Management of Carcinoma Rectum

8/9/2019 Management of Carcinoma Rectum

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anagement of anagement of arcinoma Rectumarcinoma Rectum

Budhi Nath Adhikari


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Clinical Evaluation :

HistoryOften asymptomaticSymptoms occur late

Rectal complaints, non specificRisk factors


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Physical ExaminationDRE palpable massLiver enlargement, previous operations

Assessment of the patient's analsphincter


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InvestigationRigid proctosigmoidoscopcopyfeasibility of local excision and obtain an

adequate tissue biopsy


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Endorectal ultrasoundPreoperative staging - depth and nodalenlargement

Confirmation of nodal metastasis withultrasound-guided needle biopsy is lessreliable

Overstaging

less able to distinguish accurately T1 from T2cancers, stenotic lesions and in patients withprior radiation


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CT scansRegional tumor extension, lymphatic anddistant metastases, and tumor-relatedcomplications such as perforation or fistulaformation.

Less accurate than endoluminal scan (localspread, adjacent organ invasion) betterfor distant metastasis and recurrentdisease detection


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MRILarger field of view, less operator- and

technique-dependent, allows study of stenotictumors

Discriminate small-volume nodal disease andsubtle transmural invasion , local recurrence

Identifies involved perirectal nodes on thebasis of characteristics other than size

Identifies foci not only within the mesorectumbut also outside the mesorectal fasciaDouble-contrast MRI may permit more accurate T staging


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Tumour markerCEAUp to 95% of patients with advanced

hepatic metastasis will have a CEA levelabove 20 ng/mL.

Normal preoperative CEA levels willidentify patients who will not benefitfrom following CEA levelspostoperatively


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PETAssessing the extent of pathologic response of primary rectal cancer to preoperativechemoradiation and may predict long-termoutcome.

Detection of recurrence of rectal cancer aftersurgical resection and full-dose external-beam radiation therapy

Relatively inaccurate for nodal metastases


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Histopathologic examination of the specimenobtained via biopsy or local excision

Chest x-ray or chest CT scan to excludepulmonary metastases

Subjective and objective assessment of the patient's anal sphincter function

Prostate-specific antigen

Baseline investigations


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TNM StagingDescribe the anatomic extent, planningtreatment, evaluating response to treatment,comparing the results of various treatmentregimens, and determining prognosis

stage I, the tumor invades upto the muscularispropria

stage II, the tumor invades completely throughthis layer.

stage III, lymph node metastasisstage IV, metastatic disease


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ag ng


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Poor prognostic factorsPoorly differentiated cancersDirect tumor extension into adjacent structures

(T4 lesions)

Lymphatic, vascular, or perineural invasion;andBowel obstruction


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Principles of Treatment

Surgical resection is the cornerstone of therapyLiver metastasisSuperficially invasive, small cancers may be

managed effectively with local excision.Deeply invasive tumors require major surgery:

LAR or APR

Locally advanced tumors adherent to adjoiningstructures such as the sacrum, pelvicsidewall, prostate, or bladder, require an evenmore extensive operation.


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Goals of Surgery The primary goal of surgical treatment forrectal cancer is complete eradication of theprimary tumor along with the adjacentmesorectal tissue , LNs and the superiorhemorrhoidal artery pedicle.

reestablishment of bowel continuity andcontinence preferable


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Resection Margin2 cm distal margin, if not poorly differentiatedor distant spread

5 cm proximal margin recommendedRadial Margin of 5 cm - more critical than the

proximal or distal margin for local control andis an independent predictor of both localrecurrence and survival


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Local ExcisionDisease-free survival may be less; 12% of T1

and 22% of T2 tumors should not have been

treated with local therapy ; some patientsrequire a salvage APR for ultimate cure.Palliation of symptomatic but incurable rectal

cancers


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Major risk factors for local recurrence : positivesurgical margins, trans-mural extension, andpoorly differentiated histology

Local failure or LN involvement in T1/T2Repeat local procedures rarely indicated


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Local ExcisionTransanal procedure : Tumors 3 cm 5 cmfrom the dentate line but not invading thesphincters .Day Care or OPD. Low morbidityno mortality

Transcoccygeal Excision : Larger & tumors 5 7 cm from the dentate line esp posteriorwall. Immediate mesorectal tissue adjacent tothe tumor is removed along with perirectalnodes. Fecal fistula


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Transanal endoscopic microsurgery (TEM)using Wolf operating microscope. Smalltumors 7-10 cm from the dentate line

Transanal fulgurationLocal/contact radiation therapy (Papillon

approach).


