colorectel ppt.ppt
TRANSCRIPT
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INT. ONCOLOGY CONF. NAIROBI, OCTOBER 2011
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THEME Translating recent advances into local practice/clinical care
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RECTAL CANCER
Progress in MULTIMODAL THERAPY of Rectal Cancer is one of the BEST examples of success of Clinical Research in the last 2 decades.
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RECTAL CARCINOMA RECENT ADVANCES -- OVERALL1.SPHINCTER SAVING PROCEDURES UP FROM 15% TO 50% -- NO COLOSTOMY (IMPROVED QOL)2. OVERALL FIVE YR SURVIVAL UP FROM 30% TO 60%3. DEPTH OF INVASION DECREASED BY 40%-60% WITH ADJUVANT Rx4. LYMPH NODE STATUS AND REC. FREE SURVIVAL - SAME
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RECENT ADVANCES 1. MOLECULAR BIOLOGY 2. SURGERY 3. IMAGING MRI, CT AND PET4. CHEMO/RADIOTHERAPY
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MOLECULAR BIOLOGY DNA CHIP TECH. DNA SEQUENCE CHECKED -- APC GENE FAP -- MISMATCH REPAIR GENES HNPCCSUCH PTS.(5%) PUT ON A SURVEILLANCE PROG. --PROPHYLACTIC SURGERY
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MOLECULAR BIOLOGY
DNA SEQUENCE OF MICROSATELLITE INSTABILITY -- GOOD RESPONSE WITH 5 FU CHEMO.
P21 MARKER POSITIVE RADIOSENSITIVE
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MOLECULAR BIOLOGY
P53 PROTEIN MUTANT EXPRESSED -- RADIORESISTANT
KRAS, DCC, AND P53 -- IF +ve POOR PROGNOSIS
MICROSATELLITE INSTABILITY OR LOW Cox2 EXPRESSION & P21 MARKER IF +ve GOOD PROGNOSIS
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SURGICAL CHALLANGES
I-STAGING
II-USE OF CH/RT
III-SURGICAL TECHNIQUE
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I - STAGING
DECIDES TRANS ANAL LOCAL EXCISIONAPR.
NEOADJUVANT CH/RT
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TRADITIONAL STAGING
DIGITAL RECTAL EXAMINATION
CT SCANS
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NEWER STAGING METHODS
DRE
ERUS NODES
CT
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RECENT ADVANCES
DRE
ERUS
MRI
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RECENT ADVANCES
DRE
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RECTAL CA. RECENT ADVANCES
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RECENT ADVANCES ERUS
ERUS ------ BEST FOR NODAL STATUS ( OPERATOR DEPENDANT)
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STAGINGERUS T STAGE ACCURACY 60 90% N STAGE ACCURACY 60 90%MRIT STAGE ACCURACY 60 90% N STAGE 40 --- 80% ( NODES > 5mm)
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CHALLANGE
PICK UP NODES < 5mm (33%OF ALLNODES)
PICK UP MICRO METS
USE OF CH/RT
- MRIHIGH RESOLUTION THIN SLICE (
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MRIINDICATORS OF MALIGNANT NODAL INVOLVEMENT
L. NODES -- IRREGULAR BORDER -- MIXED SIGNAL INTENSITY OF NODE
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MRI
DETECTS EXTRAMURAL VENOUS INVASION (EMVI)
POOR PROGNOSIS WITHOUT CH/RT IF EMVI PRESENT
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II USE OF CH/RT (NEOADJUVANT/ADJUVANT)PTS WITH POOR HISTOLOGY
PTS WITH EXTRA MURAL SPREAD (MRI)
PTS WITH INVOLVED NODES (ERUS)
PTS WITH EMVI (MRI)
