第六节 结肠癌.docx
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第六节 结肠癌.docx
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第六节结肠癌
第六节结肠癌(Sixthcoloncancer)
第六节结肠癌
结肠癌(结肠癌)是胃肠道中常见的恶性肿瘤,以41^岁发病率高在我国65。
近20年来尤其在大城市,发病率明显上升,且有结肠癌多于直肠癌的趋势。
从病因看半
数以上来自腺瘤癌变,从形态学上可见到增生、腺瘤及癌变各阶段(图40-13)以及相应
的染色体改变。
随分子生物学技术的发展,同时存在的分子事件基因表达亦渐被认识,从
中明确癌的发生发展是一个多步骤、多阶段及多基因参与的细胞遗传性疾病。
大肠癌时从细胞向癌变演进,从腺瘤一癌序列约经历10^-15年,在此癌变过程中,
遗传突变包括癌基因激活(K-ras、c-myc、EGFR)、抑癌基因失活(APC、DCC,
p53)、错配修复基因突变(hmshi,何梁何利,pms1,PMS2,GTBP)及基因过度表
姨发减一F=F一
尹1E)所日马所有
~目APCK-ras基因DCCP53nm23?
MMR
染色体
改变
去甲基
MMR
5q12q18q17q
突变·缺失突变突变?
缺失突变·缺失缺失·突变?
图40-13大肠癌变过程模式图
(错配修复基因):
hMSH2、hMLH1、创新1创新2
达(COX-2,CD44v)OAPC基因失活致杂合性缺失,APC/汗连环通路启动促成腺瘤
进程;错配修复基因突变致基因不稳定,可出现遗传性非息肉病结肠癌(遗传性非—
息肉性结肠癌,HNPCC)综合征。
结肠癌病因虽未明确,但其相关的高危因素渐被认识,如过多的动物脂肪及动物蛋白
饮食,缺乏新鲜蔬菜及纤维素食品;缺乏适度的体力活动。
遗传易感性在结肠癌的发病中
也具有重要地位,如遗传性非息肉性结肠癌的错配修复基因突变携带的家族成员,应视为
结肠癌的一组高危人群。
有些病如家族性肠息肉病,已被公认为癌前期疾病;结肠腺瘤、
溃疡性结肠炎以及结肠血吸虫病肉芽肿,与结肠癌的发生有较密切的关系。
病理与分型根据肿瘤的大体形态可区分为:
1。
肿块型(图40-14)肿瘤向肠腔内生长,好发于右侧结肠,特别是盲肠。
2。
浸润型(图40-15)沿肠壁浸润,容易引起肠腔狭窄和肠梗阻,多发生于左侧
结肠。
3。
溃疡型(图40-16)其特点是向肠壁深层生长并向周围浸润,是结肠癌常见类型。
图40-14肿块型结肠癌
显微镜下组织学分类较常见的为:
①腺癌:
占结肠癌的大多数②粘液癌:
预后较腺。
癌差。
③未分化癌:
易侵人小血管和淋巴管,预后最差。
临床病理分期分期目的在于了解肿瘤发展过程,指导拟定治疗方案及估计预后。
国
M+}
际一般仍沿用改良的公爵分期及UICCTNM分期法提出的。
根据我国对公爵法的补充,分为:
癌仅限于肠壁内为公爵穿透肠壁侵人期。
浆膜或/及浆膜外,但无淋巴结转移者为B期。
有淋巴结转移者为C期,其中淋巴结转移
仅限于癌肿附近如结肠壁及结肠旁淋巴结者为C1期;转移至系膜和系膜根部淋巴结者为
C:
期。
已有远处转移或腹腔转移,或广泛侵及邻近脏器无法切除者为1之期。
TNM分期法:
T代表原发肿瘤,TX为无法估计原发肿瘤。
无原发肿瘤证据为来;原位癌为T;G;肿
瘤侵及粘膜肌层与粘膜下层为T1;侵及固有肌层为TZ;穿透肌层至浆膜下为T3;
Penetratingdirt
PeritoneumorinvasionofotherorgansortissuesisT4.
Nwasregionallymphnode,N,andnolymphnodecouldbeestimated;nolymphnodemetastasiswasNo;lymphnodemetastasiswas1-3
OnewasN,andtheother4andmorethan4lymphnodeswereNzo
Mfordistantmetastasis,distantmetastasiscannotbeestimatedforMX;nodistantmetastasistodistantmetastasisforallquack;M,.
