The thesis determines the value of multi-sequence computerized tomography in the diagnosis of rectal cancer undergoing radical surgery. Evaluate the results of laparoscopic surgery for radical treatment of rectal cancer. Invite you to refer to the thesis to understand the content of the study.
INTRODUCTION Rectal cancer is a common cancer of the digestive tract, a common disease in the world, especially in developed countries. According to the World Health Organization (2003), it is estimated that each year, around 572,100 people have colorectal cancer (in which colorectal cancer accounts for the most rate) In Vietnam, the rectal cancer is ranked the fifth after the bronchial, stomach, liver, and breast cancers As noted by the Hanoi Cancer Society (2002), nearly 15,000 new cases are diagnosed each year with the rate of 13.1/100000 people and about 7000 deaths To achieve high effectiveness in the treatment, computerized tomography, magnetic resonance imaging have been used to diagnose the disease and the level of organ invasion, lymph node metastasis in rectal cancer Although MRI is increasingly proving superiority, multidisciplinary computed tomography is still valuable in the diagnosis of rectal cancer, especially for the diagnosis of distant metastases, as well as the popularity of medical facilities. local, easy to carry, time taken. Thus, the strategy of treating rectal cancer for each patient is formulated more completely and accurately, with higher treatment efficiency. In the treatment of rectal cancer, surgery plays an important role, other treatments such as radiation and immunochemicals have an auxiliary role. Radical surgery in the treatment of rectal cancer is the destination of all surgeons in the treatment of cancer in general and rectal cancer in particular Radical surgery can be done with classic open surgery or laparoscopic surgery In order to contribute to perfecting the method of diagnosis and treatment of rectal cancer, we have conducted research on this topic with two objectives: 1. Determining the values of multithreaded computer tomography in the diagnosis of rectal cancer Evaluating the results of radical laparoscopic surgery treatment of rectal cancer New contributions of the thesis The dissertation has gained new results and contributed more to the specialization Indicates the diagnostic value of multithreaded computer tomography with rectal cancer In particular, the degree of invasive diagnosis has an accuracy of 88.197.4% with sensitivity of 2095.8%, specificity of 80.0100%. Diagnosis of lymph node metastasis has the accuracy of 63.576.2%, sensitivity of 48.7100%, specificity of 67.5 94.7%. Diagnosis of the disease stage has the accuracy of 63.598.3% Reporting the results of laparoscopic surgery for radical treatment of rectal cancer applied at Viet Duc University Hospital: No death after surgery, early complications after surgery 8.5%, average hospitalization time 8.4 ± 3.5 days. Recurrence rate of 15%, death of 9.3% (after 247 months) The followup results showed that the overall survival rate was 43.8 months, the average without disease was an average of 42.5 months. The sequelae of sexual disorders are 14.0%. The thesis also analyzes in depth the relationship between the degree of damage of rectal cancer and the extra time after surgery. Which has determined the extent of invasive tumor is an independent prognostic factor of the extra lifetime The thesis has contributed to further clarify the diagnostic value of rectal cancer lesions of multithreaded computer tomography and the results of radical laparoscopic surgery treatment of rectal cancer The thesis structure The thesis consists of 138 pages, including: Introduction (2 pages); Chapter 1: Literature Overview (36 pages); Chapter 2: Research subjects and methods (20 pages); Chapter 3: Results (42 pages); Chapter 4: Discussion (36 pages); Conclusion: (2 pages), The thesis has 50 data tables, 20 charts; 13 photos; 122 references (46 Vietnamese documents, 76 English