < 10% without chemoradiation, but reports indicate recurrence rates between 3%
and 50%. Transanal local excision: alarming incidence of local recurrences of 18–37% in even early tumor stages (T1, T2).
Greater than sixty percent of recurrences occur during the first 2 years after surgery.
Symptoms
Asymptomatic: detected through follow-up studies: imaging, blood work.
Symptomatic: increasing and potentially severe pain, bleeding, bowel and urinary obstruction, fecal and urinary leakage,
vaginal symptoms, fistula/abscess formation.
Differential Diagnosis
Pelvic scaring.
Inflammatory process (chronic leak, fistula, abscess, organizing hematoma, etc).
Other pelvic malignancy (eg, prostate, GYN).
Pathology
Should be consistent with primary tumor.
Evaluation
REQUIRED MINIMAL STANDARD
Patient history and follow-up data, previous surgery, current symptoms (rectal, pelvic, urinary, GYN), performance status.
Clinical examination: general appearance, abdominal exam (mass, organomegaly, etc), digital rectal exam (palpable
anastomosis, palpable lesion, involvement of pelvic floor and sphincter complex, involvement of prostate).
Colonoscopy: evidence for endoluminal recurrence or metachronous primary colorectal cancer.
Imaging:
– ERUS (for lower lesions).