Rectal Cancer
Dr. Sultan Zahir
Rectal Cancer
 Rectal cancer is a disease in which cancer cells form in
the tissues of the rectum; colorectal cancer occu...
WHO Classification of Rectal Carcinoma
 Adenocarcinoma in situ / severe dysplasia
 Adenocarcinoma
 Mucinous (colloid) a...
Clinical Presentation
 Bleeding is the most common symptom of rectal cancer,
occurring in 60% of patients. However, many ...
 Back pain: Usually a late sign caused by a tumor invading or
compressing nerve trunks
 Urinary symptoms: May occur if a...
Examination
Signs of primary cancer
 Abdominal tenderness and distension – large bowel
obstruction
 Intra-abdominal mass...
Clinical Staging
TNM Primary Lymph-node Distant Dukes
stage tumor metastasis metastasis stage
Stage 0 Tis N0 M0 A A
Stage ...
Dukes classification-
Dukes A: Invasion into but not through the bowel wall.
Dukes B: Invasion through the bowel wall but ...
Tis T1 T2 T3 T4
Extension
to an adjacent
organ
Mucosa
Muscularis mucosae
Submucosa
Muscularis propria
Subserosa
Serosa
TNM...
Stage and Prognosis
Stage 5-year Survival (%)
0,1 Tis,T1;No;Mo > 90
I T2;No;Mo 80-85
II T3-4;No;Mo 70-75
III T2;N1-3;Mo 70...
Diagnostic Workup
 History—including family history of colorectal cancer or
polyps
 Physical examinations including DRE ...
Colonoscopy or barium enema
Figure: Carcinoma of the rectum. Double-
contrast barium enema shows a long
segment of concent...
Transrectal ultrasound –EUS
 use for clinical staging.
 80-95% accurate in tumor staging
 70-75% accurate in mesorectal...
CT scan
 Part of routine workup of patients
 Useful in identifying enlarged pelvic lymph-nodes
and metastasis outside th...
Figure: Mucinous adenocarcinoma of the
rectum. CT scan shows a large
heterogeneous mass (M) with areas of
cystic component...
Magnetic Resonance Imaging (MRI)
 Greater accuracy in defining extent of rectal cancer
extension and also location & stag...
Figure: Mucinous adenocarcinoma of
the rectum. T2-weighted MRI shows high
signal intensity (arrowheads) of the
cancer lesi...
PET with FDG
 Shows promise as the most sensitive study
for the detection of metastatic disease in
the liver and elsewher...
 CEA: High CEA levels associated with poorer survival
 Routine investigation
 Complete blood count, KFT, LFT
 Chest X-...
Treatment
Surgery Chemotherapy Radiotherapy
Surgical Options
 Trans-anal resection
 Anterior resection/CAA
 Abdomino-perineal
■ Local excision
• Transanal
• Total mesorectal excision
■ Direct contact radiotherapy
■ Electrocautery
Local Treatment (L...
■ Tumor < 8 cm from anal verge
■ Tumor size < 3 cm ( < 1/3 circumference)
■ Histology; well or moderately differentiated
■...
■ Full thickness disc excision
■ 2 cm margin
■ Full thickness stay sutures
■ Use electrocautery
■ Closure of incision may ...
Transanal excision
 For T1 or T2 tumors
 Somewhat controversial
 due to higher local
 recurrence rates
 Only routinel...
Surgical principles
 High vascular ligation
(Corder, Br J Surg, 1992)
 Remove lymph node basin
(Total Mesorectal Excisio...
Total Mesorectal Excision
Total mesorectal excision
 Standardized technique
 4 to 9% local recurrence rate
 Heald, Lancet 1986
 Lavery, Surgery ...
Abdomino-perineal resection
Anterior resection
 Cancer of the rectum
 Join colon to low rectum
 Permanent colostomy
if tumor too low
Colorectal Anastomosis
 Suture by hand
 Staple with instrument
 Sometimes protect with temporary
ostomy
Colonic J-pouch
 Proposed by Parc and
Lazorthes 1986
 6cm vs 12 cm pouch
 Increases reservoir
 Improves short term
fun...
Coloplasty
Fazio et al, DCR 2000
Concerns regarding Laparoscpic
Surgery
 Learning curve
 Reduced ability to define distant disease
 Difficulty localizin...
