Banyumas CA Colorectal

7/30/2019 Banyumas CA Colorectal

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CARCINOMA

COLORECTAL

SYAM SUHARYONO

SESARIUS BIMO

NI PUTU DIAN AYU P

RENDI AJI PRIHANINGTYASMARIA RIANDIKA

MUHAMMAD ZAKIY MUNTAZAR


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TIPE TUMOR

1. Epithelial tumor

columnar/glandular epitelium adenoma/

adenocarcinoma

1. t

Epithelial tumor

Columnar/galndular epithelium adenoma/adenosarcoma

Colon, Rectum

Lymphoid Tumor

Ileum terminal

Stromal Tumor (GISTs)

Phenotype of a pacemaker cell

found in the muscle coat(intestinal Cell of Cajal)

Secondary (metastatic Cancer)

Tipe Tumor


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EPITHELIAL TUMOR

Epithelial Tumor

Columnar/glandularepithelium

Adenoma (5%adenosarcoma)

Adenosarcoma

Suamous epithelium(lower anal canal)

SCC


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Epithelial polyp

Hamartoma

Peutz-Jegherspolyp small

intestine

Juvenile polyp colon,rectum

Commonest :hyperplastic

polypDistal colon and

rectum

EPITHELIAL TUMOR


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EPITHELIAL POLY


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LYMPHOID TUMOR

Lymphoidtumor

B-lymphosit

MALToma

BurkittLymphoma

Mantle cellLymphoma

T-celllymphoma

Proximaljejunum


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STROMAL TUMOR

Stro

malTum

or

Behaviour isanpredictable

Large size, high mitoticrate malignancy

Bona fide smooth

muscle rectum


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METASTATIC CANCER

Intestinal tractis not acommon site

Primary source: melanoma,breast, lung

cancer

Small intestine comon site


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EPIDEMIOLOGY

Ca Colorectal

West

All cancerdiagnosed/year

Secondary cancer death after lung cancer

USA

8,5%

55.000 death/year

Highest : west Lowest : developing world


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INCIDENCE

Colonic cancer

M=F

Rectal Cancer F=2M


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INCIDENCE

Colorectal cancer

Japan, urban China,male polynesian in

Hawaii

High Mortality :ageing population 65-

75 year

Genetic error :multiple neoplasma,early age hereditary

colorectal Ca

Rapid increaseWestern life style

Is age related


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ETIOLOGY

Enviromentalfactors

GeneticfactorsIs

notk

nowm

Isnot

known


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ENVIRONMENT FACTOR

Dietaryand life

stylefactor

vegetableanf fibre

Meat andfat

Calciumand bile

acid

Selenium

Smokingand

alcohol

NSAID


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GENETIC FACTORS

HIGHPREVALENCE

POLYMORPHISMS

N-Acetyltransferase andcitochrome P450 enzyms

Methylenetetrahydrofolatereductase

RARE INHERITEDSYNDROMES

Familial adenomatouspolyposis

Hereditary Non-PolyposisColorectal Cancer

Germline Mutation of TGFB type II Receptor


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CHRONIC INFLAMMATION

UlcerativeCollitis Crohns

Disease


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PREVENTION

Prevention ofradical surgery

Prevention ofdeath


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PREVENTION

Lifestyle adjusment

Taking preventif medication(chemoprevention)

Screening asymptomatic subject forrisk factors


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SCREENING

Testing faeces for occult blood

Endoscopic examination of themucosal lining of the large bowel

Demonstration of a high riskgenetic mutation


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PREINVASIVE LESION


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ADENOMA

Adenoma

Show a spectrum of changes ranging from low-grade dysplasia high-grade

dysplasia

Malignant transformation with time

Adenoma and maligna share similar demographic data

Removal of adenoma reduce frequency of cancer

Genetic changes in adenomas are present in carcinoma


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ADENOMA

Macroscopic

Sessile elevation < 5mm but increasing growthis associated with the formation of a stalkcomposed of normal mucosa and submucosa

Polypoid growth that may be sessile orpedunculated

Minority : flat/depressed lesion

Head is darker than surrounding normalmucosa, lobulated baby cauliflower

Microscopic

Tubular, tubulovillous, villous

Tubules are lined by columnar epithelium andembedded within lamina propia

Vili comprise a covering of columnarepithelium and a core of lamina propria


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GROSS APPEARANCES

Well circumscribed with little growth beyond their macroscopically visible borders

Mass protuding into the bowel lumen

Protuberant masses are more common in the caecum and ascending colon

The bowel content are fluid in this region and obstruction is uncommon

Chronic bleeding from the ulcerated surface anemia

Palpation of a mass in the right iliac fossa

Cancer arising in the splenic flexure and left colon are associated with stricturing

obstruction

Cancer of rectum : are often ulcerating, passage of bright red blood per rectum or the

sensation of incomplete evacuation


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HISTOPATOLOGY

90% colorectal cancer : ADENOCARCINOMA composed of

glandular structures containing variable amounts of mucin

80% colorectal cancer : well circumscribed invasive margin

20% colorectal carcinoma show widespread dissection of normal

structures and often extensive invasion around nerve and within small

vessel 70% colorectal carcinoma arise through chromosomal instability


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GRADING

Grade 1

Well differentiated adenocarcinoma The glands are regular and the epithel resembles adenomatous tubules

Grade 2

Moderately differentiated adenocarcinoma The glands show complex budding, irregular outpouching or gland within gland structure

Grade 3

Poorly differentiated adenocarcinoma Glands are highly irregular or distorted

Grade 4 Undifferentiated carcinoma


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DIAGNOSTIC

Anamnesis

Physical Examination

RECTAL TOUCHER Lab Examination

Radiologic Diagnostic COLON IN LOOP CT SCAN ABDOMENCek Metastasis USG RO THORAX BONE SCANNING BNO-IVP Endoscopy


