123 Diagnosis Dominant symptoms include rectal bleeding 703 change in bowel

123 diagnosis dominant symptoms include rectal

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12.3 Diagnosis Dominant symptoms include rectal bleeding (70.3%), change in bowel habits (66.4%), abdominal pain/discomfort (60.0%), intestinal obstruction (43.6%), mucus discharge (24.3%) and tenesmus (30.8%). Majority (91%) are palpable on digital rectal examination. Proctoscopic/Sigmoidoscopic biopsy and histopathology completes the diagnosis. 12.4 Staging and Risk Assessment For local staging of rectal cancer MRI and EUS (or Contrast enhanced CT pelvis if not available) are recommended. Chest X ray with liver US or CT Chest and abdomen are recommended for distant metastases. Complete colonoscopy should be done before or after surgery. The surgical specimen is evaluated for surgical margins (proximal, distal, circumferential), examination of at least 12 nodes and vascular and nerve invasion. Rectal cancer is staged using the TNM system (table 1). Stalked and sessile adenomas should be classified using the Haggit system (Table 27)
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National Guidelines for Cancer Management Kenya 77 Table 25: TNM Staging for Rectal Carcinoma Primary Tumor (T) TX primary tumor cannot be assessed T0 no evidence of primary tumor Tis carcinoma in situ: intraepithelial or invasion of lamina propria T1 tumor invades submucosa T2 tumor invades muscularis propria T3 tumor invades through muscularis propria into subserosa or into nonperitonealized pericolic or perirectal tissues T4 tumor directly invades other organs or structures and/or perforates visceral peritoneum Regional Lymph Nodes (N) NX regional lymph nodes cannot be assessed N0 no regional lymph node metastasis N1 metastasis in one to three regional lymph nodes N2 metastasis in four or more regional lymph nodes Distant Metastases (M) MX distant metastasis cannot be assessed M0 no distant metastasis M1 distant metastasis Table 26: Stage Grouping AJCC Staging for Rectal Carcinoma TNM Classification Dukes Stages Stages Stage 0 Tis N0 M0 Stage I T1 N0 M0 A T2 N0 M0 B1 Stage II T3 N0 M0 B2 Stage III T1, T2 N1 or N2 M0 C1 Stage IV Any T Any N M1 D Stage V T3, T4 N1 or N2 M0 C2 T4 N0 M0 B2
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National Guidelines for Cancer Management Kenya 78 Table 27: Haggit system for polyps with invasive cancer Level 0 Carcinoma in situ, not invading muscularis mucosa Level 1 Invasion into submucosa, limited to head of polyp Level 2 Cancer invades neck of polyp Level 3 Cancer invades stalk of polyp Level 4 Cancer invades submucosa of bowel wall = T1 All sessile polyps with invasive Cancer are level 4 by Haggitt’s criteria Level 1-3 are limited to polyp wall and do not involve normal bowel wall 12.5 Management 12.5.1 Treatment of localised disease The aim of treatment is complete (R0) resection with sphincter preservation. The treatment is planned in a multidisciplinary setting. Surgical options include local, anterior and abdominoperineal resections. Total Mesorectal Excision (TME) must be performed to remove all mesorectal fat and all involved nodes and reduce local recurrence.
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National Guidelines for Cancer Management Kenya 79 Table 28: Treatment Options by Stages Malignant polyps; (Haggit 1-3; T1 sm1 N0) Early cancer (cT1–2, some cT3, N0) and
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