TNMstagingcomparedwithDukesstagingisshownintable40-10
Table40-1comparisonofTNMstagingwithDukesstaging
TNMstaging
Dukesstaging
Nc
TisTITZPlush
O
I
AnyTN,
Nz
AnyTNM
Coloncancerismainlylymphaticmetastasis,firsttothecolonwallandthecolonlymphnode,andthentothemesentericvasculararoundandintestinal
Mesentericlymphnode.Hematogenousmetastasisismorecommonintheliver,followedbylung,bone,etc..Coloncancercanalsobedirectlyinfiltratedintothevicinity
Organ.Suchasthesigmoidcolon,bladder,uterus,ofteninvadeureter.Transversecoloncancercaninvadethestomachwall,andevenformtheinterior.
Exfoliatedcancercellscanalsobetransferredinperitonealimplants.
TheclinicalmanifestationofCRCisthatitusuallyhasnospecialsymptomsintheearlystageofdevelopment.Themainsymptomsarefollowingsymptoms:
1.thechangeofdefecationhabitandfecalcharacterisusuallytheearliestsymptom.Mostofthemwereincreaseddefecationfrequencyandabdomen
Containingblood,pus,ormucusinthestool.
Theabdominalpainisoneofthe2.earlysymptoms,oftenpersistentpainpositioningisnotclear,oronlyforabdominaldiscomfortorabdominal
Distensionoftheabdomenandthepresenceofintestinalobstructionareaggravatedbyabdominalpainorparoxysmalangina.
3.,theabdominalmassismostlytumorbodyitself,andsometimesmaybeobstructionintheproximalgutcavityfecalaccumulation.Mostofthelumpsarehard,
Nodular.Asforthetransverseandsigmoidcoloncancercanhavecertainactivity.Ifthecancerpenetratestheconcurrentinfection,thetumorissolid
Definiteandmarkedtenderness.
4.,intestinalobstructionsymptomsaregenerallycoloncancerinthemiddleandlatesymptoms,mostlychronic,incompleteintestinalobstruction,theLord
Thesymptomsarebloatingandconstipation.Abdominalpainorparoxysmalangina.Whenacompleteobstructionoccurs,thesymptomsareexacerbated.Leftcolon
Cancercansometimesbeacuteandcompletecolonicobstructionisthefirstsymptom.
Bereluctanttoleave
Dipinthefragrance,lookforwardtoL
5.,systemicsymptomsduetochronicbleeding,cancerulceration,infection,toxinsabsorption,etc.,patientscanappearanemiaanddisappear
Lean,weak,lowheat,etc.Thediseasemayoccurlatehepatomegaly,jaundice,edema,ascites,rectaltumor,supraclavicularconcave
Lymphnodeenlargementandcachexia.
Becauseofthepathologicaltypeandlocationofthecancer,theclinicalmanifestationsaredifferent.Ingeneral,rightcoloncancerischaracterizedbysystemicsymptoms,
Anemia,abdominalmasswerethemainmanifestationsofleftcoloncancerwithintestinalobstruction,constipation,diarrhea,hematocheziaandothersymptoms.
Theearlysymptomsofcoloncancerarenotobviousandeasilyoverlooked.Anypersonwhoisover40yearsofageandanyofthefollowingshallbelistedas
Highriskpopulation:
OIlevelrelativeswithcolorectalcancerhistory;thehistoryofcancerorintestinaladenomasorpolypshistory;thefecaloccultbloodtest
Testpositive;thefollowingfiveperformancethantwoitems:
mucousbloodystool,chronicdiarrhea,chronicconstipation,chronicappendicitis
Historyandhistoryoftrauma.Inthisgroup,thehigh-riskgroupunderwentfibercolonoscopyorX-raybariumenemaorbariumgasdoublecontrast
Itisnotdifficulttomakeadefinitediagnosis.TypeBultrasonographyandCTscanwereperformedtounderstandabdominalmassesandenlargedlymphnodesandtodetecttheliver
Whetherthereareanytransfersandsoonarehelpful.Serumcarcinoembryonicantigen(CEA)valueswereapproximately60higherinbowelthaninnormalcoloncancerpatients,however
Theoppositesexisnothigh.Forpostoperativejudgment,prognosisandrecurrence,therewillbesomehelp.
Theprincipleoftreatmentiscomprehensivetreatmentbasedonsurgicalresection.
