醫(yī)學(xué)精品課件：結(jié)直腸癌

1、COLORECTAL CARCINOMA,ZHANG Jimin, MD., PhD. Gastrointestinal Department of Surgery, The Second Hospital, Guangzhou Medical University,2,Cecum Ascending Colon Transverse Colon Descending Colon Sigmoid Colon Rectum,ANATOMY,3,12 15 cm peritoneal portion and pelvis portion mesorectum,Mesorectum,全直腸系膜切除(

2、TME) Total Mesorectum Excision,ABOUT RECTUM,4,common tumor in gastrointe- stinal tract occur mostly at 4165 years old colon cancer seems more and more in recent 20 years proliferationadenoma -carcinoma, about 1015 years,INTRODUCTION,5,PATHOLOGY,Mass type（隆起型） 多見(jiàn)于升結(jié)腸、盲腸，腸腔內(nèi)生長(zhǎng)，轉(zhuǎn)移發(fā)生較晚 Invasive type（浸潤(rùn)型

3、） 多見(jiàn)于降結(jié)腸，腸壁內(nèi)生長(zhǎng)，易引起狹窄及梗阻 Ulceration type（潰瘍型） 最常見(jiàn)類型，向腸壁深處生長(zhǎng)，形成潰瘍，容易發(fā) 生出血、感染或者穿孔,6,MASS TYPE,7,INVASIVE TYPE,8,ULCERATIVE TYPE,9,HISTOLOGIC CLASSIFICATION,腺癌（Adenocarcinoma） 管狀腺癌（tubular adenocarcinoma） 乳頭狀腺癌（papillary adenocarcinoma） 粘液腺癌（mucinous adenocarcinoma ） 印戒細(xì)胞癌（signet-ring cell adenocarcinom

4、a） 腺鱗癌（Adenosquamous carcinoma） 通常見(jiàn)于低位直腸癌或者肛管癌 未分化癌（undifferentiated carcinoma,10,Normal epithelium,Micro- adenoma,Early-stage adenoma,Middle-stage adenoma,Carcinoma,Advanced adenoma,ETIOLOGY,Over 50 % come from the canceration of adenoma. From normal cell to cancer cells, it will need 1015 years,11

5、,HIGH RISK FACTORS,Too much animal fat or protein in food Too little vegetable and fibrin in food Too little body exercise Susceptibility in genetics Familial adenomatous polyposis (FAP) Others (adenoma, ulcerative colitis, etc,12,adenoma,FAP,13,CEA (carcinoembryonic antigen) An important marker for

6、 colorectal cancer (expressed in 60% of patients,TUMOR MARKER,14,EXTENDING ROUTES OF COLORECTAL CANCER,Lymphatic spread Hematogenous spread: hepatic metastasis Direct invasion of adjacent structures Implantation spread,15,LYMPHATIC METASTASIS,16,PATHOLOGIC STAGING,Dukes Staging: Originally developed

7、 by Dukes in 1935, and further modified in 1954 TNM Staging: Recommended by the UICC (International Union Against Cancer) (Union for International Cancer Control,17,Dukes Staging,Stage A: 腫瘤局限于腸壁，未穿透漿膜 Stage B: 腫瘤穿透漿膜，但無(wú)淋巴結(jié)轉(zhuǎn)移 Stage C: 腫瘤穿透漿膜，伴有淋巴結(jié)轉(zhuǎn)移 Stage D: 腫瘤有遠(yuǎn)處轉(zhuǎn)移，或者臨近臟器浸潤(rùn)， 導(dǎo)致無(wú)法行根治性切除,18,TNM Stagi

8、ng 2009年UICC第九版分期,T0: 無(wú)原發(fā)瘤，TX：原發(fā)瘤無(wú)法估計(jì)， Tis:原位癌 T1：腫瘤侵及粘膜及粘膜下層 T2：腫瘤侵及固有肌層 T3：腫瘤穿透肌層至漿膜下 T4：腫瘤穿透漿膜或侵及其它臟器,19,TNM Staging,N0: 無(wú)淋巴結(jié)轉(zhuǎn)移，NX：無(wú)法估計(jì)淋巴結(jié) N1：轉(zhuǎn)移區(qū)域淋巴結(jié)13個(gè) N2：轉(zhuǎn)移區(qū)域淋巴結(jié)4個(gè)以上 M0：無(wú)遠(yuǎn)處轉(zhuǎn)移， Mx：無(wú)法估計(jì)遠(yuǎn)處轉(zhuǎn)移 M1：有遠(yuǎn)處轉(zhuǎn)移,20,HIGH-RISK PATIENTS,If the patients over 40 years old: Family history of colorectal cancer Famil

9、ial adenomatous polyposis (FAP) Occult blood (+) in feces mucopurulent bloody stool, diarrhea, constipation, chronic appendicitis, etc CEA is over expressed,21,CARCINOMA OF COLON,22,CLINICAL FEATURES,changes of bowel habits and stool (diarrhea, constipation, bleeding) stomachaches mass in abdomen ob

