Presentation on Carcinoma rectum - with medical and surgical management.

1. Carcinoma Rectum
Moderator - Dr Shishira Ranade

2. ANATOMY

6. Nodes in the origin of
sigmoid branches
Nodes in the origin of inferior
mesenteric artery
Sacral nodes
Internal iliac nodes
Inguinal nodes

8. Aetiology
Red meat and saturated fatty acids
Alcohol and Smoking
FAP - defect in APC gene on chromosome 5q21
HNPCC - MSH2 & MLH1 gene defect
Family history - any first degree relatives
(increases by two times)
Inflammatory bowel disease - Ulcerative Colitis

9. Adenoma - Carcinoma sequence
• Accounts for upto 80 % of sporadic colon tumours
and typically includes mutation of APC gene

11. Clinical Features
Bleeding per rectum
Altered bowel habbits (Spurious Diarrhoea)
Tenesmus
Pain with defecation
Anemia, loss of appetite, malnutrition,
Urinary symptoms

12. Digital Rectal Examination
(DRE)
• Assessment of tumor size,
mobility and fixation,
anterior or posterior
location, relationship to
sphincter mechanism and
the distance from the anal
verge.

13. Rigid Proctoscope
• Demonstrates the proximal
and distal levels of the mass
from anal verge
• Extent of circumferential
involvement
• Orientation within the lumen
• Aids in determining the
feasibility of local excision

14. Colonoscopy
• To rule out
synchronous
cancers - which
occur 2 - 8% of the
time.

15. Laboratory studies
• Complete Blood count
• Serum Electrolytes
• Liver Enzymes
• CEA (Carcinoembryonic antigen)

16. CT scan
• Regional tumor extension
• Lymphatic and distant
metastasis
• Tumor related complications -
perforation or fistula formation

17. Transrectal Endoluminal
Ultrasound
Permits accurate characterisation of the primary
tumor and the status of the perirectal lymph nodes

19. MRI
• Endorectal coil magnetic
resonance imaging (ecMRI)
and surface coil MRI
• Permits larger field of view
and less operator and
technique dependent

20. TRUS MRI CECT
Range of
Accuracy-
(Local tumor
invasion
80 - 95% 75 - 85% 65 - 75%
Rectal nodal
involvement
70 - 75%
ecMRI - 95%
MRI- 60-65%
55-65%
Distant
Metastasis
— 75 - 87%

21. Recommended Imaging
• Pelvic MRI or endorectal Ultrasound and CT scan
of chest, abdomen and pelvis

22. TNM Classification

27. CRM - in pathological staging
• Circumferential resected margin - closest radial
margin between the deepest penetration of the
tumour and the edge of resected soft tissue around
the rectum - measured in millimetres
• CRM is a strong predictor of both local recurrence
and overall survival.
• Positive CRM - tumour within 1 mm from the
transected margin.

28. Principles of Treatment
• Surgical resection in the cornerstone of curative
therapy - Primary goal is complete eradication of
the primary tumor along with the adjacent
mesorectal tissue and the superior rectal artery
pedicle.
• Resected margins
• Distal Margin - 2 cms ; Proximal margin - 5 cms
• Circumferential radial margin - distal mesorectal excision 5 cms
below the lower border of the tumour

29. Local Excision
• Indicated for mobile tumors smaller than 3 cm in diameter
that involve less than 30% of the rectal wall circumference
and that are located in the distal rectum. These tumors should
be mobile, not fixed, limited to submucosa (T1), well or
moderately differentiated histologically and have no lymphatic
or vascular invasion.

30. Transanal Excision
• Indicated in small distal
rectal tutors which are 6
- 8 cms above the anal
verge.
• Circumferential full
thickness dissection
upto perirectal fat is
done with a margin of 1
cm from the border of
tumour

31. Transcoccygeal Excision
Approach to anterior lesion Approach to posterior lesion

32. Transanal Endoscopic
Microsurgery
• Small benign and malignant
lesions in the mid and
proximal rectum that are too
high for transanal excision.