documents), appendices, research form, patient list. CHAPTER 1. LITERATURE OVERVIEW 1.4. CT ANATOMICAL CHARACTERISTICS OF RECTUM AND PELVIS For computerized rectal tomography, the patient is cleared of stool with enemas or indented 11.5 liters of fluid into the colorectal. Helical technique from diaphragm arch to edge of anus with thin cutting thickness on axial, reconstructed on two (sagital) and horizontal (coronal) planes 1.4.1. Rectal position and structure * Rectal position: On the sagial plane it is possible to locate the rectum by measuring the distance from the anus. Rectal 1/3 section on anal margin 1015cm, 1/3 median between anal margin 5 10cm, low segment 5cm anal margin. On the horizontal plane (axial), the rectum looks like a round tube with a diameter of 35cm The wall of the rectum is about 36 mm thick * Structure of rectal walls: Rectal wall consists of 4 layers. On computerized tomography, the layers of the rectum wall are indistinguishable 1.4.2. Related topographical anatomy Rectal balls are covered partially by peritoneal, on the front and two sides with the related parts: front, back, side * On a horizontal plane (axial): Between men and women have similar or different images depending on the location of computer tomography, in men with seminal vesicles, prostate, In women with uterus, vagina. There are 3 basic cutting positions Low slice through the anal canal 1/3 middle slice Upper 1/3 slice, the same for both men and women 1.5. SURGICAL TREATMENT OF RECTAL CANCER Surgery is the main treatment for rectal cancer. 1.5.3. Endoscopic surgery to treat rectal cancer In 1990, Moises Jacob was the first one who applied the laparoscopic cancer surgery. The oncological research results show that laparoscopic surgery has the ability to cut and remove lymph nodes horizontally with open surgery Indications for laparoscopic surgery for rectal cancer are not limited with age but need to fully evaluate respiratory and circulatory function. Location and number of trocar: 46 trocar depending on the habits of the surgeon. The amount of blood lost during surgery ranges from 30 60ml. The overall complication rate is 5 18% The rate of complications in laparoscopic surgery is lower than that of open surgery confirming the feasibility of laparoscopic surgery. Postoperative results between hand and machine connection showed no difference in complications or deaths. 1.6. SITUATION OF LAPAROSCOPIC SURGERY FOR RECTAL CANCER TREATMENT IN THE WORLD AND IN VIETNAM 1.6.1. In the world In the world, there have been many studies on laparoscopic rectal cancer surgery compared and compared with open surgery for many good results Zhou G et al (2004) compared rectal cancer patients undergoing laparoscopic surgery (82 patients) and open surgery (89 patients) found that laparoscopic surgery had the amount of blood loss (20 ml: 5–120 ml) less than open surgery (92 ml: 50–200ml), p 0.05). Baek JH et al. (2015) studied 230 patients with 5year diseasefree survival time of rectal cancer patients 83% (laparoscopic surgery) and 74.6% (open surgery), ( p> 0.05). 1.6.2. In Vietnam In Vietnam, laparoscopic surgery has been used since 1992 at Cho Ray Hospital. Currently, rectal cancer laparoscopic surgery has been carried out in many hospitals such as Viet Duc University Hospital, National Cancer Hospital, Military Hospital 103, Hue Central Hospital Nguyen Hoang Bac et al. (2010) retrospectively examine 482 rectal cancer surgery patients at Ho Chi Minh City University of Medicine and Pharmacy Hospital to see 329 cases of rectal segmentectomy and 19 posterior colonoscopy. subject, 134 surgery Miles. There are 21 cases of open surgery. Two patients had damage to the ureter, 22 patients (6%) had a rectal fistula, and three patients had early bowel obstruction after Miles surgery. Average hospitalization time of 6.9 days Pham Van Binh (2017) studied 53 patients on 1/3 of rectal cancer who had surgery to cut the colorectal segment and connected the machine, the average