1. by
UKShrivastava
Prof &Head Surgery Department
AIMST University
Malaysia

2. Definition------- Uncontrolled cell growth in
the lining of bowel, colon and rectum
if remain untreated, grows into the
muscular layer and then to out side
All such growth confined to mucosa only
are early cancer and curable. That is T I tumor
Considered to be 4th most commonly
diagnosed cancer in the world & 2nd
most frequent cause of cancer death

3. Age ---Seen in people above 50years of age
Polyp– majority start in polyp, which develop in
lining of bowel mucosa
Genetics -HNPCC(lynch syndrome), FAP,
Gardner Syndrome
Family History-- Raises two fold
Personal History—Either of polyp or any cancer
I.B.D. ---- Ulcerative colitis, Crohn’s Disease

4. Diet----- High animal fat & low fiber diet
Smoking-- Studies shows high incidence
Obesity---- High incidence
Physical activity---Sedentary life style raises
Non Steroidal Anti inflammatory Drugs---
Studies says it reduces the incidence
So better food with fruits, green vegetables
Exercise, non smoking Reduces the
incidence

5. Change in bowel habits
Blood in stools
Constipation & feeling of incomplete
deification
General Abdominal Discomfort
Weight loss, Poor appetite
Continued Tiredness
Vomiting, Anemia

6. 1 Faecal Occult blood---Either by Guaic test or
Immunochemical reaction
Usually 50 to 70 yrs
High risk 40 years
2 Flexible sigmoidoscopy-- low risk 5 years
High risk 2 years
3 Colonoscopy----- low risk 10 years
High risk 5 years
If required get Bx

7. 4 Virtual Colonoscopy--- super x-ray of colon
air is pumped to colon to
expand CT pictures are taken
Bx can not be taken
5 Double Contrast Barium Enema
6 Digital rectal examination
7 Endoscopic rectal ultrasound
8 Abdominal U/S , X-ray chest MRI pelvis,CT
scan and
Positron Emission Tomography PET scan
9 CEA estimation-- Tumor marker for follow up

8. Stage I----- Growth invades inner mucosa &
Sub mucosa NO lymph node
Stage II----- Penetrates to mesorectal tissues
NO lymph node
Stage III------ Regardless to penetration the
Lymph nodes are involved
Stage IV ------ Evidence of cancer in other
parts of body ( metastatic)

9. CRITERIA’S
Tumor small chance of metastasizing
due to paucity of lymphatic's in
colorectal mucosa
These tumors are usually well to
moderately differentiated,
Absence of lympho vascular & neural
Invasion
ALL such lesions if with in 8 to 10 cm from anal
verge& the tumor is of size 3 to 4 cm occupying
1/3 of circumference of rectal wall are best treated
BY TRANS ANAL EXCISION

10. Presentations ------
A Polypoidal carcinoma
B Large pedunculated or sessile Adenoma
C Small ulcerated adeno carcinoma
TO DETECT SUCH EARLY LESIONS SCREENING
IS ALWAYS REQUIRED AND CURE IS POSSIBLE
BY
TRANS ANAL ENDOSCOPIC MICROSURGERY

11. Screening for all rectal bleeding
On colonoscopy-irregularity of mucosa they
look like
mucosal pinkness
superficial granularity,nodularity
mucosal fading, or depression
hemorrhagic spots
What to do? Spray the mucosa with indigo
carmine make it visualize & Bx

12. Magnifying colonoscopy is helpful
Endo rectal ultra sonography is helpful
Very sensitive Invx for Ti & Tii tumor
Helpful to find residual tumor after
polypectomy
MRI--- This is helpful to find tumor invading
beyond submucosa to muscularis coat
MRI & Ultrasound both good for L.N. Mets
PET is used only see the pelvic recurrence
SLN bx after isosulfan blue dye injection

13. It must include---- Accurate histology
Safe oncologic procedure
High chance of cure
Minimum morbidity
PROCEDURE DESTROYING HISTOGY NOT
GOOD
a Electro coagulation
b Endocavitory Radiation
c Laser and Cryotherapy

