Post on 14-Apr-2018
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CARCINOMA
COLORECTAL
SYAM SUHARYONO
SESARIUS BIMO
NI PUTU DIAN AYU P
RENDI AJI PRIHANINGTYASMARIA RIANDIKA
MUHAMMAD ZAKIY MUNTAZAR
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TIPE TUMOR
1. Epithelial tumor
columnar/glandular epitelium adenoma/
adenocarcinoma
1. t
Epithelial tumor
Columnar/galndular epithelium adenoma/adenosarcoma
Colon, Rectum
Lymphoid Tumor
Ileum terminal
Stromal Tumor (GISTs)
Phenotype of a pacemaker cell
found in the muscle coat(intestinal Cell of Cajal)
Secondary (metastatic Cancer)
Tipe Tumor
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EPITHELIAL TUMOR
Epithelial Tumor
Columnar/glandularepithelium
Adenoma (5%adenosarcoma)
Adenosarcoma
Suamous epithelium(lower anal canal)
SCC
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Epithelial polyp
Hamartoma
Peutz-Jegherspolyp small
intestine
Juvenile polyp colon,rectum
Commonest :hyperplastic
polypDistal colon and
rectum
EPITHELIAL TUMOR
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EPITHELIAL POLY
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LYMPHOID TUMOR
Lymphoidtumor
B-lymphosit
MALToma
BurkittLymphoma
Mantle cellLymphoma
T-celllymphoma
Proximaljejunum
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STROMAL TUMOR
Stro
malTum
or
Behaviour isanpredictable
Large size, high mitoticrate malignancy
Bona fide smooth
muscle rectum
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METASTATIC CANCER
Intestinal tractis not acommon site
Primary source: melanoma,breast, lung
cancer
Small intestine comon site
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EPIDEMIOLOGY
Ca Colorectal
West
All cancerdiagnosed/year
Secondary cancer death after lung cancer
USA
8,5%
55.000 death/year
Highest : west Lowest : developing world
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INCIDENCE
Colonic cancer
M=F
Rectal Cancer F=2M
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INCIDENCE
Colorectal cancer
Japan, urban China,male polynesian in
Hawaii
High Mortality :ageing population 65-
75 year
Genetic error :multiple neoplasma,early age hereditary
colorectal Ca
Rapid increaseWestern life style
Is age related
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ETIOLOGY
Enviromentalfactors
GeneticfactorsIs
notk
nowm
Isnot
known
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ENVIRONMENT FACTOR
Dietaryand life
stylefactor
vegetableanf fibre
Meat andfat
Calciumand bile
acid
Selenium
Smokingand
alcohol
NSAID
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GENETIC FACTORS
HIGHPREVALENCE
POLYMORPHISMS
N-Acetyltransferase andcitochrome P450 enzyms
Methylenetetrahydrofolatereductase
RARE INHERITEDSYNDROMES
Familial adenomatouspolyposis
Hereditary Non-PolyposisColorectal Cancer
Germline Mutation of TGFB type II Receptor
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CHRONIC INFLAMMATION
UlcerativeCollitis Crohns
Disease
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PREVENTION
Prevention ofradical surgery
Prevention ofdeath
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PREVENTION
Lifestyle adjusment
Taking preventif medication(chemoprevention)
Screening asymptomatic subject forrisk factors
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SCREENING
Testing faeces for occult blood
Endoscopic examination of themucosal lining of the large bowel
Demonstration of a high riskgenetic mutation
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PREINVASIVE LESION
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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
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ADENOMA
Macroscopic
Sessile elevation < 5mm but increasing growthis associated with the formation of a stalkcomposed of normal mucosa and submucosa
Polypoid growth that may be sessile orpedunculated
Minority : flat/depressed lesion
Head is darker than surrounding normalmucosa, lobulated baby cauliflower
Microscopic
Tubular, tubulovillous, villous
Tubules are lined by columnar epithelium andembedded within lamina propia
Vili comprise a covering of columnarepithelium and a core of lamina propria
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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
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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
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GRADING
Grade 1
Well differentiated adenocarcinoma The glands are regular and the epithel resembles adenomatous tubules
Grade 2
Moderately differentiated adenocarcinoma The glands show complex budding, irregular outpouching or gland within gland structure
Grade 3
Poorly differentiated adenocarcinoma Glands are highly irregular or distorted
Grade 4 Undifferentiated carcinoma
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DIAGNOSTIC
Anamnesis
Physical Examination
RECTAL TOUCHER Lab Examination
Radiologic Diagnostic COLON IN LOOP CT SCAN ABDOMENCek Metastasis USG RO THORAX BONE SCANNING BNO-IVP Endoscopy
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SIGN & SYMPTOM
Depend on the location, size, type
Abdominal pain
Anemia
Weight loss
Perubahan defikasi
Diarrhea
Blood in feses
Obstruction
Komplikasi : Perforasi, peritonitis
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SIGN & SYMPTOM
KOLON
KANAN
KOLON KIRI REKTTUM
Tipe tumor
Kaliber kolonFesesFungsi
Polipoid,ulseratifBesarCairabsorbsi
Stenosis
KecilSetengah padatpenyimpanan
Infiltratif,polipoidBesarPadatdefekasi
Gejala klinisDispepsiaPerub.polaBABObstruksiDarah dalam
tinja
KolitisSeringDiare
JarangMikroskopis
ObstruksiJarangKonstipasi,progresiDominanmikro/makro
ProktitisJarangTenesmus
JarangMakros
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LABORATORIUM
Routine blood : Hb, AL
Urinalysis
Hepar and ren function
CEA : urine,feses
< 10 ng/ml : stadium dini
> 10 ng.mL : stadium lanjut
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RADIOLOGIC
EXAMINATION
Colon in Loop
CT Scan Abdomen
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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.
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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.
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CONTOH
Pemeriksaan CIL yang menunjukan lesi apple core dengan penyempitan circumferential
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CONT..
Dilatasi usus proximal ke obstruksi. Anak panah menunjukkan etiology obstruksi.
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ENDOSCOPY
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VENOUS INVASION
Increase the risk of metastatic spread to the liver via the portal
vein
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TNM CLASSIFICATION
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METASTATIS
Carcinoma Colorectal
Direct
Hematogen
Limfogen
Transperitoneal
Nerve
Intraluminer
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METASTASIS
Ca Rectum
Direct
Limfogen
Hematogen
Nerve
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SURVIVAL
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JASS PROGNOSTIC
CLASSIFICATION
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RECURRENT AND DISTANT
DISEASE
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THE FUTURE
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MANAGEMENT
Operative Therapy (cutting)
Radiation therapy (burning)
Chemotherapy (poisoning)
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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
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Paliatif Mengilangkan gejala obstruksi Tumor tidak diangkat karena telah metastase
Colon kanan (Illeotransversostomi) : dilakukan pada tumor di kolon kanan, ileumterminal 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
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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
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KEMOTERAPI
Menghambat pertumbuhan neoplastik
5 FU merupakan ntinepolstik menghambat eznim asam nuklea ,
dan menghambat fosfat necluotide dan enzim ribonucleotide difosfat
reduktase
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REFERENSI
The Cancer Handbook Weinberg 2003
Imaging in Oncology from The University of Texas M.D. Anderson Cancer CenterRusdy Ghazali Maleuka- Radiologi Diagnostik 2006
Cermin Dunia Kedokteran No. 85 1998
Robbins Basic Pathology 7th Edition
www.emedicine.com
www.wikiradiography.com
http://www.emedicine.com/http://www.wikiradiography.com/http://www.wikiradiography.com/http://www.emedicine.com/