Oncology

Benign tumors of the rectum

Lecture: Benign tumors of the rectum
By Professor: Armine Andryan
Ministry of Health <Disease control and prevention National Center>
SNCO "Shirak" Branch Deputy Director,
Coordinator of Epidemiology
Benign tumors of the rectum

They are rare.Non-epithelial tumors include fibromas,

lipomas, myomas, lymphangiomas, cavernous angiomas,
neurofibromas.Cavernous angiomas can be a source of
significant bleeding.A cystic tumor is multiple papillary
growths of the mucous membrane, which can be either in
the form of a tumor nodule or cover the mucosa with a
large area. May undergo malignant
transformation.Diagnosis is made by digital rectal
examination (palpation of a soft, mobile tumor),
rectoromanoscopy and biopsy.Treatment. surgery,
electrocoagulation, electroresection, in individual cases -
resection of the affected part of the intestine.
Rectal cancer
Rectal cancer occupies a leading place among tumors
of the gastrointestinal tract.It mostly affects people
aged 50-60, with equal frequency in men and
women.Precancerous diseases play a major role in the
development of rectal cancer: polyps, non-specific
ulcerative colitis, Crohn's disease, chronic
paraproctitis, hemorrhoids, cracks and cysts. Some
importance is also given to the nature of the food
taken (easily digestible food, which contains little slag
and a large amount of chemicals used in food
preservation).
Rectal cancer
Rectal cancer can be located in the anal canal (about
10%), ampullary area (about 60%), rectosigmoid area
(about 30%).Macroscopically, exophytic (polyposis-
mushroom-like, cystic-papillary, plaque-like),
endophytic (diffuse-infiltrative, ulcer-infiltrative) and
mixed forms are distinguished.Histological structure.
adenocarcinoma (90%), mucinous (5%), solid (2%),
squamous cell (if located below the colon).
The spread of rectal cancer.
• local - due to tumor growth on all sides; the direct
growth of the tumor through the intestinal wall occurs
mainly in the transverse direction (explained by the
segmental arrangement of blood and lymphatic
vessels);
• lymphogenic metastasis - esophageal, post-abdominal,
para-aortic, inguinal, inguinal lymph nodes;
• hematogenous metastasis - liver (40-45%), lungs (10-
15%), bones;
• implantation metastasis - dissemination through
abdominal muscle.
Classification of rectal cancer
according to the TNM