surgery time was 136.7 34.5 minutes (Internal surgery soi 171.8 45.7 minutes; open surgery: 124 17.2 minutes). The average hospitalization time after surgery is 10.2 2.6 days. The total extra life of 3 years is 85.1% CHAPTER 2 RESEARCH SUBJECTS AND METHDS 2.1. RESEARCH SUBJECTS Including rectal cancer patients who underwent radical laparoscopic surgery at VietnamGermany Hospital from June 2013 to June 2015 2.1.1. Criteria for selecting patients The patient was diagnosed with a lower rectal cancer tumors less than 15cm from the edge of the anus Having an anatomical diagnosis of Adenocarcinoma disease Performing multithreaded computer tomography pelvic region Radical laparoscopic surgery for radical treatment at Viet Duc University Hospital 2.1.2. Exclusion criteria patients refuse to cooperate, not to undergo laparoscopic surgery. Patients should not receive pelvic region multithreaded computer tomography. Cases of comorbidities such as heart failure, hypertension, stroke, chronic asthma, bronchial asthma, uncontrolled or life threatening diabetes Anal cancer, prostate colon cancer Temporary treatment of rectal cancer 2.2. RESEARCH METHODS 2.2.1. Research design Study design: prospective descriptive study, combined with longitudinal comparison to monitor and evaluate results after laparoscopic surgery 2.2.2. Research variables All information was collected by questionnaires through sample cases, direct patient visits, multithreaded computer tomography, tumor invasion assessment, GPB comparison and evaluation of surgical results. including: 2.2.2.1. General characteristics of studied patients Age, gender, occupation Serum CEA test Colonoscopy by soft tube 2.2.2.2. Multithreaded computer tomography in rectal cancer Using the 64reading computerized tomography machine Dawy GE ligh speed including 2CPU and 4 screens of US origin Multithreaded computer tomography of pelvic region and intravenous contrast injection to assess: Evaluating tumor characteristics, including: tumor size, tumor density according to the perimeter of the rectum (accounting for 1/2, 2/4, 3/4 and the circumference). Level of invasive tumor, assessment of degree of pelvic and pelvic lymph node metastasis, evaluation of distant metastasis, evaluation of stage of disease, assessment of invasive level of rectal cancer on computerized tomography multisequence according to the division of Thoeni in 2 stages: localized tumor in rectum wall, invasive tumor 2.2.2.3. Anatomy results after surgery * Macrobody: Postoperative tumors were assessed for macrobody lesions in terms of location, size, shape, and properties; Cut a slice at the 2cm invasive position to assess the degree of rectal wall invasion. Lymph nodes are analyzed for evaluation: location, size, number of lymph nodes. * Microbody: Tumors and lymphomas are read and analyzed by GPB specialists. 2.2.2.4. Assess the stage of rectal cancer * Classify TNM according to UICC 2010 2.2.2.5. Results in radical laparoscopic surgery of rectal cancer: Surgical characteristics, operation time: in minutes Accident during surgery: Bleeding, vaginal perforation, ureteral damage, bladder. posterior urethral lesion, blood transfusion during surgery. 2.2.2.6 Early results after laparoscopic radical surgery for rectal cancer Death after surgery Complications after surgery: intra abdominal bleeding; peritonitis; Postoperative urinary retention; infection of the abdominal incision; infection of the episiotomy incision; artificial anal prolapse, artificial anal lag; splitting of abdominal wall; early bowel obstruction after surgery Time to return to peristalsis, bladder sonde withdrawal time after surgery, hospitalization time after surgery: in days 2.2.2.7. Results after radical surgery rectal cancer Periodic examination and monitoring, record the following information: Postoperative sequelae, the rate of local recurrence and metastases Evaluate sexual function after surgery A number of factors affecting total and nonsurgical survival time: age, gender, CEA