Anal canal cancer
History taking】 1.
1. Persistent pain, aggravated after defecation. Meng Yong, Department of Anorectology, Jinan Hospital of Traditional Chinese Medicine
2. Small amount of blood in the stool, gradually worsening.
3. change in stool habit, increase in frequency, feeling of impurity in defecation.
Physical examination
1. General examination.
2. Rectal finger examination: a lump can be found, which is wart-like and movable in the early stage, and if an ulcer is formed, there will be pressure pain.
Auxiliary examination
1.Routine examination before surgery.
2. pathological tissue examination.
Diagnosis
The diagnosis can be confirmed based on clinical symptoms and local examination, and finally pathological tissue examination.
Staging of anal canal cancer.
T1: tumor diameter <2cm.
T2: tumor diameter 2 to 4 cm.
T3: tumor diameter >4cm, movable, not invading the vagina, less than 2/3 of the anal circumference.
T4a: tumor invading the vagina or larger than 2/3 of the anal circumference.
T4b: tumor invaded skin, rectum, vaginal mucosa or fixed.
Differential diagnosis
1. Rectal cancer: it can invade the anal canal, and the diagnosis depends on pathological examination.
2. Anal sinus tract: infected anal sinus tract sometimes resembles anal canal cancer, but the anal sinus tract is mostly in the anterior and posterior middle of the anal canal and connected with the dentate line, and the mucosa of the anal canal is intact. Biopsy can confirm the diagnosis.
3. Malignant melanoma: The appearance resembles thrombosed internal hemorrhoids, but on palpation it is a hard nodule with occasional pressure pain. Biopsy can confirm the diagnosis.
【Treatment principle
The treatment method depends on the tumor site, whether the sphincter is invaded or not and whether the inguinal lymph nodes are metastatic or not.
Local excision: Only a few squamous anal canal carcinomas are suitable for local excision therapy, if the tumor is small, superficial, movable and biopsy confirms good differentiation of tumor cells.
2. Combined abdominal perineal resection plus permanent artificial anus (Miles surgery): the best treatment for squamous carcinoma of the anal canal that invades tissues above the dentate line.
3. Radiotherapy and chemotherapy.
Efficacy criteria
1）Cure: radical excision, incision healing, no complications.
2) Improvement: palliative resection and symptom reduction.
3. Not cured: non-surgical treatment, or no treatment.
【Discharge criteria】
Discharged after reaching clinical cure or improvement and stable condition.
Colorectal cancer
Medical history taking
1. change in bowel habits and blood in stool.
2. abdominal pain and abdominal discomfort
3. abdominal masses.
4. symptoms of acute and chronic intestinal obstruction.
5. chronic wasting manifestations such as anemia.
6. acute colonic perforation and peritonitis.
7. history of chronic diarrhea, polyps, schistosomiasis infection, cholecystectomy, if necessary.
8. any family history of colon cancer.
Physical examination
1. General examination: whether there is wasting, anemia, swelling, superficial lymph node enlargement, etc.; abdominal examination: whether there is abdominal distention, abdominal mass, hepatomegaly, ascites, etc.; if abdominal mass is found, the location, shape, size, texture, smoothness and activity of the mass must be clarified.
2. Rectal finger examination: if a mass is found, the nature, location, extent and relationship with prostate or vaginal uterus should be determined, and whether the finger stains with blood.
Ancillary tests
1. stool routine plus occult blood test.
2. CEA measurement.
3. barium enema examination.
4. fiberoptic colonoscopy and proctoscopy, and pathological examination for abnormalities found.
5. B-mode ultrasonography for intra-abdominal masses and liver metastases.
6. CT examination: to understand intra-abdominal lymph nodes and liver metastases.
7. ECT examination to understand bone metastases if necessary.
8. Routine examination before general surgery.
Diagnosis】
Based on the medical history, physical examination and auxiliary examination, the diagnosis can generally be clarified, and the pathological diagnosis can be obtained by fiber colonoscopy biopsy.
Differential diagnosis
Differential diagnosis should be made with the following diseases.
1. chronic colitis, clonorchiasis, etc.
2. chronic dysentery.
3. periappendiceal abscess.
4. benign tumors and polyps in the intestinal cavity.
Colorectal cancer clinicopathological staging: The staging currently used in China was formed after the addition of Dukes’ staging on the basis of the National Conference on Bowel Cancer in 1978.