14. Options Pathological stage
1 Standard polypectomy -- Pedunculated
adenoma & ERC Ti
2 Endoscopic mucosal - Flat &depressed
resections adenoma >3cm
3 TEM Large adenoma
Ti smi smii smiii& Tii
4 Anterior Resection T I smiii Tii with poor
differetiation, vascular
invasion & incomplete
excision

15. Park’s per anal exicision—
ideal for tumor at 6-10cm from anal verge
assessed with fibro optic anal retractor
posterior tumor position Trendelenburg
anterior tumor jack-knife position
lateral tumor either left or right lateral position
full thickness with 1cm margin removed
underlying mesorectal fat palpated ,for L.N.
Defect sutured or stappled, pt can eat ,discharged
complication few 5% bleed, R/V fistula, retention

16. Anterior Resection---
Required for high risk ERC patient
ERC with sub mucosal level ii and iii invasion
For poorly differentiated growth
Evidence of lymphovascular & neural
invasion
Whenever the dissected margins are positive
Inadequate tissues for histological
assessment
RARE TO GO FOR A.P.R. IN ERC CASES

17. Management depends on histology of tumor
Important to handle the excised tumor with care
Should be submitted fresh with all treatmement
details.
A Pedunculated Type– Ip, Ips, Is
B Flat Type ---- flat elevated IIa, flat depression
IIa +IIc., flat elevated.and
depression,type
C Depressed Type
Laterally spreading Type laterally spreading

18. Adenoma-- Pedunculated 42to85% cases
Sessile 15to58% of cases
All ERC are T1 tumor ( TNM) classification
Haggitt described sub mucosal invasion in
polyp
at level 1,2,3, Invasive ca in sessile is L 4
Kikuchi classified the sessile lesion
sm1a , sm1b , sm1c, sm2 sm3
1/4 1/2 >1/2 , in-between, mus.pro

19. Size---- < 5mm never found to have Ca
> 1cm have Ca focus in 40% of cases
those above 42mm of size Ca in 80%
Villous adenoma highest risk in 30% of cases
adenoma found in rectum high risk for Ca 24%
adenoma in Rt colon 6% and lt Colon 8% cases
Low-risk ERC completely excised, no lympho-
vascular invasion and well differentiated
Achieved by polypectomy or by TEM sm1 &T
High risk all Sm2 and sm3 growth with invasion
OVERALL LYMPH NODE METS IN ERC T1 TUMOR IS
RARE
5to20%in sm2 and sm3 group

20. Many studies claim benefit chemo radiation
for growth upto7cm anal verge resectable
ERC
with complete response 5 FU, leucovorin # RT
( 30% ) NO Further treatment
All those with incomplete response- surgery
for removal of residual growth
Adjuvant Chemoradiation – only for T2 rectal
Ca

21. ERC which has high histological grade that is
All sm3 and sm2 with invasion with, neural
and lymphatic invasion
Tumor those ulcerated or flat raised variety
Tumor showing invasion to resected margins
Tumor in rectum, recurrence is higher than other part
of large bowel
ERC lying in lower third of rectum Six fold high
risk than upper part
Molecular Marker-cyclin dependent kinase inhibitor
better prognosis and sucrose isomaltase higher
recurrence

22. Regular endoscopic surveillance for recurrence
Endorectal ultrasonograph- at each follow up
Digital rectal examination, and sigmoidoscopy
every 3 months for 3 years 6 months 2 years
then every year
CEA estimation to be done each visit of patient
MRI and PET if required to be done
All those cases had RTH should have longer
follow up recurrence make at longer gap

23. Recurrence totally depends on Histology and
molecular biology of the ERC
Overall recurrence after local excision 10%
Oxford study group 5 yr disease free survival
after TEM is 79% for ERC
The U.S.National cancer studies low risk100%
5 yr DFS high risk 29% 10yrDFS
Those having Chemoradition show better survival
In case of LN mets DFS goes down to 36% only.

24. Early diagnosis
and treatment of ERC improves the outcome
Mass screening programmer are MUST
Improved histological staging is important
Classical surgery always afford better cure
Low risk ERC with local excision and TEM do
match the outcome , preserving rectal
function
High risk with TEM outcome NOT that good