1.radicalresectionofcoloncancershouldincludethebowelmixanditsmesenteryandregionallymphnodesofthecarcinoma.
(1)righthemicolectomyforthececumandascendingcolon,hepaticflexureofcoloncancer.Thececumandascendingcolon
Cancerresection,includingrighttransversecolon,ascendingcolonandcecum,includingsome15^-20cmterminalileum(Figure40-
17),
Fortheendorendtosideanastomosisofileumandcolon.Forthecancerofthehepaticflexureofthecolon,itmustbeexcisedinadditiontotheaboverange
Thelymphnodesofthecolonandgastroomentalrightarterygroup.
Figure40-17righthalfcolonresectionrange
(2)thetransversecolonresection(Figure40-18):
suitablefortransversecoloncancer.Includesresectionofthehepaticflexureofthecolonandsplenicflexure
Andthegastrocolicligamentoflymphnodeforascendinganddescendingcolonicanastomosis.Ifthetensionatbothendsistoolargetokiss
Together,transversecolonresectionoftheleftsideofthedescendingcolon,ascendingcolon,sigmoidcolonanastomosisfor.
(3)lefthemicolectomy:
suitableforcolon,splenicflexureanddescendingcoloncancer.Theextentofresectionincludingtransversecolon,lefthalf
Thebowelisresected,andpartialorallsigmoidcolon(Fig.40-19)isremovedaccordingtothelocationofthedescendingcolon,andthenthecolonorthecolonisremoved
End-to-endanastomosisofintestineandrectum.
(4)radicalresectionofsigmoidcoloncancershouldbedoneaccordingtothelengthofsigmoidcolonandthelocationofthecancer
Theentiresigmoidcolonandallthedescendingcolonwereresected,orthewholesigmoidcolon,partofthedescendingcolonandpartoftherectumwereremoved,andthecolonwasremoved
Fortiethchapters
A,
Figure40-18colonresection
Figure40-19lefthalfcolectomyrange
Anastomosisofrectum(Figure40-20)0
2.colorectalcancerassociatedwithacuteintestinalobstructionsurgeryshouldbecarriedoutingastrointestinalreduction
Pressure,correctwaterandelectrolytedisturbances,andacid-baseimbalanceafterproperpreparation,
Earlysurgery.Rightcoloncancerisresectionofrightcolonforprimaryileum
Anastomosis.Ifthepatientisnotallowed,hewillhaveacolostomyfirsttorelievetheobstruction.Thetwostage
Radicalresectionwasperformed.Ifthecancercannotberemoved,thedistalileumcanbesevered,
Inthecutendileotransversoendtosideanastomosis,thedistalterminalileumproximalcolostomy.Left
Whencoloncanceriscomplicatedwithacuteintestinalobstruction,itshouldbedoneintheproximalpartoftheobstruction
Transversostomy,fullypreparedinintestinalconditions,thenthetwostageoperationforroot
Therapeuticresection.Ifthetumorcannotberemoved,thenpalliativecolostomywillbeperformed.
Inthespecificoperationofcoloncancerresection,thetumorshouldbelocatedfirst
Theproximalbowelwithgauzetiedtopreventcancercellsintheintestinalcavityexpansion
Looseplanting.Thebloodvesselsarethenligatedtopreventmetastasisofthecancercells.
Ananti-cancerdrug,suchas5-FU,isthenremovedwithintestinalresection.
Figure40-20extentofresectionofsigmoidcolon
Canbedilutedintheclosedlumenoftheintestine
Coloncancersurgeryusuallyrequiresadequatebowelpreparation,andbowelpreparationisprimarilytheevacuationofintestinaltractandproperintestinalantibiotics
Application.Intestinalemptying:
therearemanymethods,and12-24hoursbeforetheoperation,thecompoundpolyethyleneglycolelectrolytepowder2000-istakenorally
3000mlororalmannitol.Alsothedaybeforesurgery,orallaxatives,suchascastoroilandSennaorMagnesiumSulfateliquidetc..
Unlessthereisasuspectedintestinalobstruction,thereisasmallbowelcleansingmethodforrepeatedcleansingenema.Themakingofintestinalantibiotics
Usage:
routineuseofmetronidazole,0.4g,threetimesaday,neomycin1g,twotimesaday,onedaybeforesurgery.Notrecommended
Bowelpreparationforthreedays.
3.forch
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