Intestinal tumours

Intestinal tumours Small intestinal tumours :-Small intestinal tumours are rare. Benign tumours. These may cause intussusception or may bleed. Adenoma, submucous lipoma, and leiomyoma. Peutz-Jegher's syndrome consists of: Multiple familial intestinal hamartomatous polyps mainly affecting the jejunum. Melanosis of the oral mucous membrane and the lips. The disease is not precancerous, therefore, only the com­plicated polyps (those causing bleeding or intussusception) require removal or excision of the affected intestinal seg­ment.

Melanin spots on the lips of a patient afflicted with Peutz– Jeghers syndrome

Malignant tumours. In order of frequency, these are: Non-Hodgkin's lymphoma. Adenocarcinoma, Carcinoid tumour of the small intestine which is less common than that of the appendix but tends to be more malignant.

Small bowel adenocarcinoma.

TUMOURS OF THE LARGE INTESTINE Colorectal tumours :- Tumours of the colon and the rectum share common properties and are, therefore, commonly referred to as colo-rectal tumours. Benign tumours :- Benign colorectal tumours usually form polyps.

Malignant tumours Primary • Carcinoma. • Carcinoid tumour. • Sarcomas. Secondary. These are the result of invasion from a nearby malig­nant tumour. Two of the above tumours deserve detailed consideration, these are familial polyposis coli (FPC), and carcinoma.

Familial adenomatous polyposis Aetiology FPC is an autosomal dominant disease. Approximately 50% of the children of affected parents have this disorder, and only individuals with polyps transmit the disease. Males are affected more than females. Pathology The colon and rectum are full of multiple polyps (at least 100) which are sessile and pedunculated . The sigmoid colon and rectum are the commonest sites of affec­tion. Three histological types are recognized; the tubular, tubulo-villous, and villous.

Familial adenomatous polyposis

Left untreated, carcinoma develops in 100% of the affected patients by the fifth decade. The malignant potential is re­lated to the size, and to the type of the adenoma. The inci­dence of malignancy is highest with villous adenomas that are bigger than 2 cni. Gardner's syndrome is a variant of FPC. In addition to the above, there are polyps in the rest of the gastrointestinal tract, osleomas of the mandible and skull, cysts, soft tissue tumours, and desmoid tumours of the abdominal wall.

Clinical features Polyps usually present between the ages of 10 and 15 years. The commonest symptoms are diarrhoea, bleeding, arid abdominal pain. Investigations Barium enema shows multiple rounded filling defects throughout the colon and the rectum . Sigmoidectomy or colonoscopy and biopsy prove the nature of the disease.

Treatment Colectomy with ileorectal anastomosis has in the past been the usual operation because it avoids an ileostomy in a young patient and the risks of pelvic dissection to nerve function. The rectum is subsequently cleared of polyps by snaring or fulguration. The patients are examined by flexible sigmoidoscopy at 6- monthly intervals thereafter. The alternative is a restorative proctocolectomy with an ileoanal anastomosis. This has a higher complication rate than ileorectal anastomosis. It is indicated in patients with serious rectal involvement with polyps, those who are likely to be poor at attending for follow-up and those with an established cancer of the rectum or sigmoid. However, it is now used more frequently for less severe cases. There have been reports of cancers developing after stapled anastomosis when a small remnant of rectal mucosa is left behind. The family members should be periodically examined by colonoscopy and similarly treated if they develop polyps. The avoidance of an ileostomy encourages the asymptomatic per­son to have the operation.

Carcinoma of the colon

Carcinoma of the colon The disease is une of the leading causes of death from cancer in the Western society. The peak incidence is in the seventh decade of life. Aetiology Solitary villous adenoma. Familial polyposis coli, and Gardner's syndrome. As mentioned the risk is 100% in untreated cases. Cancer is more prone to de­velop in large adenomas that are larger than 2 cm particularly those of the villous variety. Ulcerative colitis. The risk is highest with pancolitis of more than 10 years duration. The disease is more common in Western countries probably due lo lack of high fibre diet and increased animal fat. Uretero-colic anastomosis.

Pathology Microscopically, the neoplasm is a columnar cell carcinoma originating in the colonic epithelium. Macroscopically, the tumor may take one of four forms .Type 4 is the least malignant form. It is likely that all carcinomas start as a benign adenoma, the so called ‘adenoma–carcinoma sequence’. The distribution of adenoma in the colon also mirrors that of carcinoma. The annular variety tends to give rise to obstructive symptoms, whereas the others will present more commonly with bleeding. The sites and distribution of cases of cancer are shown in the following Figure Tumors are more common in the left colon and rectum.

