1. Advanced Colorectal Cancer 嘉義長庚醫院 大腸直腸外科 葉重宏

2. 大腸直腸癌發生率 十萬人口發生率 美國 紐約 31.0 日本人 30.8 中國人 31.3 台灣 19.0 新加坡 中國人 15.9 香港 12.5 大陸、上海 7.6 菲律賓 4.1 印度 1.8 一生中得大腸直腸癌機會 6% ，如果有家族史則 機會上升。

3. 發 生 率 ( 1996 ) 男 性 女 性 肝 癌 子 宮 頸 癌 肺癌 乳癌 大 腸 直 腸 癌 大 腸 直 腸 癌 2943 2309 ( 27.43 ) ( 21.39 ) 5252 ( 23.85 ) 大腸直腸癌的台灣現況 ( 一 )

4. 大腸直腸癌的台灣現況 ( 二 ) 致死率 ( 1999 ) 全民 男 性 女 性 肺 癌 肝 癌 肺 癌 肝 癌 肺 癌 肝 癌 大 腸 直 腸 癌 大 腸 直 腸 癌 大 腸 直 腸 癌 ( 14.21 ) ( 15.92 ) ( 12.51 ) 3128 1796 1332

5. Complicated Carcinoma Synchronous polyps and / or Carcinoma Obstruction Perforation Bleeding Invasion of Adjacent viscera

6. Invasion to Adjacent Viscera Abdominal wall Small bowel Urinary bladder Uterus Stomach Spleen Ureter Duodenum Another segment of colon

7. Incidence (1) 6 % ~ 12 % of all patients with colon Carcinoma without distal metastasis invaded adjacent viscera

8. Incidence (2) Gall, Tonak, and altendorf – 1987 1918 cases for curative resection for Colorectal CA 121 cases ( 6.3 % ) with multi-visceral involvement Uterus 39 % Small bowel 21 % Urinary bladder 16 % Abdominal wall 4 %

9. Character of invasion (1) Sometimes these adhesion is caused by inflammation not by malignant infiltration  The prognosis might be better than originally anticipated

10. Character of invasion (2) No. of Adhesions (%) Authors patients Carcinomatous Inflammatory McGlone et al. 1982 24 66 34 Pittam et al. 1984 44 33 67 Eldar et al. 1985 84 68 32 Glass et al. 1986 69 49 51 Gall et al. 1987 121 55 45 Hunter et al. 1987 28 39 61 Eisenberg et al. 1990 58 84 16 Montesani et al. 1991 35 71 29 Curley et al. 1992 101 70 30 Izbicki et al 1995 83 54 46

11. Principle of treatment (1) En bloc resection Conservative treatment for : Duodenum Bladder base Morbidity and mortality vs. benefit from radical resection

12. Principle of treatment (2) Curley et al. – 1994 12 cases extended R ’ t hemicolectomy and pancreaticoduodenectomy No mortality was noted Talamonti et al. – 1993 36 cases AR + total cystectomy 34 cases AR + partial cystectomy Mortality 3/36 and 0/34 5-year survival rate 52 %

13. Principle of treatment (3) Gall et al. – 1987 5-year survival rate with en bloc resection : 49 % ~ 54 % Inadvertently torn or transected the invasion : 17 %

14. Principle of treatment (4) Hunter et al. – 1987 standard en bloc colectomy colectomy resection with seperation 5-year Survival 55 % 61 % 23 % Recurrence 33 % 36 % 77 % Local recurrence 11 % 18 % 69 %

15. Operative mortality Gall et al. (1987 ) 12 % Hunter et al. (1987) 0 % Pittam et al. (1984) 14 % Lopez et al. (1993) 6 % Montesani et al. (1991) 0 %

16. Operative Morbidity Kroneman et al (1991) 6 % Landercasper et al. (1992) 24% Lopez et al.( 1993) 7 %

17. 5-year survival rate McGlone et al. ( 1982 ) 79% Eldar et al. ( 1985 ) 35% Glass et al. ( 1986 ) 70% Gall et al. ( 1987 ) 52% Montesani et al. ( 1991 ) 30% Curley et al. ( 1992 ) 54%

18. Summary Fair prognosis in some cases Improved morbidity rate Decrease mortality rate Improve 5-year survival rate after en bloc resection  Encourage : En bloc resection

19. Thank You