5. Dukes” stage A: the cancer is confined to the intestinal wall and there is no lymph node metastasis. It can be further divided into three sub-stages.
(1) Stage A0: the cancer is confined within the mucosa.
(2) Stage A1: penetration of the mucosal muscle layer to reach the submucosa.
(3) Stage A2: Involving the muscular layer but not penetrating the plasma membrane.
(6) Dukes” B stage: the cancer penetrates the plasma layer of the intestinal wall or invades the adjacent peripheral tissues outside the plasma membrane, but there is no lymph node metastasis.
7) Dukes” stage C: cancer penetrates the intestinal wall and has lymph node metastasis; it can be divided into two sub-stages.
(1) Stage C1: lymph node metastasis is limited to the vicinity of the cancer, such as the colon wall and paracolic colon.
(2) Stage C2: lymph node metastasis to the root of the mesenteric vessels.
(2) Stage C2: lymph node metastasis to the root of mesenteric vessels. 8.
Treatment principles
1) Surgical indications: Surgery is the only curable treatment for colorectal cancer. Therefore, except for advanced cases with very poor systemic conditions that cannot tolerate surgical treatment, surgery should be actively explored to remove the tumor.
2. preoperative preparation, general preparation, correction of anemia and water-electrolyte disorders, improvement of general nutrition; intestinal preparation, starting a semi-liquid diet with less residue 3 days before surgery, changing to a liquid diet 1 day before surgery; starting oral streptomycin, methotrexate and vitamin K4 3 days before surgery, starting oral laxative (senna or grated sesame oil) at noon 1 day before surgery, clean enema in the evening or morning before surgery; placing gastric tube and urinary catheter in the morning of surgery.
3. Surgical methods.
(1) Radical resection, suitable for complete resection of cancer, including cases with isolated liver metastases.
Colon cancer: the scope of resection includes the tumor, normal intestinal segments of not less than 10 cm on both sides and its corresponding mesentery and regional lymph nodes; right hemicolectomy, left hemicolectomy, transverse colectomy or sigmoid colectomy can be chosen according to the location of the tumor in different colons.
Rectal cancer: the resection area should include more than 10 cm of the proximal end of the cancer, more than 2.5 cm of the distal end of the normal intestinal canal, and the corresponding lymph nodes around the mesentery and inferior mesenteric artery; for Dukes stage B and C tumors below the peritoneal reflex, the lymph nodes in the pelvic side wall should also be cleared. Depending on the distance of the cancer from the anus and local conditions, anterior abdominal resection (Dixon’s operation), combined transabdominal perineal resection (Miles’ operation), transabdominal anorectal resection, coloanal sleeve anastomosis (Parks’ operation) or total pelvic organ resection can be chosen.
(2) Palliative surgery: For advanced cases with extensive metastases and no possibility of radical treatment, palliative surgery can be sought to reduce the tumor load, or short-circuit surgery or colostomy to relieve the symptoms of obstruction.
(3) Emergency surgery: for cases with combined intestinal obstruction, ineffective gastrointestinal decompression or colon perforation combined with diffuse peritonitis, right hemicolectomy and anastomosis can be performed in one stage, while left hemicolectomy and rectal cancer can be performed in one stage or transverse colostomy first, depending on the general condition of the patient, intraoperative abdominal contamination and intestinal congestion and edema, and second stage resection can be performed one to three months later.
(4) Adjuvant therapy: adjuvant chemotherapy, suitable for Dukes’ stage B and C cases and after palliative resection; the program can be 5-FU + levamisole, FM or FMC program.
Adjuvant radiotherapy: Preoperative radiotherapy is suitable for ulcerated rectal cancer with large, fixed or deeply infiltrated tumors, which can improve the surgical resection rate, reduce the recurrence rate and medical dissemination. Postoperative radiotherapy is suitable for incomplete resection or postoperative pathological confirmation of tumor residue at the cut edge.
Efficacy criteria
1) Cure: radical resection and incision healing.
2. Improvement: palliative resection, incision healing, or mass reduction without surgical treatment.
3. not cured: non-surgical treatment, the mass did not shrink; or not treated.
【Discharge criteria
Discharged if clinical cure or improvement, incision healing and stable condition are achieved.