肿瘤临床诊断研究

COLORECTALCARCINOMAZHANGJimin,MD.,PhD.GastrointestinalDepartmentofSurgery,TheSecondHospital,GuangzhouMedicalUniversity1第1页●

Cecum●

AscendingColon●

TransverseColon●

DescendingColon●

SigmoidColon●

RectumANATOMY2第2页●

12~15cm●

peritonealportionandpelvisportion●

mesorectumMesorectum全直肠系膜切除(TME)TotalMesorectumExcisionABOUTRECTUM3第3页●commontumoringastrointe-stinaltract

●occurmostlyat41~65yearsold

●coloncancerseemsmoreandmoreinrecent20years●proliferation—adenoma--carcinoma,about10~15yearsINTRODUCTION4第4页PATHOLOGY●

Masstype（隆起型）

多见于升结肠、盲肠，肠腔内生长，转移发生较晚●

Invasivetype（浸润型）

多见于降结肠，肠壁内生长，易引起狭窄及梗阻●

Ulcerationtype（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5第5页MASSTYPE6第6页INVASIVETYPE7第7页ULCERATIVETYPE8第8页HISTOLOGICCLASSIFICATION腺癌（Adenocarcinoma）●

管状腺癌（tubularadenocarcinoma）

●乳头状腺癌（papillaryadenocarcinoma）●粘液腺癌（mucinousadenocarcinoma）●

印戒细胞癌（signet-ringcelladenocarcinoma）腺鳞癌（Adenosquamouscarcinoma）

一般见于低位直肠癌或者肛管癌未分化癌（undifferentiatedcarcinoma）9第9页NormalepitheliumMicro-adenomaEarly-stageadenomaMiddle-stageadenomaCarcinomaAdvancedadenomaETIOLOGYOver50%comefromthecancerationofadenoma.Fromnormalcelltocancercells,itwillneed10~15years10第10页HIGHRISKFACTORS●

Toomuchanimalfatorproteininfood●

Toolittlevegetableandfibrininfood●

Toolittlebodyexercise●

Susceptibilityingenetics●

Familialadenomatouspolyposis(FAP)●

Others(adenoma,ulcerativecolitis,etc)11第11页adenomaFAP12第12页CEA(carcinoembryonicantigen)Animportantmarkerforcolorectalcancer(expressedin60%ofpatients)TUMORMARKER13第13页EXTENDINGROUTESOFCOLORECTALCANCER●

Lymphaticspread●

Hematogenousspread:hepaticmetastasis●

Directinvasionofadjacentstructures●

Implantationspread14第14页LYMPHATICMETASTASIS15第15页PATHOLOGICSTAGING●

DukesStaging:

OriginallydevelopedbyDukesin1935,andfurthermodifiedin1954●

TNMStaging:RecommendedbytheUICC

(InternationalUnionAgainstCancer)(UnionforInternationalCancerControl)16第16页DukesStaging●

StageA:

肿瘤局限于肠壁，未穿透浆膜●

StageB:

肿瘤穿透浆膜，但无淋巴结转移●

StageC:肿瘤穿透浆膜，伴有淋巴结转移●

StageD:

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17第17页TNMStaging202023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他脏器18第18页TNMStaging●N0:

无淋巴结转移，NX：无法估计淋巴结●N1：转移区域淋巴结1~3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19第19页HIGH-RISKPATIENTSIfthepatientsover40yearsold:●

Familyhistoryofcolorectalcancer●

Familialadenomatouspolyposis(FAP)●

Occultblood(+)infeces●

mucopurulentbloodystool,diarrhea,constipation,chronicappendicitis,etc…●

CEAisoverexpressed20第20页CARCINOMAOFCOLON21第21页CLINICALFEATURES●

changesofbowelhabitsandstool

(diarrhea,constipation,bleeding……)●

stomachaches●

massinabdomen●

obstruction●

generalsymptoms(anemia,weightlose,asthenia,fever……)22第22页DifferencesofColonCancer

inAscendingwithindescendinginrightcolon:●

anemia●

weakness●

weightloss●

massinleftcolon:●

changesinfeces●obstruction…23第23页IMAGINGSTUDIES24第24页BARIUMENEMARADIOGRAPHY25第25页COLONOSCOPY26第26页CTSCANNING27第27页TREATMENT●