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Rectal cancer

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Rectal cancer

  1. 1. Rectal Cancer Dr. Sultan Zahir
  2. 2. Rectal Cancer  Rectal cancer is a disease in which cancer cells form in the tissues of the rectum; colorectal cancer occurs in the colon or rectum. Adenocarcinomas comprise the vast majority (98%) of colon and rectal cancers; more rare rectal cancers include lymphoma (1.3%), carcinoid (0.4%), and sarcoma (0.3%).  Second most common cancer death after lung cancer.  Lifetime risk  1 in 10 for men  1 in 14 for women  Generally affect patients > 50 years (>90% of cases)
  3. 3. WHO Classification of Rectal Carcinoma  Adenocarcinoma in situ / severe dysplasia  Adenocarcinoma  Mucinous (colloid) adenocarcinoma (>50% mucinous)  Signet ring cell carcinoma (>50% signet ring cells)  Squamous cell (epidermoid) carcinoma  Adenosquamous carcinoma  Small-cell (oat cell) carcinoma  Medullary carcinoma  Undifferentiated Carcinoma
  4. 4. Clinical Presentation  Bleeding is the most common symptom of rectal cancer, occurring in 60% of patients. However, many rectal cancers produce no symptoms and are discovered during digital or proctoscopic screening examinations. Other signs and symptoms of rectal cancer may include the following:  Change in bowel habits (43%): Often in the form of diarrhea; the caliber of the stool may change; there may be a feeling of incomplete evacuation and tenesmus  Occult bleeding (26%): Detected via a fecal occult blood test (FOBT)  Abdominal pain (20%): May be colicky and accompanied by bloating
  5. 5.  Back pain: Usually a late sign caused by a tumor invading or compressing nerve trunks  Urinary symptoms: May occur if a tumor invades or compresses the bladder or prostate  Malaise (9%)  Pelvic pain (5%): Late symptom, usually indicating nerve trunk involvement  Emergencies such as peritonitis from perforation (3%) or jaundice, which may occur with liver metastases (< 1%)  ( Rectal metastasis travel along portal drainage to liver via superior rectal vein as well as systemic drainage to lung via middle inferior rectal veins.)
  6. 6. Examination Signs of primary cancer  Abdominal tenderness and distension – large bowel obstruction  Intra-abdominal mass Digital rectal examination – most are in the lowest 12cm and reached by examining finger  Rigid sigmoidoscope Signs of metastasis and complications  Signs of anaemia  Hepatomegaly (mets)  Monophonic wheeze  Bone pain
  7. 7. Clinical Staging TNM Primary Lymph-node Distant Dukes stage tumor metastasis metastasis stage Stage 0 Tis N0 M0 A A Stage I T1 N0 M0 A A1 T2 N0 M0 A B1 Stage II T3 N0 M0 B B2 T4 N0 M0 B B2 Stage III A any T N1 M0 C C1/C2 B any T N2, N3 M0 C C1/C2 Stage IV any T any N M1 D D Astler-Coller modified Dukes stage
  8. 8. Dukes classification- Dukes A: Invasion into but not through the bowel wall. Dukes B: Invasion through the bowel wall but not involving lymph nodes. Dukes C: Involvement of lymph nodes Dukes D: Widespread metastases Modified astler coller classification- Stage A : Limited to mucosa. Stage B1 : Extending into muscularis propria but not penetrating through it; nodes not involved. Stage B2 : Penetrating through muscularis propria; nodes not involved Stage C1 : Extending into muscularis propria but not penetrating through it. Nodes involved Stage C2 : Penetrating through muscularis propria. Nodes involved Stage D: Distant metastatic spread
  9. 9. Tis T1 T2 T3 T4 Extension to an adjacent organ Mucosa Muscularis mucosae Submucosa Muscularis propria Subserosa Serosa TNM Classification
  10. 10. Stage and Prognosis Stage 5-year Survival (%) 0,1 Tis,T1;No;Mo > 90 I T2;No;Mo 80-85 II T3-4;No;Mo 70-75 III T2;N1-3;Mo 70-75 III T3;N1-3;Mo 50-65 III T4;N1-2;Mo 25-45 IV M1 <3
  11. 11. Diagnostic Workup  History—including family history of colorectal cancer or polyps  Physical examinations including DRE and complete pelvic examination in women: size, location, ulceration, mobile vs. tethered vs. fixed, distance from anal verge and sphincter functions.  Proctoscopy—including assessment of mobility, minimum diameter of the lumen, and distance from the anal verge  Biopsy of the primary tumor
  12. 12. Colonoscopy or barium enema Figure: Carcinoma of the rectum. Double- contrast barium enema shows a long segment of concentric luminal narrowing (arrows) along the rectum with minimal irregularity of the mucosal surface. To evaluate remainder of large bowel to rule out synchronous tumor or presence of polyp syndrome.