before surgery, tumor size, degree of differentiation of tumor cells, degree of invasion, metastasis lymphadenopathy and the stage of the disease 2.2.3. Endoscopic surgical procedure * Equipment: Complete for a laparoscopic surgery * Preparation before surgery: Preparation of colon before surgery Anesthesia: intubation * Patient posture and position of surgeon * The surgical stages 2.2.4. Data processing Data were managed and analyzed by SPSS 22.0 software. The difference was statistically significant between groups when p 70 years old Total ± SD patient s 24 17 13 64 59.8 12.2 patients patients 5.1 3.4 20.3 14.4 15 16 2.5 6.8 12.7 13.6 12 39 33 7.6 10.2 33.1 28.0 11.0 12 10.2 25 21.2 54.2 60.2 12.8 54 45.8 118 60.0 12.5 (26 86) 100.0 p>0.05 The average age of male patients (59.8 12.2 years) was not different from female patients (60.2 12.8 years), p> 0.05 Male account for 54.2%, female is 45.8%. The male to female ratio is 1.19 3.1.4. Subclinical characteristics Table 3.3 Cancer fetal antigen characteristics (CEA) CEA concentration Number of patients (ng/ml) (n = 118) Normal 89 High 29 (± SD) Median (smallest largest) Rate (%) 75.4 24.6 7.8 30.8 3.2 (0 330) High serum CEA concentration in rectal cancer patients had 29/118 patients, accounting for 24.6% Average concentration of 7.8 ± 30.8 ng / ml 3.1.5. Histological characteristics of rectal cancer Table 3.6. Histopathological characteristics of rectal cancer Histopathologi Number of cal patients Rate (%) characteristics Macrobody (n= 118) Microbody (n= 118) Degree of differentiation (n= 118) Ulcers Swells Ulcerative swelling Infiltrates 13 42 61 11.0 35.6 51.7 1.7 Adenocarcinoma 118 100 High Moderate Weak 19 87 16.1 73.7 12 10.2 Evaluation of macrobody showed that ulcerative body accounted for the highest proportion (51.7%), followed by warts (35.6%) and ulcers (11.0%). There is 1.7% of infiltrates Of the 118 patients with rectal carcinoma, the majority had moderate degree of differentiation (73.7%), 16.1% with high grade and 10.2% with poor differentiation Table 3.7. Features of lymph node metastasis of rectal cancer Đặc điểm di căn hạch Location of lymph node metastases (n= 118) Number of lymph nodes (n= 118) (stage N) Number of patients Zero Around the rectum In front of the overhang Inferior mesenteric Zero (N0) 1 3 (N1) ≥4 (N2) Rate (%) 80 22 67.8 18.6 2.5 13 80 28 11.0 67.8 23.7 10 8.5 Assessing lymph node status in surgery saw: Number of lymph nodes: 67.8% of cases without lymph node metastases (N0); 23.7% of cases metastases from 1 to 3 lymph nodes (N1); only 8.5% of metastases ≥4 lymph nodes (N2) Locations of lymph node metastasis: lymph nodes around the rectum (18.6%), anterior lymph nodes (2.5%), mesenteric lymph nodes (11.0%) Table 3.8. Stage of rectal cancer disease on anatomical pathology AJCC Stage 0 Stage I Stage II Stage III TNM Dukes TisN0M0 T1N0M0; A T2N0M0 IIa T3N0M0 IIb T4aN0M0 IIc T4bN0M0 Subtotal IIIa T12N12aM0 T34aN1M0; IIIb T23N2aM0; T12N2bM0 T4aN2aM0; IIIc T34N2bM0; T4bN12M0 Subtotal Number of patients Rate % 2.5 30 25.4 B B B C 44 47 37.3 2.5 39.8 1.7 C 31 26.3 C 4.2 38 32.2 Anatomy of postoperative disease in 118 rectal cancer surgery patients found: According to TNM classification, stage is 2.5%; Phase I is 25.4%; Phase II is 39.8% (IIa: 37.3% and IIb: 2.5%); Stage III is 32.2% (IIIa is 1.7%; IIIb is 26.3%; IIIc is 4.2%). There are no cases of stage IV Classified by Duckes: Dukes A period is 25.4%; Dukes B is 39.8% and Dukes C is 32.2% 3.2.2 Diagnosis of lymph node metastasis through multithreaded computer tomography Table 3.14. Reconstructing lymph node metastases stage of rectal cancer via multithreaded computer tomography with pathology Stage N on computeriz ed Stage N on Total pathological tomography (Number of surgery patients,%) N0 N1 N2 39 16 25 80 N0 50.0% 55.6% 67.8% 95.1% 16 10 28 N1 4.9% 22.2% 23.7% 50.0% 10 10 N2 0 8.5% 22.2% 41 32 45 118 Total 100.0% 100.0% 100.0% 100.0% Comparing the lymph node metastatic stage of rectal cancer through multithreaded