Surgicalresectionofthelesion,anddissectionofitsregionallymphnodes●

Chemotherapy●

Radiotherapy●

Biotherapy●

Imunotherapy●

Genetherapy28第28页(1)RadicalColectomy●

右半结肠切除+区域淋巴结打扫●

横结肠切除+区域淋巴结打扫●左半结肠切除+区域淋巴结打扫●乙状结肠切除+区域淋巴结打扫29第29页右半结肠癌切除范畴左半结肠癌切除范畴横结肠癌切除范畴乙状结肠癌切除范畴30第30页(2)WithAcuteObstructionInAscendingColon:

●

Wellstatus:右半结肠切除+回肠-横结肠吻合术●

Poorstatus:盲肠造瘘，然后二次切除31第31页InDescendingColon●

一方面横结肠造瘘解除梗阻●

然后在充足肠道准备下手术切除32第32页ChemotherapyBasicagent: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33第33页CARCINOMAOFRECTUM34第34页●

Morethancoloncarcinoma(1.5:1)●

60%~75%inlowerrectum●

10%~15%<30yearoldETIOLOGICALCHARACTERISTIC35第35页(1)DirectInvasionto:wallofbowel,adjacentorgan,suchas:womb,prostate,bladder,seminalis,vagina,ureter……SPREAD&

METASTASIS36第36页腹积极脉旁淋巴结(2)LymphaticSpread

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37第37页(B)低位肿瘤向上方或者侧方转移(C)齿状线周边旳肿瘤向上方、侧方或者腹股沟淋巴结转移38第38页(3)HematogenousSpread

●

Throughportalveintoliver●

About10%~15%ofpatientswithlivermetastasis●

Throughiliacveintolungbone,orbrain39第39页(4)ImplantationMetastasis●

Implantationmetastasisoccurinupperrectalcanceroccasionally40第40页CLINICALFEATURES●

直肠刺激症状:

便意频数;里急后重；排便习惯变化●

肠腔狭窄症状:

便条形状变化或不完全梗阻●

癌肿破溃感染症状:

血便或粘液脓血便41第41页●

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…42第42页DIAGNOSIS(1)大便潜血实验（Testforoccultblood）:usedasprimarytestforhighriskpeople(2)

直肠指诊（RectalTouch）:themostimportanttestfordiagnosis(3)

结肠镜检（Endoscopy）:fordiagnosisandbiopsy,about5%~10%

ofcasesweremultipletumor43第43页(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旳浸润状况●

PET-CT:评价有无远处转移及估测预后44第44页

(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45第45页TREATMENT（一）手术治疗：

Themostimportantradicaltreatmentforrectalcarcinoma46第46页(1)局部切除LocalResection:suitableforearlystage,withasmallsize,locatedinmucosa

●经肛门局部切除术

●骶后径路局部切除术47第47页（2）腹会阴联合直肠癌根治术既往—金原则手术Milesoperation：themostlyusedradicaloperationforlowerrectalcarcinoma48第48页DixonOperation:

suitablefortumorover5cmapartfromanus(3)经腹直肠癌切除术—直肠低位前切除术49第49页(4)经腹直肠癌切除、近端造口、远端封闭手术HartmannOperation:

suitableforthecaseswithapoorstatus,forwhomneitherMilesnorDixoncan’tbeaccepted50第50页●后盆腔脏器打扫（PosteriorPelvicExenteration）radicalresectionwithhysterectomy●全盆腔脏器打扫（PelvicExenteration）

radicalresectionwithcystectomyandhysterectomy51第51页(2)Ridiotherapy●

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