Carcinoma rectum

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  • 1. Carcinoma rectum Dr. vinayak lokare JMMC & RI
  • 2.  
  • 3. Etiology
    • average lifetime risk - 6%
    • risk increases two- to fourfold history of or a first-degree relative with colorectal cancer.
    • Inflammatory bowel disease (IBD)
    • Genetics –
      • familial adenomatous polyposis (FAP) - APC gene on chromosome 5q21
      • hereditary nonpolyposis colorectal cancer (HNPCC)
  • 4. Anatomy
    • divided into three portions
    • lower rectum -3 to 6 cm from the anal verge
    • midrectum - 5 to 6 to 8 to 10 cm
    • upper rectum - 8 to 10 to 12 to 15 cm
    • determination of the location of the boundary between rectum and sigmoid colon is important in defining adjuvant therapy
  • 5. anatomy
    • upper extent of the rectum can be identified where the tenia spread to form a longitudinal coat of muscle
    • The distance from the anal sphincter musculature is clinically of more importance than the distance from the anal verge, as it has implications for the ability to perform sphincter-sparing surgery
  • 6.  
  • 7. Lymphatic drainage
    • Upper rectum - follows the course of the superior hemorrhoidal artery toward the inferior mesenteric artery
    • Middle rectum - follow the middle hemorrhoidal artery
    • lesions occur below the dentate line, the lymphatic drainage is via the inguinal nodes and external iliac chain
  • 8. Types
    • Macroscopic
      • Proliferative
      • Ulcerative
      • Tubular
    • Microscopic
      • Adenocarcinoma
      • Colloid carcinoma
      • Squamous cell carcinoma
  • 9. Clinical features
    • Bleeding per rectum – mucous +/-
    • Alteration of bowel habits – increasing constipation, early morning diarrhoea
    • Sense of incomplete defeacation
    • Intestinal obstruction
    • Pain
    • Loss of appetite ,weight loss , joundice , ascitis
  • 10. Investigations
    • USG abdomen
    • Proctosigmoidoscopy / biopsy
    • Colonoscopy
    • contrast CT of the pelvis and the abdomen
    • Endoscopic USG
  • 11.
    • Chest X-ray
    • Liver function tests
    • Renal function tests
    • Baseline CEA levels
  • 12. staging
    • Dukes’ staging
    • A- limited to bowel wall
    • B-spread outside the bowel wall
    • C-involvement of lymph nodes
    • Astler- Coller modification
    • B1-infiltration into muscularis propria
    • B2- infiltration beyond muscularis propria into serosa
  • 13.
    • C1- lymph node involvement but did not penetrate the entire bowel wall
    • C2- tumors that invaded lymph nodes and did penetrate the entire wall (C2).
  • 14. TNM staging
    • 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 the muscularis propria into the subserosa, or into nonperitonealized pericolic or perirectal tissues
    • T4 Tumor directly invades other organs or structures and/or perforates visceral peritoneum [†]
  • 15.
    • NX- Regional lymph nodes cannot be assessed N0- No regional lymph node metastasis
    • N1 - Metastasis in 1 to 3 regional lymph nodes
    • N2- Metastasis in 4 or more regional lymph nodes
  • 16.
    • MX Distant metastasis cannot be assessed
    • M0 - No distant metastasis
    • M1 - Distant metastasis
  • 17.
    • STAGE T N M DUKES [§] MAC [§]
    • 0 Tis N0 M0    
    • I T1 N0 M0 A A 
    • T2 N0 M0 A B1
    • IIA T3 N0 M0 B B2
    • IIB T4 N0 M0 B B3
    • IIIA T1-T2 N1 M0 C C1
    • IIIB T3-T4 N1 M0 C C2
    • IIIC Any T N2 M0 C C1/C2
    • IV Any T Any N M1   D
  • 18. Treatment
    • Stage 1
    • TEM
      • EUS- T1, T2
      • <40% circumference involvement
      • Well- mod. Differentiated
      • HPR – no lymphatic / venous invasion
  • 19.
    • posterior proctotomy- Kraske procedure
      • large posterior lesions
      • allows for the mobilization of the rectum and a full-thickness local excision
    • T2 lesions-
      • Adjuvant chemoradiation
  • 20.
    • Endocavitary radiation therapy
      • T1 or T2 tumors less than 3 cm,
      • not poorly differentiated,
      • with no evidence of nodal involvement
    • four rounds of 2,500 to 3,000 cGy each with 2 to 3 weeks between treatments
  • 21. Stage 2 and stage 3
    • Preoperative
    • Chemo therapy – 5-FU(350mg/m2/day) for 5 days
    • Leucovorin(20mg/m2) for 5 days
    • 2cycles
    • Radiotherapy 5000cGy
    • Surgery after 4-6 wks
  • 22.
    • Surgery
    • Upper rectum – anterior resection
    • Middle rectum – low anterior resection
    • Low rectum - low anterior resection / APR
    • Adjuvant chemotherapy
    • 5-FU + leucovorin – 4 cycles
  • 23. Stage 4
    • Preoperative chemo radiation
    • APR
    • Post operative chemo / RT
  • 24. radiotherapy
    • Proximal – sacral prmontary
    • Distal – 2 cm below primary tumor mass
    • Lateral – pelvic wall
    • Posterior – sacrum
    • Anterior – posterior border of vagina / prostate
  • 25.
    • 5-FU based adjuvant chemotherapy has been the standard of care for advanced rectal cancer
      • 5-FU treats micrometastases
      • – 5-FU acts as a radiosensitizer
    • Continuous infusion has shown improved survival and increased time to relapse when compared to bolus therapy