computer tomography with pathology showed that the incidence of computed tomography was highest at stage N0 (95.1%), followed by N1 ( 50.0%) and N2 (22.2%) 3.2.3. Phase diagnosis results through computerized tomography Table 3.16. Diagnosis of stage of rectal cancer on computerized tomography Number of Rate AJCC TNM Dukes patients (%) (n= 118) Stage 0 TisN0M0 0.8 Stage I T1N0M0; A 18 15.3 T2N0M0 Stage IIa T3N0M0 B 21 17.8 II Stage III IIb IIc Subtotal IIIa IIIb IIIc Subtotal T4aN0M0 T4bN0M0 B B C 22 0.8 18.6 5.9 T12N12aM0 T34aN1M0;T2 3N2aM0;T12N2bM0 T4aN2aM0; T3 4N2bM0;T4bN12M0 C 67 56.8 C 2.5 77 65.3 On computerized tomography images of 118 rectal cancer patients: Classification according to TNM: period 0 is 0.8%; Phase I is 15.3%; Phase II is 18.6%; Phase III is 65.3%. There were no cases of distant metastasis (stage IV) Classified by Duckes: Dukes A period is 15.3%; Dukes B is 18.6% and Dukes C is 65.3% Table 3.17. Reconstructing rectal cancer stage by multithreaded computer tomography with pathology Stage of Stage of Total rectal rectal (n = 118) cancer on cancer on pathologi computed cal tomograp surgery hy (Number of patients, %) Stage 0 Stage I Stage II Stage III Stage 0 0 11.1% 2.5% 100.0% 16 13 30 Stage I 4.5% 16.9% 25.4% 88.9% 19 28 47 Stage II 0 36.4% 39.8% 86.4% Stage III 0 Total 100.0% 18 100.0% 9.1% 22 100.0% 36 46.8% 77 100.0% 38 32.2% 118 100.0% Comparison of diagnosis of stage rectal cancer through multithreaded computer tomography with GPB found the highest proportion of diagnosis matching in stage (1/1 patient), followed by stage I (88.9% ), Phase II (86.4%) and the lowest is Stage III (46.8%) Table 3.18. Diagnostic value for rectal cancer stage according to AJCC of multireaded computed tomography Stage of Stage of rectal cancer (AJCC) on pathological surgery rectal cancer (AJCC) on Stage 0 Stage I Stage II Stage III computerize d tomography Sensitivity (%) 33.3 53.3 40.4 94.7 Specificity (%) 100 97.7 95.7 48.7 Positive forecast value (%) 100 88.8 86.3 46.7 Negative forecast value (%) 1.7 14.0 29.1 4.8 Accuracy (%) 98.3 86.4 73.7 63.5 The sensitivity of diagnosis of rectal cancer stage of multidisciplinary computed tomography ranges from 33.3% to 94.7% The specificity for diagnosing the stage of rectal cancer in multi computed tomography ranges from 48.7% to 100% Positive predictive value in rectal cancer stage diagnosis of multi computed tomography ranged from 46.7% to 100.0% Negative predictive value in rectal cancer stage diagnosis of multidisciplinary computed tomography ranged from 1.7% to 29.1% The accuracy in diagnosing rectal cancer stage of multithreading computer tomography ranges from 63.5% to 98.3% 3.3. LAPAROSCOPIC SURGERY METHOD OF RADICAL TREATMENT OF RECTAL CANCER 3.3.2. Surgical time Table 3.22. Time for laparoscopic surgery to treat rectal cancer Cut the rectum and Miles Total connect surgery (n= 118) Surgica immedi (n= 37) ately l time (minute (n= 81) s) Number Numbe Number of Rate r of Rate of Rate patient (%) patient (%) patient (%) s s s 0.05 The average laparoscopic surgery time is 171.4 ± 38.6 minutes (the shortest: 82 minutes; the longest: 330 minutes). The majority of patients had surgery time ≥150 minutes (78.8%) The average laparoscopic surgery time in the immediate rectal segmentation group (170.0 42.1 minutes) was not different from the Miles surgery group (174.6 30.0 minutes), p> 0.05 Table 3.26. Time of hospitalization after surgery Time of Cut the hospita rectum lization and Miles Total after connect surgery (n= 118) surgery immedi (n= 37) (day) ately (n= 81) Numbe Rate Number Rate Number Rate r of (%) of (%) of (%) patient patients patients 0.05 Average hospitalization time after surgery: 8.4 ± 3.5 days (shortest: 5 days and longest: 35 days). Most patients had a hospital stay of ≥7 days after surgery (91.5%). The postoperative hospital stay in the Miles surgical group (7.7 2.3 days) tended to be shorter than the immediate rectal incision (8.7 3.9 days), but the difference No statistical