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Amenable to Local Excision

T1N0 or T2N0 lesion


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Radical ResectionAPR with permanent colostomy : Distal Rectallesions involving the sphincter or incontinent pts

Low anterior resection with colorectal

anastomosis : Proximal rectal and midrectallesionsHartmann ProcedurePelvic Exenteration and Sacrectomy : Resection of

the anus, the rectum, the bladder, the ureters,and the pelvic reproductive organs

The primary goal of radical resection is to removethe rectal cancer, the rectosigmoid mesentery,and the mesorectum with clear margins


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APRAPR offers no survival advantage oversphincter-sparing procedures

significant morbidity (Urinary complications,perineal wound infections, sexualdysfunction, change in body image ) of 61%and mortality upto 6.3% with recurrencesupto 20%.

T3N0 moderately or well-differentiatedcancers invading less than 2 mm intoperirectal fat low locoregionalrecurrence


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LAR: no incontinence, no extensive pelvicdisease, limited life expectation and lesionwith resected margin above internal sphincterbut risk of recurrence , anastomotic leak &incontinence

body build, sex, obesity, lesion level, localspread, perforation or abscess, size/fixation,grade, obstruction, bowel preparation &general medical condition.

Ultralow colorectal & coloanal anastomosistogether with a colonic pouch or coloplasty


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Other Treatment OptionsLaparoscopic TMEEndocavitary radiationElectrocoagulationLaser vaporization using neodymium:yttrium-

aluminum-garnet laser


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Palliative ProceduresAfter surgical resection , improvement noted in40% with bleeding, 70% with obstruction, and20% with pain.

Seek comorbidities, and patient desires andgoals

Hidden ColostomyHigh Ligation of Inferior Mesenteric Artery


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Obstructing Cancer of

the Rectumloop ileostomyUsually T3 or N1 lesion: the patient is treated

with neoadjuvant chemoradiation andconsidered for subsequent surgical resection


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Therapy

pelvic sidewall recurrenceperipheral neuropathy and ureteral stenosis


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Neoadjuvant

Chemoradiation T3 or N1 rectal carcinomabulky T2 lesions near the sphincters

Neoadjuvant therapy then is followed by TMEwith APR or TME with an end-to-side, colonic

J-pouch, or coloplasty reconstruction.

no difference in overall survival


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Advantagessignificant decrease in the local recurrence rate(6% versus 13%), as well as toxicity

ability to deliver higher doses of chemotherapydownstage the tumor (60 80% cases)achieve a pathologic complete response (15

30% cases)

Decreased radiation enteritis thereby morecomplete radiation therapy


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Eliminate the micrometastatic disease presentat the time of surgery.

Increased resectability,Improves local control and survival in stage II

and III patientsDecreased distant metastasis

Regimens used: 5FU + Leucovorin


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Chemoradiotherapy


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RecurrenceInadequate removal , Implantation at sutureline , New Lesion

5% to 10% synchronous cancers and 30%adenomatous polypsClinical detectionWorkups

Related to the extent of transmuraldisease and associated involvement of regional lymph nodes


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Between 60% and 84% of recurrences are seenin the first 24 months and 90% within 48months.

Median time to recurrence is 1122 months.Local recurrence rates ranges between 4% and

50%.Radiotherapy or surgeryFollow-up: Clinical, CEA , Colonoscopy ,CT


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THANK YOU

Management of Carcinoma Rectum

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