CA DESENDING COLON WITH SECONDARIES IN OVARIES by shimeiyan

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									CA DESENDING COLON WITH SECONDARIES IN OVARIES.
Dr qura tul ain PGR ESW

BIODATA
NIGHAT 40Y/F Resident of Sialkot Admitted through OPD 14/11/09

Presenting complaints:
Altered bowel habits………3 months Abdominal distention………3 months Abdominal pain……………..3 months Mass in lower abdomen……2 months

HOPI
My patient was in usual state of health when she noticed her altered bowel habits. now for last 3 months she was constipated. she was unable to pass stool without medication which she took from local GP and hakeems.she was passing flatus Along with this she also developed off and on abdominal distention which

Cont.
Was associated with colicky abdominal pain. patient associate her abdominal pain and distention with intake of rice. her pain and distention relieved by defecation and at times she had to induce vomiting to relieve her pain and distention. There is also history of anorexia and weight loss for last3 months.

cont
Patient also noticed a mass in her lower abdomen for last 2 months which was gradually increasing in size was associated with dull aching pain in lower abdomen all the time. There is also of polymenorrhagia for last one year. No other systemic complaint.

cont
Past history Personal history: Family history Menstrual history Socioeconomic history

General physical examination
Markedly pale patient sitting on bed well oriented in time place and person with vitals: Pulse :96/min B.P : 120/80 Temp:98.6F R/R:18/min Pallor: markedly pale Assessable lymphnodes:not palpable

ABDOMINAL EXAMINATION
INSPECTION Abdomen moving with respiration with central inverted umblicus.no visible scar mark pulsation ,peristalsis' or veins. PALATION On palpation there is a hard mass slightly tender palpable in the lower abdomen 20*12 involving RIF hypogastrium and LIF of irregular margins and surface over lying skin normal lower limit not palpable. rest of abdomen is soft n non tender. liver spleen

cont
Percussion Percussion note is dull in lower abdomen. shifting dullness is not positive. Auscultation Bowel sounds exaggerated

cont
Per rectal examination No external findings. tone normal. mucosa normal and mobile. rectum collapsed finger stained with fecal matter Per vaginal examination Bilaterally hard adenaxal masses are palpable on both sides on bimanual palpation. right side mass is about 12*10 slightly tender and relatively mobile irregular shape not fixed to uterus

cont
Left sided adenaxal mass is also hard 8*7 size mobile not fixed to uterus and its is tender. uterus normal.

SYSTEMIC EXAMINATION
CVS S1+S2+0 RESP NVB+0 CNS Grossly intact.

INVESTIGATIONS
HB: 8.7 TLC: 5800 P; 67% L; 30% M; 02% E; 01%

CONT
B.UREA; 52 S.CREAT;1.0 BSL; 135 S.Na;135 S.K; 3.8 S.BIL;1.0 S.ALK;240 SGPT;60 SGOT;55

CONT
PT 2 SEC PROLONGED APTT 1SEC PROLONGED INR 1.2 ANTI HCV NON REACTIVE HBSAG NON REACTIVE

CONT
CA-125 30.2U/ml NORMAL VALUE less than 35 CEA 53.0ng/ml NORMAL VALUE less than 5.1

CT SCAN WITH IV AND ORAL CONTRAST.
Bilateral ovarian heterogeneously enhancing cystic masses noted with thick network like enhancing septae as well .larger one noted on right side measuring 11cm and left one 6cm. These ovarian masses are associated with adhesion formation with ileum,mesentry,redundand sigmoid and lower omentum as well.

cont
There is enhancing circumferential mural segmental growth in descending colon with serosal invasion and luminal narrowing also associated with thickening and nodularity of surrounding fat. Also seen thickening of mesentery with multiple tiny nodules.

cont
Normal liver,GB,spleen,kidneys,adrenals and pancreas. Impression ;a malignant growth of descending colon with metastatic deposits in mesentery and ovaries.

DOUBLE CONTRAST BA-ENEMA
Contrast given per rectum and study carry out under fluoroscopic control. rectum and sigmoid colon are normally opacified. Marked narrowing giving apple core appearance and shouldering noted in descending colon beyond splenic flexure. Transverse and ascending colon and ceacum normal.

COLONOSCOPY.
PR EXAMINATION NORMAL RECTUM; NORMAL MUCOSA AND VASCULATURE SIGMOID COLON; NORMAL MUCOSA AND VASCULATURE. DESCENDING COLON; CAULIFLOWER LIKE CIRCUMFRENTIAL GROWTH IN THE PROXIMAL DESCENDING COLON WITH COMPLETE OCLUSION OF THE LUMEN.MULTIPLE BIOPSIES TAKEN.