significance (p> 0.05) 3.5 DISTANT RESULTS AFTER RADICAL LAPAROSCOPIC TREATMENT OF RECTAL CANCER 107/118 patients (90.7%) were monitored after surgery with an average time of 29.3 8.3 months (2 47 months) 3.5.1. Sequelae, recurrence and death after surgery Table 3.28. Recurrence and death rates after surgery in patients with rectal cancer Number of Death, Rate Time patients recurrence (%) (± SD) [median] (n= 107) 23.3 ± 11.4 (1 36) Death 10 9.3 [median: 25.0] 26.0 ± 9.8 (7.0 47.0) Recurrence 16 15.0 [median: 25.5] The recurrence rate is 15.0%. The average relapse time was 26.0 9.8 months (7 47 months) [median: 25.5 months] The death rate is 9.3%. The average time of death was 23.3 ± 11.4 months (136 months) [median: 25.0 months] 3.5.2. Complete survival time and diseasefree survival Table 3.29. Complete survival time of rectal cancer patients Complete survival Number of died Rate (%) time (month) 12 24 36 ±SE (KTC 95%) patients (±SE) (n= 10) 98.1 1.3 94.9 2.2 10 83.7 5.5 43.8 0.9 (KTC 95%: 42.0 45.7) The overall survival rate of 12, 24 and 36 months was 98.1%; 94.9% and 83.7%. The average overall survival time was 43.8 0.9 months (95% CI: 42.0 45.7) Figure 3.1. Complete survival time of rectal cancer patients Table 3.30. Diseasefree survival time of rectal cancer patients Diseasefree survival time (month) 12 24 36 47 ±SE (KTC 95%) Number of relapsed Rate (%) patients (±SE) (n = 16) 98.1 1.3 93.8 2.4 15 76.9 6.0 16 42.5 1.0 (KTC 95%: 40.3 44.6) The rate of survival without disease 12, 24 and 36 months was 98.1%; 93.8% and 76.9%. The median nondisease survival time was 42.5 1.0 (95% CI: 40.344.6) Figure 3.2. Diseasefree survival time of rectal cancer patient CHAPTER 4 DISCUSSION 4.1. CHARACTERISTICS OF STUDIED SUBJECTS 4.1.1. Age Rectal cancer is increasing, usually after 40 years of age and increases most in the age group of 5070 years. Through research, the average age of patients is 60.0 ± 12.5 years old. (2686 years old). The mean age of male patients (59.8±12.2 years) was not different from female patients (60.2 ±12.8 years), p> 0.05 4.1.2. Gender The majority of studies show that the proportion of rectal cancer patients is male than female. Male patients have a harder time predicting surgery than female patients due to the narrower pelvic anatomy The research results show that men account for 54.2%, women are 45.8%. The male to female ratio is 1.19. This is also consistent with some studies on the sex of rectal cancer patients 4.1.3. Distribution of patients by geography Research shows that patients in rural areas still account for the majority (79.7%), including some remote provinces such as Lai Chau, Cao Bang and Dien Bien. This result is similar to that of Pham Van Binh researched at National Cancer Hospital (2012), 72.59% of rural patients. 4.2 CLINICAL AND SUBCLINICAL CHARACTERISTICS OF RECTAL CANCER 4.2.2. Subclinical characteristics of rectal cancer 4.2.2.1. Cancer fetal antigen characteristics (CEA) Many studies show that CEA levels increase over 60% of patients with colorectal cancer, especially rising 80% to 100% in the advanced stage, especially when there is distant metastases in the liver, lungs According to Duong Xuan Loc et al. (2011), the majority of patients with CEA cancer marker increased above 10 ng /ml (72.2%) and CA19.9 increased over 37 ng / ml by 15.6%. The study showed that the average CEA concentration of rectal cancer patients was 7.8 ± 30.8 ng / ml. High serum CEA levels in rectal cancer patients had 29/118 patients, accounting for 24.6% This is also consistent with the comment of Trinh Hong Son (2011) 40.7% of patients with high CEA; 88% of CEA cases> 5 ng / ml are stage T3 and T4 cancers The CEA rate increased among the very differentiated, moderate and inferioriated groups, respectively, by 30.8%; 42.9%; 51.2%, the difference is statistically significant with p 10 mm is considered abnormal. Computerized tomography cannot distinguish benign or malignant lymph nodes. Moreover, malignant ganglia may be diameter