2. “ Surgery is the only curative treatment for
rectal Carcinoma”
Main principle :
Wide local resection
of cancer by
achieving
histologically
negative margins and
Performing a total
mesorectal excision
(TME)
3. All patients with invasive rectal CA should be
discussed in MDT Conference
Though surgical resection is the cornerstone of curative
therapy for patients with potentially resectable rectal cancer,
(CRT) has emerged as an important component of curative
therapy for transmural or node-positive rectal cancers
because local recurrences are more common than with colon
primaries.
9. Ø Trans anal excision (Trans anal endoscopic microsurgery/TEM) if following criteria can
be fulfilled
• <30% circumference of bowel
• <3cm in size
• >3mm margin clearance can be achieved
• Mobile
• Within 8cm from anal verge
• T1 only
• No LVI or PNI
• Well to moderately differentiated
• No lymphadenopathy on imaging
11. T1 Lesions
after excision
• High risk features are
• Positive margins
• Lymphovascular invasion
• Poorly differentiated tumors,
• Sm3 invasion (submucosal invasion to the lower third of the
submucosal level).
12. T2 Lesions
after excision
• Transabdominal resection
• Pathology R/V à No change à observe
• Pathology R/V shows T3/T4 or N+ à Sandwich regimen
(Chemo à CRT à Chemo)
13. T3-T4/ Any T with Node positive or Locally
unrectable Lesions
• Neoadjuvant
Principally a loco-regional form of therapy to reduce loco regional
recurrence risk as rectal cancer is associated with high risk of local
recurrence.
Options :
1. Short course radiotherapy
2. Long course chemoradiotherapy
14. Neoadjuvant Vs Adjuvant Treatment
Rationale for adjuvant treatment :
Accurate depth of tumor and LN status can be assessed
accurately à Stage I tumors can be spared from adj. Rx
Rationale for using neoadjuvant treatment :
• Major benefit : increased rate of sphincter preservation
• Reduction in toxicity as after LAR or APR small bowel falls into pelvis and hence
they come into radiation portals
• By neoadjuvant Rx, irradiating bowels are later removed during surgery and
hence no risk of long term toxicity eg. Perforation
• From radiobiological perspective, tumor is well oxygenated during neoadjuvant
setting while blood flow to tumor bed is compromised post surgery, hence low
sensitivity to RT
15. Trial : Neoadjuvant Vs Adjuvant
Sauer et al, 2004
823 patients, T3, T4 or N+
Two arms
1. Pre-op CRT
2. Post-Op CRT
Neoadj. Arm : RT à CT à 6/52 à Sx à CT
Adj Arm : same with additional boost of 540 cGy to tumor bed
16. Advantage of chemotherapy along with
Radiotherapy than RT
• Chemo sensitize the tissue for RT
• RT address local tissue while Chemo can act systemically to eradicate
micromets
• Chemo increase pathologic complete response (pCR) & Local control
• CRT increases sphincter preservation
• But chemo doesn’t improve the OS or DFS
17. LCRT
High Risk features
1. T4 tumors 2. N2 tumors
3. CRM Threatened situations (Direct extension,
EMVI beyond
4. Lower rectal CA
CRT Preoperatively à Chemotherapy post
operatively
1. CRT Fluoropyrimidine (5-FU or capecitabine) + RT
Surgery done in 5-12 weeks
2. Chemotherapy (FOLFOX) or CAPEOX
SCRT
MRF is only microscopic disease , N1
1. T3 with uninvolved CRM in upper & mid rectal
2. T2 but lower rectal CA
25 Gy over 5 days (M-F)
Next week Surgery (Not allowing time for RT
response)
Swedish Rectal Cancer Trail : Local control better
than surgery alone Plus OS benefit
Dutch TME Trail : Local control is better but no OS
benefit
18. Response to neoadjuvant therapy
• 50-60% down-staged
• 20% pCR
• Long term outcome of the patient directly correlates to response to neoadjuvant
- MERCURY Trial
• The patients who responded well to neoadjuvant had better DFS and OS
than those who didn’t!
• Those who responded better would likely to benefit from adjuvant therapy than
those who didn't respond well - EORTC Trial
• Down staged to ypT0-T2 will benefit from adjuvant therapy more than
ypT3-T4!
• Wait-and-See Nonoperative Approach for cCR (Clinical complete
responders)
20. • Trials ‣ ‣ ‣ ◦ ◦ ‣
• EORTC Trial initially showed that 5-FU based adjuvant therapy
Improves DFS but has no benefit in preventing LR
Longterm results of this same study showed that there is no OS
benefit, and the DFS seen earlier is also less pronounced in the
long run!
• ECOG Trial, ADORE Trial - checked the effect of additional chemo
agents to the conventional infusion 5-FU or Leucovorin or oral
capecitabine based chemotherapy!
• FOLFOX = 5-FU + Oxaliplatin (+folinic acid)
• FOLFIRI = 5-FU + Irinotecan (+folinic acid)
• CapeOx = Capecitabine + Oxaliplatin These showed benefit in DFS than 5-FU alone!
• But some studies have found that for those who had a pCR following neoadjuvant CRT +
surgery → no difference in OS/DFS/Distant recurrence rates by adding or not adding
adjuvant chemo!
22. Laparosopic Resection
COLOR II Trail
Compared to open surgery there is no difference in
• Completeness of resection
• CRM positivity
• Morbidity
• Mortality
• Primary end point - locoregional recurrence at 3 years
was identical in both arms!
But laparoscopy arm had advantages
Less loss of blood during surgery
Shorter hospital stays
Early return of bowel function
Laparoscopy disadvantages
Longer operation times
CLASICC TRAIL &
COREAN TRAIL better
5 year OS following
laparoscopy in
CLASICC tail
NCCN Recommends
(Laparoscopy)
If
• Surgeon has adequate
experience
• Tumor not locally
advanced
• No obstruction or
perforation
24. Workup for metastatic setting
• To check disease burden and state of liver/lung → Imaging
‣ CECT chest, abdomen and pelvis
• Useful initial investigation
• 70-90% sensitivity
• Done 6-12 months during surveillance to pick the metachronous mets
• MRI
• 70-80% sensitivity
• Useful in fatty liver
• PET CT
• Good sensitivity for liver mets (88-96%), extra hepatic disease (90-95%)
‣ But doesn't pick up peritoneal mets
‣ False negatives in post chemo setup, mucinous cancers, sub centimeter
lesions
‣ Laparoscopic assessment
‣ Genetic assessment for KRAS, NRAS (to decide on biological therapy - cetuximab, panitumumab