BONE SCAN
NO SCINTIGRAPHIC EVIDENCE OF ANY METASTATIC DEPOSITS IN BONES.

PRE OP PREPRATION
BLOOD TRANSFUSION GUT PREPRATION NO RESIDUAL DIET FOR 5 DAYS IV LINE SECURED MgSO4 KLEEN ENEMAS NG AND FOLEYS PASSED.

OPERATION
EXPLORATORY LAPROTOMY WAS DONE ON 11/12/09. OPERATIVE FINDINGS . Moderate ascities hard fixed tumor involving lower 3/4th of descending colon along with its mesentery. right ovarian mass of size 12*10 cm and left one of size 8*7 cm.peritoneal seedlings along with diffuse small gut mesentery seedlings.

cont
Subtotal colectomy,resection of distal 2 feet of ileum.terminal ileostomy,hartmann procedure and B/L salpingo opherectomy done.

PLAN
Discharge and refer to oncology department for further chemotherapy.

DISCUSSION ON COLORECTAL TUMORS.

SURGICAL ANATOMY
Ascending colon The ascending colon, on the right side of the abdomen, is about 25 cm long in humans.[2] It is the part of the colon from the ceacum to the hepatic flexure (the turn of the colon by the liver). It is secondarily retroperitoneal in most humans. In ruminant grazing animals, the ceacum empties into the spiral colon. Anteriorly it is related to the coils of small intestine, the right edge of the greater omentum, and the anterior abdominal wall. Posteriorly, it is related to the iliacus, the iliolumbar ligament, the quadratus lumborum, the transverse abdominis, the diaphragm at the tip of the last rib; the lateral cutaneous, ilioinguinal, and iliohypogastric nerves; the iliac branches of the iliolumbar vessels, the fourth lumbar artery, and the right kidney. The ascending colon is supplied by parasympathetic fibers of the vagus nerve (CN X). Arterial supply of the ascending colon comes from the ileocolic artery and right colic artery, both branches of the SMA. While the ileocolic artery is almost always present, the right colic can be absent in 5–15% of individuals.

CONT
Transverse colon The transverse colon is the part of the colon from the hepatic flexure to the splenic flexure (the turn of the colon by the spleen). The transverse colon hangs off the stomach, attached to it by a wide band of tissue called the greater omentum. On the posterior side, the transverse colon is connected to the posterior abdominal wall by a mesentery known as the transverse mesocolon. The transverse colon is encased in peritoneum, and is therefore mobile (unlike the parts of the colon immediately before and after it). Cancers form more frequently further along the large intestine as the contents become more solid (water is removed) in order to form feces. The proximal two-thirds of the transverse colon is perfused by the middle colic artery, a branch of superior mesenteric artery, while the latter third is supplied by branches of the inferior mesenteric artery. The "watershed" area between these two blood supplies, which represents the embryologic division between the midgut and hindgut, is an area sensitive to ischemia

CONT
Descending colon The descending colon is the part of the colon from the splenic flexure to the beginning of the sigmoid colon. The function of the descending colon in the digestive system is to store food that will be emptied into the rectum. It is retroperitoneal in two-thirds of humans. In the other third, it has a (usually short) mesentery. The arterial supply comes via the left colic artery.

CONT
Sigmoid colon The sigmoid colon is the part of the large intestine after the descending colon and before the rectum. The name sigmoid means S-shaped (see sigmoid). The walls of the sigmoid colon are muscular, and contract to increase the pressure inside the colon, causing the stool to move into the rectum. The sigmoid colon is supplied with blood from several branches (usually between 2 and 6) of the sigmoid arteries, a branch of the IMA. The IMA terminates as the superior rectal artery.

CONT
The rectum (from the Latin rectum intestinum, meaning straight intestine) is the final straight portion of the large intestine in some mammals, and the gut in others, terminating in the anus. The human rectum is about 12 cm long. Its caliber is similar to that of the sigmoid colon at its commencement, but it is dilated near its termination, forming the rectal ampulla.