The four common macroscopic varieties of carcinoma of the colon The four common macroscopic varieties of carcinoma of the colon. (1) Annular; (2) tubular; (3) ulcer; (4) cauliflower.

Spread Direct spread occurs first in the wall and then to the neighbour­ing organs, e.g., the urinary bladder. The strong fascia of De-nonvillier lying in front of the rectum retards the spread of rectal cancer to the bladder. Lymphatic spread produces tumour deposits in the epicolic, paracolic, intermediate, and then superior or inferior rnesen-teric preaortic nodes. Nodal involvement is found in 40% of cases corning to operation. Blood stream spread produces liver metastases in 20% of pa­tients coming to surgery. Transperitoneal spread leads to peritoneal nodules and as-cites.

Staging Prognosis worsens with the progress of the stage. According to Duke's staging the tumour may be; Stage A The growth is limited to the bowel wall. Stage B The growth extends outside the bowel wall, bu no metastasis to lymph nodes. Stage C There are secondary deposits in the regiona lymph nodes. C1 The local para-rectal, or para-colic, lymph nodes alone are involved. C2 The nodes accompanying the supplying blood vessels are affected. This staging does not take in account the possibility of distant metastases. In a modified Duke's staging, it is termed "D stage".

Clinical features cancer of the rectum is commoner in males, while cancer of the caecum is commoner in females. Clinical features depend upon the location of the tumour, its size, and the presence of metastases. Right colon cancer The usual presentation s vague with anaemia, weakness and loss of weight (Anaemia, Anorexia, Asthenia). The patient may present with recurrent attacks of pain in the right iliac fossa.

3. A hard mass may be present in the right side of the abdomen 3. A hard mass may be present in the right side of the abdomen. It is differentiated from appendicula mass by the long duration and absence of toxaemia and tenderness (differential diagnosis of a mas in the right iliac region). 4.The patient does not present by intestinal obstruction as the lesion is usually of the cauliflower variety. the contents are liquid and the lumen of the colon is wide. Obstruction occurs, rarely, if obstructs the ileocaecal valve.

Carcinoma of the sigmoid colon In addition to symptoms of intestinal obstruction, a low tumour may give rise to a feeling of the need for evacuation, which may result in tenesmus accompanied by the passage of mucus and blood. Bladder symptoms are not unusual and, in some instances, may herald a colovesical fistula.

Carcinoma of the transverse colon This may be mistaken for a carcinoma of the stomach because of the position of the tumour together with anaemia and lassitude. Carcinoma of the caecum and ascending colon This may present with the following: anaemia, severe and unyielding to treatment; the presence of a mass in the right iliac fossa; colonoscopy maybe needed to confirm the diagnosis; a carcinoma of the caecum can be the apex of an intussusception presenting with the symptoms of intermittent obstruction

complications intestinal obstruction occurs in 20% of cases particularly with left colon tumours. This tendency is attributed to: The smaller lumen of the left colon. Stool tends to be more solid. Carcinoma tends to be of the stenosing variety. Perforation or the formation of an enterocolic or vesicocotic fistula. Bleeding. Chronic bleeding is the rule. Massive bleeding is rare. Complications due to spread, e.g., jaundice, liver failure, and ascites.

Methods of investigation of colon cancer Flexible sigmoidoscopy Colonoscopy :- This is now the investigation of choice if colorectal cancer is suspected provided the patient is fit enough to undergo the bowel preparation. Radiology :- Double-contrast barium enema is used when colonoscopy is contraindicated

Preoperative preparation Treatment Preoperative preparation Carcinoma of the caecum Carcinoma of the caecum or ascending colon is treated when resectable by right hemicolectomy

Carcinoma of the hepatic flexure When the hepatic flexure is involved, the resection must be extended correspondingly

The extent of the resection is from right colon to descending Carcinoma of the splenic flexure or descending colon The extent of the resection is from right colon to descending colon. Sometimes, removal of the colon up to the ileum, with an ileorectal anastomosis, is preferable. Carcinoma of the pelvic colon The left half of the colon is mobilised completely

Laparoscopic surgery Adjuvant therapy

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