  13. 13. Transrectal ultrasound –EUS  use for clinical staging.  80-95% accurate in tumor staging  70-75% accurate in mesorectal lymph node staging  Very good at demonstrating layers of rectal wall  Use is limited to lesion < 14 cm from anus, not applicable for upper rectum, for stenosing tumor  Very useful in determining extension of disease into anal canal (clinical important for planning sphincter preserving surgery) Figure. Endorectal ultrasound of a T3 tumor of the rectum, extension through the muscularis propria, and into perirectal fat.
  14. 14. CT scan  Part of routine workup of patients  Useful in identifying enlarged pelvic lymph-nodes and metastasis outside the pelvis than the extent or stage of primary tumor  Limited utility in small primary cancer  Sensitivity 50-80%  Specificity 30-80%  Ability to detect pelvic and para-aortic lymph nodes is higher than peri-rectal lymph nodes.
  15. 15. Figure: Mucinous adenocarcinoma of the rectum. CT scan shows a large heterogeneous mass (M) with areas of cystic components. Note marked luminal narrowing of the rectum (arrow). Figure: Rectal cancer with uterine invasion. CT scan shows a large heterogeneous rectal mass (M) with compression and direct invasion into the posterior wall of the uterus (U).
  16. 16. Magnetic Resonance Imaging (MRI)  Greater accuracy in defining extent of rectal cancer extension and also location & stage of tumor  Also helpful in lateral extension of disease, critical in predicting circumferential margin for surgical excision.  Different approaches (body coils, endorectal MRI & phased array technique)  Mercury study:  711 patients from 11 European centers.  Extramural tumor depth by MR & histo-pathological evaluation equivalent.
  17. 17. Figure: Mucinous adenocarcinoma of the rectum. T2-weighted MRI shows high signal intensity (arrowheads) of the cancer lesion in right anterolateral side of the rectal wall. Figure: Normal rectal and perirectal anatomy on high-resolution T2-weighted MRI. Rectal mucosa (M), submucosa (SM), and muscularis propria (PM) are well discriminated. Mesorectal fascia appears as a thin, low-signal-intensity structure (arrowheads) and fuses with the remnant of urogenital septum making Denonvilliers fascia (arrows).
  18. 18. PET with FDG  Shows promise as the most sensitive study for the detection of metastatic disease in the liver and elsewhere.  Sensitivity of 97% and specificity of 76% in evaluating for recurrent colorectal cancer. cancer rectum prostate pubic bone bladder Small bowel
  19. 19.  CEA: High CEA levels associated with poorer survival  Routine investigation  Complete blood count, KFT, LFT  Chest X-ray
  20. 20. Treatment Surgery Chemotherapy Radiotherapy
  21. 21. Surgical Options  Trans-anal resection  Anterior resection/CAA  Abdomino-perineal
  22. 22. ■ Local excision • Transanal • Total mesorectal excision ■ Direct contact radiotherapy ■ Electrocautery Local Treatment (Low Rectal Cancer)
  23. 23. ■ Tumor < 8 cm from anal verge ■ Tumor size < 3 cm ( < 1/3 circumference) ■ Histology; well or moderately differentiated ■ UT1 or UT2 with or without radiotherapy ■ Absence of lymph nodes ■ Nonulcerated tumors ■ Mobile Ideal Criteria for Curative Local Treatment of Rectal Cancers
  24. 24. ■ Full thickness disc excision ■ 2 cm margin ■ Full thickness stay sutures ■ Use electrocautery ■ Closure of incision may implant or bury microscopic tumor Transanal Excision of Rectal Cancer
  25. 25. Transanal excision  For T1 or T2 tumors  Somewhat controversial  due to higher local  recurrence rates  Only routinely used in older  patients or those with  co-morbidity
  26. 26. Surgical principles  High vascular ligation (Corder, Br J Surg, 1992)  Remove lymph node basin (Total Mesorectal Excision)  “En bloc” resection if necessary
  27. 27. Total Mesorectal Excision
  28. 28. Total mesorectal excision  Standardized technique  4 to 9% local recurrence rate  Heald, Lancet 1986  Lavery, Surgery 1997  Heald, Arch Surg 1998  Dutch Trial suggests benefit with XRT
  29. 29. Abdomino-perineal resection
  30. 30. Anterior resection  Cancer of the rectum  Join colon to low rectum  Permanent colostomy if tumor too low
  31. 31. Colorectal Anastomosis  Suture by hand  Staple with instrument  Sometimes protect with temporary ostomy
  32. 32. Colonic J-pouch  Proposed by Parc and Lazorthes 1986  6cm vs 12 cm pouch  Increases reservoir  Improves short term function, reduces leak rate
  33. 33. Coloplasty Fazio et al, DCR 2000
  34. 34. Concerns regarding Laparoscpic Surgery  Learning curve  Reduced ability to define distant disease  Difficulty localizing lesion  Adequacy of resection  OR time and costs  Port implantation of tumor
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