33. Low Anterior Resection
• Anterior Proctosigmoidectomy with colorectal
anastomosis - resection of the proximal rectum or
rectosigmoid below the peritoneal reflection
through an abdominal approach

35. Superior rectal
artery is
divided at the
junction with
left colic artery
to result in a
high arterial
ligation
Colon is divided at
sigmoid
descending colon
junction using
linear staplers

38. Peritoneal incision of the pelvis
Rectum reflected anteriorly and posterior
avascular plane entered between the pre
sacral fascia of waldeyar and the fascia
propria of the rectum

39. Division of lateral stalks
Projected line of
dissection in pelvis
through Waldeyar’s and
Denovillier’s fascia

41. Total Mesorectal Excision
• Introduced by RJ Heald in 1979
• Use of sharp dissection under vision to mobilize the
rectum rather than the conventional blunt finger
dissection
• First series of 112 pts: 5yr LR 2.9% and survival 87.5%
• Local recurrence:
• Conventional surgery: 11.7 - 37.4%
• TME surgery: 1.6 - 17.8%
• Higher leaks rates reported possibly due to:
• Devascularisation of distal rectal stump
• Lower anastamosis
• Other factors: stomas, drains

42. TME - technique
Peritoneal incision around rectum
Rectosigmoid reflected ant and posterior avascular plane
developed using sharp scissor or diathermy dissection
under vision
Blobbed lipoma should be demonstrated
Posterior dissection first, then lateral and finally anterior
dissection
Do not ‘finger hook’ or clamp the lateral ‘ligaments’
Partial TME to a distance 5cm distal to tumour

43. Point of Transection
• Middle and lower cancers - Entire mesorectum with
its enveloping fascia as an intact unit should be
removed
• Upper rectal cancers - TME is extended to 5 - 6
cms below the level of the tumor.

44. Transection of the distal
rectum with a linear
stapler
Colorectal
Anastomosis
Stapling instrument
introduced through the
rectum
Descending colon purse-
string suture is tied
around the shaft of anvil
The circular stapler is
reconnected,
reapproximated, and fired The anastomosis is
complete
The proximal and distal
staple lines are examined
for intact inner “donuts”

45. Diverting Loop Ileostomy
• Should be considered in any low anastomoses (< 5 cms )
from the dentate line
• Other factors
• history of radiation
• Perioperative steroid use
• malnutrition
• elderly women with thin recto vaginal septum
• elderly patients undergoing pre operative combined modality therapy
with planned post operative chemotherapy

46. - the en bloc resection of the tumour as well as the
surrounding lymph nodes and the anal sphincters,
resulting in a permanent colostomy.
ABDOMINOPERINEAL RESECTION

47. APR
• Morbidity - 61%
• Mortality - 0 - 6.3%
• Urinary complications - 50%
• Perineal wound infections - 16%

48. Projected lines of pelvic floor
resection in vertical plane
Anal
closure
Perineal incision

49. Incision line anterior to coccyx
through anococcygeal ligament
through which scissors are used to
gain entrance to the pelvis
Planes of pelvic dissection and posterior
plane of entry into pelvis through the pelvic
floor

50. Projected lines of
pelvic floor
transection
Lateral transection of
Levator ani muscle
Completion of
anterior dissection
and removal of
rectum through
perineal wound
Anterior resection of
rectourethralis,
puborectalis, and
pubococcygeus
Pelvic floor closed
with two drains in
place

51. En Bloc Excision with
Rectum

52. Line of dissection, including
posterior wall of vagina for low
anterior rectal cancer
Posterior Vaginectomy
Lines of transection, including
posterior wall of vagina

53. Pelvic Exenteration
For locally advanced
Rectal cancer
Morbidity - 20 - 40 %
Mortality - 0 - 20%

54. Palliative resection
• Indication - stage IV
• Bleeding, Localized perforation and Obstruction
• Options
• Permanent diversion followed by chemotherapy (+/-
radiotherapy demanding on local symptoms)
• Palliative resection with a permanent colostomy followed by
chemotherapy
• Palliative resection with restoration of GI continuity followed by
chemotherapy

55. • Obstructing cancer
• Loop ileostomy for diversion —> neoadjuvant chemoradiation —>
surgical resection
• Metastatic cancer
• If life expectancy - > 6 months - palliative rectal excision
• Rectal stents / laser destruction
• Recurrent cancer
• Usually from residual cancer from pelvic wall

56. Chemoradiation