Epidemiology
Incidence rises sharply with age. Between the ages of 45 and 55, the incidence is about 25 per 100,000. Among those aged 75 and above, the rate is over 300 per 100,000 per year.1 Colon cancer is equally common in men and women, but rectal cancer is more common in men

Risk factors
Family history of colorectal neoplasia: carcinoma; adenoma under the age of 60 years:2 Past history of colorectal neoplasm: carcinoma, adenoma. Inflammatory bowel disease: ulcerative colitis, Crohn's colitis. Polyposis syndromes: familial adenomatous polyposis (Gardner's syndrome), Turcot's syndrome, attenuated adenomatous polyposis coli, flat adenoma syndrome, hamartomatous polyposis syndromes (Peutz-Jeghers syndrome, juvenile polyposis syndrome, Cowden syndrome). Hereditary non-polyposis colorectal cancer (HNPCC).

CONT
Hormonal factors: nulliparity, late age at first pregnancy, early menopause. Diet: rich in meat and fat; poor in fibre, folate and calcium. Sedentary lifestyle, obesity, smoking, high alcohol intake. Diabetes mellitus. Previous irradiation, occupational hazards, e.g. asbestos exposure. History of small bowel cancer, endometrial cancer, breast cancer or ovarian cancer

RISK FACTORS
General population Personal history of colorectal neoplasia Inflammatory bowel disease

5%

15%–20% 15%–40% 70%–80% >95%
0 20 40 60 80 100

HNPCC mutation

FAP

Lifetime risk (%)

Signs and symptoms
Local Local symptoms are more likely if the tumor is located closer to the anus. There may be a change in bowel habit (new-onset constipation or diarrhea in the absence of another cause), and a feeling of incomplete defecation (tenesmus) and reduction in diameter of stool; tenesmus and change in stool shape are both characteristic of rectal cancer. Lower gastrointestinal bleeding, including the passage of bright red blood in the stool, may indicate colorectal cancer, as may the increased presence of mucus. Melena, black stool with a tarry appearance, normally occurs in upper gastrointestinal bleeding (such as from a duodenal ulcer) but is sometimes encountered in colorectal cancer when the disease is located in the

Cont.
A tumor that is large enough to fill the entire lumen of the bowel may cause bowel obstruction. This situation is characterized by constipation, abdominal pain, abdominal distension and vomiting. This occasionally leads to the obstructed and distended bowel perforating and causing peritonitis. Certain local effects of colorectal cancer occur when the disease has become more advanced. A large tumor is more likely to be noticed on feeling the abdomen, and it may be noticed by a doctor on physical examination. The disease may invade other organs, and may cause blood or air in the urine (invasion of the bladder) or vaginal discharge (invasion of the female reproductive tract).

cont
Constitutional If a tumor has caused chronic occult bleeding, iron deficiency anemia may occur; this may be experienced as fatigue, palpitations and noticed as pallor (pale appearance of the skin). Colorectal cancer may also lead to weight loss, generally due to a decreased appetite. More unusual constitutational symptoms are an unexplained fever and one of several paraneoplastic syndrome. The most common paraneoplastic syndrome is thrombosis, usually deep vein thrombosis

cont
Metastatic Colorectal cancer most commonly spreads to the liver. This may go unnoticed, but large deposits in the liver may cause jaundice and abdominal pain (due to stretching of the capsule). If the tumor deposit obstructs the bile duct, the jaundice may be accompanied by other features of biliary obstruction, such as pale stools

Diagnosis

cont
Digital rectal exam Fecal occult blood Endoscopy:
SigmoidoscopyandColonoscopy:

Double contrast barium enema Virtual colonoscopy Standard computed axial tomography carcinoembryonic antigen

Pathology

cont
The most common colon cancer cell type is adenocarcinoma which accounts for 95% of cases. Other, rarer types include lymphoma and squamous cell carcinoma. Cancers on the right side (ascending colon and cecum) tend to be exophytic, that is, the tumour grows outwards from one location in the bowel wall. This very rarely causes obstruction of feces, and presents with symptoms such as anemia. Left-sided tumours tend to be circumferential, and can obstruct the bowel much like a napkin ring.

STAGING

CONT.
The most common staging system is the TNM (for tumors/nodes/metastases) system, from the American Joint Committee on Cancer (AJCC).

PRIMARY TUMOR T
TX PRIMARY TUMOR CANNOT BE ASSESSED T0 NO EVIDENCE OF PRIMARY TUMOR T1S CARCINOMA INSITU T1TUMOR INVADES SUBMUCOSA T2 TUMOR INVADES MUSCULARIS PROPRIA

CONT
T3 TUMOR INVADES THROUGH MUSCULARIS PROPERIA INTO THE SUBSEROSA.OR INTO NONPERITONEALIZED PERICOLIC OR PERIRECTAL TISSUES T4 TUMOR PERFORATE THE VISCERAL PERITONEUN OR DIRECTLY INVADES OTHER ORGANS OR STRUCTURES .