10、struction general symptoms (anemia, weight lose, asthenia, fever,23,Differences of Colon Cancer in Ascending with in descending,in right colon: anemia weakness weight loss mass,in left colon: changes in feces obstruction,24,IMAGING STUDIES,25,BARIUM ENEMA RADIOGRAPHY,26,COLONOSCOPY,27,CT SCANNING,28

11、,TREATMENT,Surgical resection of the lesion, and dissection of its regional lymph nodes Chemotherapy Radiotherapy Biotherapy Imunotherapy Gene therapy,29,1) Radical Colectomy,右半結(jié)腸切除+區(qū)域淋巴結(jié)清掃 橫結(jié)腸切除+區(qū)域淋巴結(jié)清掃 左半結(jié)腸切除+區(qū)域淋巴結(jié)清掃 乙狀結(jié)腸切除+區(qū)域淋巴結(jié)清掃,30,右半結(jié)腸癌切除范圍,左半結(jié)腸癌切除范圍,橫結(jié)腸癌切除范圍,乙狀結(jié)腸癌切除范圍,31,2) With Acute Obstruc

12、tion,In Ascending Colon: Well status: 右半結(jié)腸切除+回腸-橫結(jié)腸吻合術(shù) Poor status: 盲腸造瘺，然后二次切除,32,In Descending Colon 首先橫結(jié)腸造瘺解除梗阻 然后在充分腸道準(zhǔn)備下手術(shù)切除,33,Chemotherapy,Basic agent: 5-FU FOLFOX6方案：5-FU + CF+奧沙利鉑 MAYO方案： 5-FU + CF XELOX方案：卡培他濱+奧沙利鉑,34,CARCINOMA OF RECTUM,35,More than colon carcinoma (1.5:1) 60%75% in lower

13、 rectum 10%15% 30 year old,ETIOLOGICAL CHARACTERISTIC,36,1) Direct Invasion to: wall of bowel, adjacent organ, such as: womb, prostate, bladder, seminalis, vagina, ureter,SPREAD 里急后重；排便習(xí)慣改變 腸腔狹窄癥狀: 便條形狀改變或不完全梗阻 癌腫破潰感染癥狀: 血便或粘液膿血便,42,浸潤(rùn)到前列腺或者膀胱： 尿頻、尿急、尿痛或者排尿不盡感 浸潤(rùn)到骶神經(jīng): 持續(xù)性骶前區(qū)疼痛 肝轉(zhuǎn)移: 腹水、黃疸、貧血、水腫,43,DI

14、AGNOSIS,1) 大便潛血試驗(yàn)（Test for occult blood）: used as primary test for high risk people (2) 直腸指診（Rectal Touch）: the most important test for diagnosis (3) 結(jié)腸鏡檢（Endoscopy）: for diagnosis and biopsy, about 5%10% of cases were multiple tumor,44,4) 影像學(xué)檢查 結(jié)腸鋇劑造影：評(píng)價(jià)有無(wú)多發(fā)瘤及定位 腹部B超: 評(píng)價(jià)有無(wú)肝臟及腹腔淋巴結(jié)轉(zhuǎn)移 腔內(nèi)超聲: 評(píng)價(jià)中低位癌腫腸壁

15、浸潤(rùn)深度 MRI檢查：評(píng)價(jià)中低位癌腫腸壁浸潤(rùn)深度 CT 造影: 評(píng)價(jià)有無(wú)肝臟、腹腔淋巴結(jié)轉(zhuǎn)移 及盆腔內(nèi)的浸潤(rùn)情況 PET-CT: 評(píng)價(jià)有無(wú)遠(yuǎn)處轉(zhuǎn)移及估測(cè)預(yù)后,45,5) OTHERS: 腹股溝淋巴結(jié)活檢, 陰道內(nèi)診或者腹部雙合診 膀胱鏡檢查,46,TREATMENT,一）手術(shù)治療： The most important radical treatment for rectal carcinoma,47,1) 局部切除 Local Resection: suitable for early stage, with a small size, located in mucosa 經(jīng)肛門(mén)局部切除術(shù)

16、骶后徑路局部切除術(shù),48,2）腹會(huì)陰聯(lián)合直腸癌根治術(shù) 既往金標(biāo)準(zhǔn)手術(shù),Miles operation： the mostly used radical operation for lower rectal carcinoma,49,Dixon Operation: suitable for tumor over 5cm apart from anus,3) 經(jīng)腹直腸癌切除術(shù)直腸低位前切除術(shù),50,4) 經(jīng)腹直腸癌切除、近端造口、遠(yuǎn)端封閉手術(shù),Hartmann Operation: suitable for the cases with a poor status, for whom neith

17、er Miles nor Dixon cant be accepted,51,后盆腔臟器清掃 （Posterior Pelvic Exenteration） radical resection with hysterectomy 全盆腔臟器清掃 （Pelvic Exenteration） radical resection with cystectomy and hysterectomy,52,2) Ridiotherapy,Rise the resection rate used in pre-operative Suitable for late stage patient for whom the radical operation can not be accepted,53,3) Chemotherapy,Rise the 5-year survival rate as an adjuvant treatment Vein Chemotherapy Artery Chemotherapy Portal Vein Chemotherapy Peritoneal Chemotherapy New Adjuvant Chemotherapy,54,New adjuv