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CHEMOTHERAPYINJ KYTRIL 3mg Ksh 2,250/-INJ DEXAMETHAZONE 8mg Ksh 385/-INJ FLUOUROURACIL 5500mg Ksh 12,053/-INJ OXALIPLATIN 200mg Ksh 187,600/-INJ LEUCOVORIN 100mg Ksh 1,809/-INJ AVASTIN 400mg Ksh 213,806/-Kshs 417903/-
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RADIOTHERAPYEUROPEAN APPROACH(25G/5CYCLES)SHORT COURSE LOW DOSE IMMEDIATE SURGERYNO CHANGE IN PATH STAGINGLOWER COSTBETTER COMPLIANCEDOSE EQUIVALENT TO 30-33GEXPECT 66% REDUCTION IN LOCAL RECURRENCE
AMERICAN APPROACH(45 54G/28 CYCLES)PROLONGED COURSE HIGH DOSE DELAYED SURGERYBETTER SURGICAL TOLERANCEMORE TUMOR REGRESSIONEXPECT >80% REDUCTION IN LOCAL RECURRENCE
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III SURGICAL TECHNIQUE TRADITIONALPROCTECTOMY PERFORMED -- In the DARK -- Using BLUNT Dissection -- Without attention to ANATOMIC DetailRESULTED in -- Bloody operation -- Increased -- Autonomic Nerve injury -- Local Rec.
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SURGERY - TRADITIONALANT. RESECTION UPPER RECTAL CALOW ANT.RESCETION- MID RECTAL CAA.P.R. - LOWER RECTAL CA
ANY TUMOR 10cms FROM ANAL VERGE -- APR
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ANATOMY OF RECTUM
CHANGED FROM TRADIOTIONAL 22 CMS FROM ANAL VERGE TO 15 CMS
ABOVE THAT IS ALL COLON
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RECTAL CARCINOMA RECENT ADVANCES>100 YEARS SINCE MILES DESCRIBED ABDOMINO-PERINEAL-RESECTION
>25 YEARS SINCE HEALD DESCRIBED TOTAL MESORECTAL EXCISION
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III SURGICAL TECHNIQUERECENT ADV. TOTAL MESORECTAL EXISION
( EXICISION OF FASCIA ENVELOPING THE FAT PAD AROUND THE RECTUM.)
SAUSAGE APPEARANCE
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SURGERY RECENT ADVANCES
LOW-ANT RESECTION UPTO 6cms FROM ANAL VERGE
APR ONLY IF SPHINCTOR FUNCTION COMPROMISED
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RECTAL CANCER RECENT ADVANCESCAREFUL ASSESSMENT OF SxSEARLY DIGNOSIS WITH ACCURATE STAGING CH/RT - FOR SELECTED PTS- PROCTOSCOPY - SIGMOIDOSCOPY- DRE - ERUS- MRI
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OUR SCENARIOLATE PRESENTATIONADVANCED TUMORSANATOMICAL DISTORTIONLACK OF NEOADJUVENTSSURGERY MORE DIFFICULTRESULTS POORER
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COMMON PROBLEMS FACING SURGERY IN AFRICALACK OF GUIDELINES AND STANDARDS
INADEQUATE SUPERVISION
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VEINS OF SMALL & LARGE INTESTINES
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CAECAL CANCER RESECTION
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GOALS OF THERAPY FOR RECTAL CARCINOMA
DECREASE LOCAL RECURRANCE
OPTIMISE Q.O.L. AVOID COLOSTOMY
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CA. RECTAM (ESP. LOWER TUMORS) SHOULD BE DIAGNOSED EARLY
SHOULD GIVE GOOD RESULTS WITH EARLY THERAPY
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LOCAL EXPERIENCE 31 CASES OF RECTAL CA
25 APR DONE
6 LOW ANT RESECTIONS (2 Local Rec.)
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SYMPTOMSRECTAL BLEEDING LOWER RECT.TENESMUS
ALT. OF BOWEL HABITS UPPER.ANY G.I. SxS (dyspepsia)
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RECTAL CANCER
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