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SIGN & SYMPTOM

Depend on the location, size, type

Abdominal pain

Anemia

Weight loss

Perubahan defikasi

Diarrhea

Blood in feses

Obstruction

Komplikasi : Perforasi, peritonitis


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SIGN & SYMPTOM

KOLON

KANAN

KOLON KIRI REKTTUM

Tipe tumor

Kaliber kolonFesesFungsi

Polipoid,ulseratifBesarCairabsorbsi

Stenosis

KecilSetengah padatpenyimpanan

Infiltratif,polipoidBesarPadatdefekasi

Gejala klinisDispepsiaPerub.polaBABObstruksiDarah dalam

tinja

KolitisSeringDiare

JarangMikroskopis

ObstruksiJarangKonstipasi,progresiDominanmikro/makro

ProktitisJarangTenesmus

JarangMakros


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LABORATORIUM

Routine blood : Hb, AL

Urinalysis

Hepar and ren function

CEA : urine,feses

< 10 ng/ml : stadium dini

> 10 ng.mL : stadium lanjut


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RADIOLOGIC

EXAMINATION

Colon in Loop

CT Scan Abdomen


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GAMBARAN RADIOLOGIS

Pada colon in loop tampak penonjolan ke dalam lumen

(protruded lesion).

Bentuk klasik tipe ini adalah polip. Polip dapat bertangkai

(pedunculated) atau tidak bertangkai (sessile).

Dinding kolon seringkali masih baik. Bentuk ini sukar dibedakan

dengan kilitis Crohns.


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CONT

Deformitas dinding colon (Colonic wall deformity) dapat bersifat

simetris (napkin ring) atau asimetris (apple core). Lumen kolon sempit

dan irregular.

Kelakuan dinding kolon (rigidity colonic wall) bersifat segmental,

terkadang mukosa terlihat baik. Lumen kolon dapat atau tidak

menyempit. Bentuk ini sukar dibedakan dengan colitis ulseratif.


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CONTOH

Pemeriksaan CIL yang menunjukan lesi apple core dengan penyempitan circumferential


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CONT..

Dilatasi usus proximal ke obstruksi. Anak panah menunjukkan etiology obstruksi.


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ENDOSCOPY


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VENOUS INVASION

Increase the risk of metastatic spread to the liver via the portal

vein


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TNM CLASSIFICATION


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METASTATIS

Carcinoma Colorectal

Direct

Hematogen

Limfogen

Transperitoneal

Nerve

Intraluminer


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METASTASIS

Ca Rectum

Direct

Limfogen

Hematogen

Nerve


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SURVIVAL


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JASS PROGNOSTIC

CLASSIFICATION


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RECURRENT AND DISTANT

DISEASE


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THE FUTURE


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MANAGEMENT

Operative Therapy (cutting)

Radiation therapy (burning)

Chemotherapy (poisoning)


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OPERATIVE

Kuratif: Pengambilan/ pengangkatan semua tumor

Caecum dan colon ascendens (hemikolektomi dextra) Fleksura Hepatika (hemikolektomi extended)

Kolon transversum Reseksi kolon sigmoid

Rektum

12 cm dari anus (reseksi anterior)Dilakukan apabila tumor pada 1/3 bagian atas rektum

6-12 cm dari anus (low reseksi/abdominal reseksi)Dilakukan apabila tumor berada di 1/3 tengah rektum


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Paliatif Mengilangkan gejala obstruksi Tumor tidak diangkat karena telah metastase

Colon kanan (Illeotransversostomi) : dilakukan pada tumor di kolon kanan, ileumterminal dipotong, kemudian dihubungkan dengan kolon transversum, kolon ascendesnya

diinaktifkan

Colon kiri (trasnvercolostomi): dilakukan pada kolon kiri (desenden) transversum

dipotong kemudian dihubungkan ke lubang buatan di permukaan abdomen, kolon

desenden diinaktifkan

Rektum (Sigmoidostomi) Sigmoid dipotong lalu dihubungkan dengan lubang buatan di permukaan abdomen


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RADIOTHERAPY

Tujuan efek sittoksik selektif pada sel tumor dengan kerusakan minial pada jaringan

normal dan sekitarnya

Dilakuakan pra bedah, pasca bedah , atau inoperable tumor

Dilakukan pada keganasan rektosigmoid Dukes B,C, dan D

Pada kasus tanpa reseksi atau anastomose dilakukan segera paska bedah

Radio terapi prabedah bertujuan untuk mengurangi viablitias tumor sehingga

memperbaiki kontrol lokal dan ketahanan hidup, bisa memepermudah reseksi

Radioterapi pasca bedah adalah memungkinkan seleksi penderita dengna peningkstan

rekurensi lokal berdasar hasil pemeriksaan histopatologi spesimen operasi


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KEMOTERAPI

Menghambat pertumbuhan neoplastik

5 FU merupakan ntinepolstik menghambat eznim asam nuklea ,

dan menghambat fosfat necluotide dan enzim ribonucleotide difosfat

reduktase


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REFERENSI

The Cancer Handbook Weinberg 2003

Imaging in Oncology from The University of Texas M.D. Anderson Cancer CenterRusdy Ghazali Maleuka- Radiologi Diagnostik 2006

Cermin Dunia Kedokteran No. 85 1998

Robbins Basic Pathology 7th Edition

www.emedicine.com

www.wikiradiography.com
http://www.emedicine.com/http://www.wikiradiography.com/http://www.wikiradiography.com/http://www.emedicine.com/

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