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,全直肠系膜切
2、除(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） 多见于升结肠、盲肠，肠腔内生长，转移发生较晚 Invasive type
3、（浸润型） 多见于降结肠，肠壁内生长，易引起狭窄及梗阻 Ulceration type（溃疡型） 最常见类型，向肠壁深处生长，形成溃疡，容易发 生出血、感染或者穿孔,6,MASS TYPE,7,INVASIVE TYPE,8,ULCERATIVE TYPE,9,HISTOLOGIC CLASSIFICATION,腺癌（Adenocarcinoma） 管状腺癌（tubular adenocarcinoma） 乳头状腺癌（papillary adenocarcinoma） 粘液腺癌（mucinous adenocarcinoma ） 印戒细胞癌（signet-ring cell adenocarc
4、inoma） 腺鳞癌（Adenosquamous carcinoma） 通常见于低位直肠癌或者肛管癌 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 yea
5、rs,11,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 mar
6、ker for 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
7、 developed 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: 肿瘤局限于肠壁，未穿透浆膜 Stage B: 肿瘤穿透浆膜，但无淋巴结转移 Stage C: 肿瘤穿透浆膜，伴有淋巴结转移 Stage D: 肿瘤有远处转移，或者临近脏器浸润， 导致无法行根治性切除,
8、18,TNM Staging 2009年UICC第九版分期,T0: 无原发瘤，TX：原发瘤无法估计， Tis:原位癌 T1：肿瘤侵及粘膜及粘膜下层 T2：肿瘤侵及固有肌层 T3：肿瘤穿透肌层至浆膜下 T4：肿瘤穿透浆膜或侵及其它脏器,19,TNM Staging,N0: 无淋巴结转移，NX：无法估计淋巴结 N1：转移区域淋巴结13个 N2：转移区域淋巴结4个以上 M0：无远处转移， Mx：无法估计远处转移 M1：有远处转移,20,HIGH-RISK PATIENTS,If the patients over 40 years old: Family history of colorectal
9、cancer Familial 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
10、in abdomen obstruction 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,
11、CT SCANNING,28,TREATMENT, Surgical resection of the lesion, and dissection of its regional lymph nodes Chemotherapy Radiotherapy Biotherapy Imunotherapy Gene therapy,29,(1) Radical Colectomy, 右半结肠切除+区域淋巴结清扫 横结肠切除+区域淋巴结清扫 左半结肠切除+区域淋巴结清扫 乙状结肠切除+区域淋巴结清扫,30,右半结肠癌切除范围,左半结肠癌切除范围,横结肠癌切除范围,乙状结肠癌切除范围,31,(2)
12、With Acute Obstruction,In Ascending Colon: Well status: 右半结肠切除+回肠-横结肠吻合术 Poor status: 盲肠造瘘，然后二次切除,32,In Descending Colon 首先横结肠造瘘解除梗阻 然后在充分肠道准备下手术切除,33,Chemotherapy,Basic agent: 5-FU FOLFOX6方案：5-FU + CF+奥沙利铂 MAYO方案： 5-FU + CF XELOX方案：卡培他滨+奥沙利铂,34,CARCINOMA OF RECTUM,35, More than colon carcinoma (1.5
13、:1) 60%75% in lower 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 & METASTASIS,37,腹主动脉旁淋巴结,(2) Lymphatic Spread,肠系膜下动脉旁淋巴结,直肠上动脉旁淋巴结,(A) 高位肿瘤向高处转移,38,(B) 低位肿瘤向上方或者侧方转移
14、 (C) 齿状线周围的肿瘤向上方、侧方 或者腹股沟淋巴结转移,39,(3) Hematogenous Spread, Through portal vein to liver About 10%15% of patients with liver metastasis Through iliac vein to lung bone, or brain,40,(4) Implantation Metastasis, Implantation metastasis occur in upper rectal cancer occasionally,41,CLINICAL FEATURES, 直肠刺
15、激症状: 便意频数; 里急后重；排便习惯改变 肠腔狭窄症状: 便条形状改变或不完全梗阻 癌肿破溃感染症状: 血便或粘液脓血便,42, 浸润到前列腺或者膀胱： 尿频、尿急、尿痛或者排尿不尽感 浸润到骶神经: 持续性骶前区疼痛 肝转移: 腹水、黄疸、贫血、水肿 ,43,DIAGNOSIS,(1) 大便潜血试验（Test for occult blood）: used as primary test for high risk people (2) 直肠指诊（Rectal Touch）: the most important test for diagnosis (3) 结肠镜检（Endoscopy
16、）: for diagnosis and biopsy, about 5%10% of cases were multiple tumor,44,(4) 影像学检查 结肠钡剂造影：评价有无多发瘤及定位 腹部B超: 评价有无肝脏及腹腔淋巴结转移 腔内超声: 评价中低位癌肿肠壁浸润深度 MRI检查：评价中低位癌肿肠壁浸润深度 CT 造影: 评价有无肝脏、腹腔淋巴结转移 及盆腔内的浸润情况 PET-CT: 评价有无远处转移及估测预后,45,(5) OTHERS: 腹股沟淋巴结活检, 阴道内诊或者腹部双合诊 膀胱镜检查,46,TREATMENT,（一）手术治疗： The most important
17、radical treatment for rectal carcinoma,47,(1) 局部切除 Local Resection: suitable for early stage, with a small size, located in mucosa 经肛门局部切除术 骶后径路局部切除术,48,（2）腹会阴联合直肠癌根治术 既往金标准手术,Miles operation： the mostly used radical operation for lower rectal carcinoma,49,Dixon Operation: suitable for tumor over 5c
18、m apart from anus,(3) 经腹直肠癌切除术直肠低位前切除术,50,(4) 经腹直肠癌切除、近端造口、远端封闭手术,Hartmann Operation: suitable for the cases with a poor status, for whom neither Miles nor Dixon cant be accepted,51, 后盆腔脏器清扫 （Posterior Pelvic Exenteration） radical resection with hysterectomy 全盆腔脏器清扫 （Pelvic Exenteration） radical res
19、ection 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 Chemothera
20、py Portal Vein Chemotherapy Peritoneal Chemotherapy New Adjuvant Chemotherapy,54,*New adjuvant therapy,三、四期患者手术前单用或者联合应用 放疗、化疗，可以使肿瘤体积缩小，降 低分期，提高手术切除率。但一期患者 不建议应用。,55,(4) Others: Biotherapy Immunity Therapy Target Therapy Gene Therapy,56,Our Research Project,Target Chemotherapy of Colorectal Cancer Induced by Gene Transfection and Cytokines,57,Thank You for Your Attention,