system(7th edition, 2009)/see classification of colon

cancer/
Clinical picture.
There are 4 groups of symptoms.
1. pathological productions: blood, mucus, rarely pus;
2. bowel function disorder: constipation, diarrhea,
tenesmus, symptoms of intestinal obstruction,
3. painful and dark feelings,
4. general symptoms: general weakness, dizziness, loss
of appetite, anemia, hyperthermia.
Anal tube cancer is characterized by:
• dull nature, constant pain in the anus region, which
intensifies during defecation - is a dominant and rather early
symptom (this zone is quite rich in nerve endings);
• as a result of ulceration of the tumor, the inflammatory
process is activated and pathological mixtures are formed in
the feces: blood, mucus, pus, intensification of pain, formation
of cysts,
• gas and stool incontinence occurs as a result of tumor
ingrowth into the anal sphincter,
• narrowing of the narrowest part of the rectum by a tumor
quickly leads to the development of intestinal obstruction,
• metastases in the inguinal lymph nodes.
Anal tube cancer is characterized by:
In the case of ampullary cancer, the symptoms are poor.
• the first symptom: pathological mixtures in feces,
• at the same time or a little later - bowel disorders,
• pain occurs when the tumor spreads beyond the bowel
wall and affects the surrounding organs and tissues.
• Intestinal obstruction rarely develops (the ampulla is
the widest part of the rectum).Cancer of the
rectosigmoid part of the rectum is manifested by
progressive constipation with further development of
complete obstruction.
Complications of rectal cancer.
In the later periods of the development of the disease,
various regular complications occur, such as:
• metastases in regional lymph nodes and distant
organs,
• ingrowth into neighboring organs.
Ingrowth into neighboring organs.
 sacrum
 in women: the back wall of the vagina, in the case of the formation
of the rectovaginal tube, the production of feces from the vagina is
observed,
 in men: prostate gland and back wall of the bladder - dysuria,
pollakiuria, leukocyturia, dull pains in the lumbar region; in the
case of rectovesical duct formation, the production of feces and
gases during urination (fecaluria, pneumaturia) is observed.
 passage of the tumor to the small intestine, sigmoid mesenchyme,
 Pressure of the ureter and pelvic veins - hydronephrosis, edema of
the lower limb(s),
 pressure or ingrowth of large veins - pains of an intravesical nature;
Ingrowth into neighboring organs.
• rectal cancer is often complicated by infectious
complications, paraproctal abscess (phlegmon), and in
the case of supraampullary cancer, even by the
development of peritonitis;
• intestinal obstruction,
• intestinal perforation (perforation),
• intestinal bleeding.
The diagnosis.
 • digital examination of the rectum (per rectum) - the purpose
is to determine the presence of a tumor, its location (distance
from the sphincter), its length, mobility, the presence of
ulceration, the degree of narrowing of the intestinal lumen, the
nature of production from the intestine; in women, a per
vaginam examination is also performed;
 • colonoscopy, rectomanoscopy and tumor biopsy;
 • X-ray examinations - irigoscopy (primary multiple colon
tumors are possible);
 • ultrasound examination, transrectal ultrasound examination;
 • computer and magnetic resonance stratigraphy;
 • laparoscopy.
Differential diagnosis.
hemorrhoidsrectal polyp,
 tuberculosis of the rectum, syphilis.
Treatment.
The main method of treatment is surgical treatment. In the
absence of complications and distant metastases, radical
operations are performed: removal of the affected part of
the intestine with the mesentery and regional lymph
nodes.Radical operations are:
• Canew-Miles operation - abdominal extirpation of the
rectum - in the case of a tumor less than 6-7 cm from the
anus (linea anocutanea) - the extirpation of the rectum is
performed with the pelvic lymph nodes and sphincter
through the abdominal entrance and the formation of the
connecting anus in the left iliac region. with
transabdominal access;
Treatment.
• Abdominal-anal extirpation of the rectum with the
lowering of the sigmoid (or transverse) intestine
towards the scrotum - is performed when the tumor is
7-12 cm from the anus (anocutaneous line);• anterior
resection of the rectum with the formation of an
interintestinal anastomosis (Dixon's operation) -
performed when the tumor is more than 12 cm from
the anus (anocutaneous line); currently, the radical
nature of this operation is considered controversial,
preference is given to operations to remove the entire
mesentery of the rectum - total mesorectomies;
Treatment.
• Hartmann's surgery (obstructive resection) - is
performed when the tumor is more than 12 cm away
from the anus (anocutaneous line), in case of
impossibility of primary anastomosis formation (for
example, intestinal obstruction);
• pelvic evisceration (exenteration of pelvic organs) -
performed in cases of locally-spread or recurrent rectal
tumors, in case radiation and/or chemotherapy are
ineffective.
Treatment.
Palliative and symptomatic operations (colostomy) are
performed in case of contraindications to radical
operations.Radiotherapy can be used in the pre- and
post-operative regions in order to increase the
radicality of the operation. In stages II and III of the
tumor process, adjuvant radiation therapy is combined
with chemotherapy (5-fluorouracil). Radiation therapy
can be used alone or in combination with
chemotherapy to treat unresectable, locally advanced
rectal cancer.
Treatment.
In the case of squamous cell cancer of the anal canal,
chemoradiotherapy is considered the standard of
treatment, surgery is performed in case of
ineffectiveness of conservative treatment (rectal
peritoneum extirpation). In case of inguinal lymph
node involvement, inguinal or inguinal
lymphadenectomy is also performed.
Drug treatment of colorectal cancer
Mainly applied
• as a postoperative adjuvant treatment
,• in case of disseminated forms – as a palliative
treatment.The main used drugs are:
• antimetabolites - 5-fluorouracil, fluorofur (Tegafur),
capecitabine (Xeloda), raltitrexide (Tomudex)
• drugs of plant origin (alkaloids) - irinotecan
(Kampto)
• drugs of the platinum group - oxaliplatin (eloxatin).
Drug treatment of colorectal cancer
The above drugs are often used in combined regimens
- FOLFOX, FOLFIRI, CAPIRI regimens.They are used
for targeted treatmen
t• from antiangiogenic drugs - bevacizumab (avastin),
• From EGFR-inhibitors – cetuximab
(Erbitux).Targeted therapy drugs are used in
combination with chemotherapy drugs.