REGIONAL LYMPH NODES (N)
NX CANNOT BE ASSESSED N0 NO NODES N1 1TO 3 PERICOLIC OR PERIRECTAL LYMPHNODES N2 4 OR MORE LYMPHNODES N3 ANY LYMPHNODE ALONG THE COURSE OF NAMED VASCULAR TRUNK.

DISTANT METASTASIS
MX CANNOT BE ASSESSED M0 NO METASTASIS M1 DISTANT METASTASIS

STAGE GROUPING
STAGE
DUKES MODIFIE D ASTLER COLLAR

0 I II A II B IIIA IIIB IIIC IV

TIS T1 T2 T3 T4 T1-2 T3-4 ANY T ANY T

N0 N0 N0 N0 N0 N1 N1 N2 ANY N

M0 M0 M0 M0 M0 M0 M0 M0 M1

A A B B C C2/C3

A B1 B2 B3 C1

DUKES SYSTEM OF CLASSIFICATION.
DUKES A TUMOR CONFINED TO THE WALL.

CONT
DUKES B TUMOR INVADING THROUGH THE WALL

CONT
DUKES C With lymph node(s) involvement (this is
further subdivided into C1 lymph node involvement where the apical node is not involved and C2 where the apical lymph node is involved

CONT
DUKES D With distant metastasis

Management
SURGERY CHEMOTHERAPY RADIOTHERAPY

SURGERY
Surgeries can be categorized into curative, palliative, bypass, fecal diversion, or open-and-close.

CHEMOTHERPY
Chemotherapy is used to reduce the likelihood of metastasis developing, shrink tumor size, or slow tumor growth. Chemotherapy is often applied after surgery (adjuvant), before surgery (neo-adjuvant), or as the primary therapy (palliative).

CONT
Adjuvant (after surgery) chemotherapy. One regimen involves the combination of infusional 5fluorouracil, leucovorin, and oxaliplatin (FOLFOX) 5-fluorouracil (5-FU) or Capecitabine (Xeloda) Leucovorin (LV, Folinic Acid) Oxaliplatin (Eloxatin)

RADIOTHERPY
Radiotherapy is not used routinely in colon cancer, as it could lead to radiation enteritis, and it is difficult to target specific portions of the colon. It is more common for radiation to be used in rectal cancer, since the rectum does not move as much as the colon and is thus easier to target. Indications include:

CONT
Colon cancer pain relief and palliation - targeted at metastatic tumor deposits if they compress vital structures and/or cause pain Rectal cancer neoadjuvant - given before surgery in patients with tumors that extend outside the rectum or have spread to regional lymph nodes, in order to decrease the risk of recurrence following surgery or to allow for less invasive surgical approaches (such as a low anterior resection instead of an abdomino-perineal resection) adjuvant - where a tumor perforates the rectum or involves regional lymph nodes (AJCC T3 or T4 tumors or Duke's B or C tumors) palliative - to decrease the tumor burden in order to relieve or prevent symptoms

FOLLOW UP
The aims of follow-up are to diagnose in the earliest possible stage any metastasis or tumors that develop later but did not originate from the original cancer (metachronous lesions).

CONT
The U.S. National Comprehensive Cancer Network and American Society of Clinical Oncology provide guidelines for the follow-up of colon cancer. A medical history and physical examination are recommended every 3 to 6 months for 2 years, then every 6 months for 5 years.

CONT
Carcinoembryonic antigen blood level measurements follow the same timing, but are only advised for patients with T2 or greater lesions who are candidates for intervention

CONT
A CT-scan of the chest, abdomen and pelvis can be considered annually for the first 3 years for patients who are at high risk of recurrence (for example, patients who had poorly differentiated tumors or venous or lymphatic invasion) and are candidates for curative surgery (with the aim to cure).

CONT.
A colonoscopy can be done after 1 year, except if it could not be done during the initial staging because of an obstructing mass, in which case it should be performed after 3 to 6 months. I

5 YEARS SURVIVAL RATE
S tage Description
A B C D Limited to the bowel wall Extension to pericolic fat; no nodes Regional lymph node metastases Distant metastases (liver, lung, bone)

5-yr Survival Rate, % 83
70 30 10

THANK U


								
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