CARCINOMA COLORECTAL

SYAM SUHARYONO
SESARIUS BIMO NI PUTU DIAN AYU P RENDI AJI PRIHANINGTYAS

MARIA RIANDIKA
MUHAMMAD ZAKIY MUNTAZAR

1. Epithelial tumor

Epithelial tumor Columnar/galndular epithelium adenoma/adenosarcoma Colon, Rectum

TIPE TUMOR

Lymphoid Tumor Ileum terminal

columnar/glandular epitelium adenoma/ adenocarcinoma 1. t

Tipe Tumor

Stromal Tumor (GISTs) Phenotype of a pacemaker cell found in the muscle coat (intestinal Cell of Cajal)

Secondary (metastatic Cancer)

EPITHELIAL TUMOR
Epithelial Tumor

Columnar/glandular epithelium

Suamous epithelium (lower anal canal)

Adenoma (5% adenosarcoma)

Adenosarcoma

SCC

EPITHELIAL TUMOR

Hamartoma Epithelial polyp Commonest : hyperplastic polyp

Peutz-Jeghers polyp small intestine Juvenile polyp colon,rectum Distal colon and rectum

EPITHELIAL POLY

LYMPHOID TUMOR
MALToma Blymphosit Lymphoid tumor T-cell lymphoma Burkitt Lymphoma Mantle cell Lymphoma Proximal jejunum

STROMAL TUMOR

Stromal Tumor

Behaviour is anpredictable

Large size, high mitotic rate malignancy

Bona fide smooth muscle rectum

METASTATIC CANCER

Small intestine comon site Primary source : melanoma, breast, lung cancer Intestinal tract is not a common site

EPIDEMIOLOGY
Ca Colorectal Secondary cancer death after lung cancer
USA

West

55.000 death/year
Highest : west Lowest : developing world

All cancer diagnosed/year

8,5%

INCIDENCE
Colonic cancer M=F

Rectal Cancer F=2M

INCIDENCE
Colorectal cancer

Rapid increase Western life style

Is age related

Japan, urban China, male polynesian in Hawaii

High Mortality : ageing population 6575 year

Genetic error : multiple neoplasma, early age hereditary colorectal Ca

ETIOLOGY
Is not knowm

Enviromental factors

Genetic factors
Is not known

ENVIRONMENT FACTOR
vegetable anf fibre NSAID

Smoking and alcohol

Dietary and life style factor

Selenium

Meat and fat

Calcium and bile acid

GENETIC FACTORS
HIGH PREVALENCE POLYMORPHISMS RARE INHERITED SYNDROMES

N-Acetyltransferase and citochrome P450 enzyms

Familial adenomatous polyposis

Methylenetetrahydrofolate reductase

Hereditary Non-Polyposis Colorectal Cancer

Germline Mutation of TGF B type II Receptor

CHRONIC INFLAMMATION

Ulcerative Collitis

Crohns Disease

PREVENTION
Prevention of radical surgery

Prevention of death

PREVENTION
Lifestyle adjusment Taking preventif medication (chemoprevention) Screening asymptomatic subject for risk factors

SCREENING
Testing faeces for occult blood
Endoscopic examination of the mucosal lining of the large bowel Demonstration of a high risk genetic mutation

PREINVASIVE LESION

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

ADENOMA
Macroscopic
Sessile elevation < 5mm but increasing growth is associated with the formation of a stalk composed of normal mucosa and submucosa

Microscopic
Tubular, tubulovillous, villous

Polypoid growth that may be sessile or pedunculated

Tubules are lined by columnar epithelium and embedded within lamina propia

Minority : flat/depressed lesion

Vili comprise a covering of columnar epithelium and a core of lamina propria

Head is darker than surrounding normal mucosa, lobulated baby cauliflower

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

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

GRADING
Well differentiated adenocarcinoma Grade 1 The glands are regular and the epithel resembles adenomatous tubules Moderately differentiated adenocarcinoma Grade 2 The glands show complex budding, irregular outpouching or gland within gland structure Poorly differentiated adenocarcinoma Grade 3 Glands are highly irregular or distorted

Grade 4

Undifferentiated carcinoma

DIAGNOSTIC
Anamnesis Physical Examination
RECTAL TOUCHER

Lab Examination

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

SIGN & SYMPTOM

Depend on the location, size, type Abdominal pain Anemia Weight loss Perubahan defikasi Diarrhea Blood in feses Obstruction

Komplikasi : Perforasi, peritonitis

SIGN & SYMPTOM

KOLON KANAN Tipe tumor Kaliber kolon Feses Fungsi Gejala klinis Dispepsia Perub.pola BAB Obstruksi Darah dalam tinja Polipoid, ulseratif Besar Cair absorbsi Kolitis Sering Diare Jarang Mikroskopis KOLON KIRI REKTTUM Stenosis Kecil Setengah padat penyimpanan Obstruksi Jarang Konstipasi, progresi Dominan mikro/makro Infiltratif, polipoid Besar Padat defekasi Proktitis Jarang Tenesmus Jarang Makros

LABORATORIUM
Routine blood : Hb, AL Urinalysis Hepar and ren function CEA : urine,feses < 10 ng/ml : stadium dini > 10 ng.mL : stadium lanjut

RADIOLOGIC EXAMINATION
Colon in Loop CT Scan Abdomen

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.

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.

CONTOH

Pemeriksaan CIL yang menunjukan lesi apple core dengan penyempitan circumferential

CONT..

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

ENDOSCOPY

VENOUS INVASION
Increase the risk of metastatic spread to the liver via the portal vein

TNM CLASSIFICATION

METASTATIS
Carcinoma Colorectal
Direct Hematogen Limfogen Transperitoneal Nerve Intraluminer

METASTASIS
Ca Rectum
Direct Limfogen Hematogen Nerve

SURVIVAL

JASS PROGNOSTIC CLASSIFICATION

RECURRENT AND DISTANT DISEASE

THE FUTURE

MANAGEMENT
Operative Therapy (cutting) Radiation therapy (burning) Chemotherapy (poisoning)

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 <6cm (Miles procedure) Dilakukan apabila tumor terletak di 1/3 bawah rektum

 Paliatif
Mengilangkan gejala obstruksi Tumor tidak diangkat karena telah metastase

Colon kanan (Illeotransversostomi) : dilakukan pada tumor di kolon kanan, ileum terminal 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

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

KEMOTERAPI
Menghambat pertumbuhan neoplastik 5 FU merupakan ntinepolstik menghambat eznim asam nuklea , dan menghambat fosfat necluotide dan enzim ribonucleotide difosfat reduktase

REFERENSI
The Cancer Handbook Weinberg 2003 Imaging in Oncology from The University of Texas M.D. Anderson Cancer Center Rusdy Ghazali Maleuka- Radiologi Diagnostik 2006 Cermin Dunia Kedokteran No. 85 1998 Robbins Basic Pathology 7th Edition www.emedicine.com www.wikiradiography.com