Management on rectal carcinoma

1. PROFESSOR PANKAJ G. JANI. M.MED., FRCS.
DEPT. OF SURGERY, UNIVERSITY OF NAIROBI. KENYATTA
NATIONAL HOSPITAL
CHAIR. EXAMINATIONS AND CREDENTIALS COMMITTEE
COSECSA
INT. ONCOLOGY CONF. NAIROBI, OCTOBER
2011

2. THEME
Translating recent advances
into local practice/clinical
care

3. RECTAL CANCER
Progress in MULTIMODAL
THERAPY of Rectal Cancer is one
of the BEST examples of success of
Clinical Research in the last 2
decades.

5. RECTAL CARCINOMA – RECENT
ADVANCES -- OVERALL
1.SPHINCTER SAVING PROCEDURES – UP
FROM 15% TO 50% -- NO COLOSTOMY
(IMPROVED QOL)
2. OVERALL FIVE YR SURVIVAL – UP FROM
30% TO 60%
3. DEPTH OF INVASION – DECREASED BY
40%-60% WITH ADJUVANT Rx
4. LYMPH NODE STATUS AND REC. FREE
SURVIVAL - SAME

6. RECENT ADVANCES
1. MOLECULAR BIOLOGY
2. SURGERY
3. IMAGING – MRI, CT AND PET
4. CHEMO/RADIOTHERAPY

7. MOLECULAR BIOLOGY
 DNA CHIP TECH. – DNA SEQUENCE
CHECKED
-- APC GENE – FAP
-- MISMATCH REPAIR GENES – HNPCC
 SUCH PTS.(5%) PUT ON A
SURVEILLANCE PROG. --PROPHYLACTIC
SURGERY

8. MOLECULAR BIOLOGY
 DNA SEQUENCE OF MICROSATELLITE
INSTABILITY
-- GOOD RESPONSE WITH 5 FU CHEMO.
 P21 MARKER POSITIVE – RADIOSENSITIVE

9. MOLECULAR BIOLOGY
 P53 PROTEIN MUTANT EXPRESSED --
RADIORESISTANT
 KRAS, DCC, AND P53 -- IF +ve – POOR PROGNOSIS
 MICROSATELLITE INSTABILITY OR LOW Cox2
EXPRESSION & P21 MARKER – IF +ve – GOOD
PROGNOSIS

11. SURGICAL CHALLANGES
 I - STAGING
 II - USE OF CH/RT
 III- SURGICAL TECHNIQUE

12. I - STAGING
DECIDES –TRANS ANAL LOCAL
EXCISIONAPR
.
NEOADJUVANT CH/RT

13. TRADITIONAL STAGING
DIGITAL RECTAL EXAMINATION
CT SCANS

14. NEWER STAGING METHODS
DRE
ERUS – NODES
CT

15. RECENT ADVANCES
DRE
ERUS
MRI

16. RECENT ADVANCES
DRE

17. RECTAL CA. RECENT ADVANCES

18. RECENT ADVANCES ERUS
ERUS
------ BEST FOR NODAL
STATUS
( OPERATOR DEPENDANT)

19. STAGING
 ERUS
 T STAGE ACCURACY 60 – 90%
 N STAGE ACCURACY 60 – 90%
 MRI
 T STAGE ACCURACY 60 – 90%
 N STAGE 40 --- 80%
 ( NODES > 5mm)

20. CHALLANGE
PICK UP NODES < 5mm (33%OF ALL
NODES)
PICK UP MICRO METS
USE OF CH/RT

21. MRI
 HIGH RESOLUTION THIN SLICE (<1mm)
 DEPTH OF EXTRAMURAL SPREAD ACCURATELY
IDENTIFIED (AIDS CIRCUMFERENTIAL RESECTION
MARGIN)
 TRADITIONAL
- PROXIMAL
- DISTAL
 RECENT ADV. – CIRCUMFERENTIAL RESEC. MARGINS
IMP.

22. MRI
INDICATORS OF MALIGNANT
NODAL INVOLVEMENT
L. NODES
-- IRREGULAR BORDER
-- MIXED SIGNAL INTENSITY OF
NODE

23. MRI
DETECTS EXTRAMURAL VENOUS
INVASION (EMVI)
 POOR PROGNOSIS WITHOUT
CH/RT IF EMVI PRESENT

25. II USE OF CH/RT
(NEOADJUVANT/ADJUVANT)
 PTS WITH POOR HISTOLOGY
 PTS WITH EXTRA MURAL SPREAD (MRI)
 PTS WITH INVOLVED NODES (ERUS)
 PTS WITH EMVI (MRI)

26. CHEMOTHERAPY
 INJ KYTRIL 3mg Ksh
2,250/-
 INJ DEXAMETHAZONE 8mg Ksh
385/-
 INJ FLUOUROURACIL 5500mg Ksh 12,053/-
 INJ OXALIPLATIN 200mg Ksh
187,600/-
 INJ LEUCOVORIN 100mg Ksh 1,809/-
 INJ AVASTIN 400mg Ksh 213,806/-
Kshs 417903/-

27. RADIOTHERAPY
 EUROPEAN APPROACH
 (25G/5CYCLES)
 SHORT COURSE – LOW
DOSE – IMMEDIATE
SURGERY
 NO CHANGE IN PATH
STAGING
 LOWER COST
 BETTER COMPLIANCE
 DOSE EQUIVALENT TO
30-33G
 EXPECT 66%
REDUCTION IN LOCAL
RECURRENCE
 AMERICAN APPROACH
 (45 – 54G/28 CYCLES)
 PROLONGED COURSE –
HIGH DOSE – DELAYED
SURGERY
 BETTER SURGICAL
TOLERANCE
 MORE TUMOR
REGRESSION
 EXPECT >80%
REDUCTION IN LOCAL
RECURRENCE

29. III SURGICAL TECHNIQUE
TRADITIONAL
 PROCTECTOMY PERFORMED
-- In the DARK
-- Using BLUNT Dissection
-- Without attention to ANATOMIC
Detail
RESULTED in
-- Bloody operation
-- Increased -- Autonomic Nerve injury
-- Local Rec.

30. SURGERY - TRADITIONAL
ANT. RESECTION – UPPER ⅓ RECTAL
CA
LOW ANT.RESCETION - MID ⅓
RECTAL CA
A.P.R. - LOWER ⅓ RECTAL
CA
ANY TUMOR 10cms FROM ANAL
VERGE -- APR

31. ANATOMY OF RECTUM
CHANGED FROM TRADIOTIONAL 22
CMS FROM ANAL VERGE TO 15 CMS
ABOVE THAT IS ALL COLON

32. RECTAL CARCINOMA RECENT
ADVANCES
 >100 YEARS SINCE MILES DESCRIBED
ABDOMINO-PERINEAL-RESECTION
 >25 YEARS SINCE HEALD DESCRIBED
TOTAL MESORECTAL EXCISION

33. III SURGICAL TECHNIQUE
RECENT ADV.
TOTAL MESORECTAL EXISION
( EXICISION OF FASCIA
ENVELOPING THE FAT PAD
AROUND THE RECTUM.)
SAUSAGE APPEARANCE

34. SURGERY – RECENT ADVANCES
LOW-ANT RESECTION – UPTO ≏
6cms FROM ANAL VERGE
APR – ONLY IF SPHINCTOR
FUNCTION COMPROMISED

35. RECTAL CANCER – RECENT
ADVANCES
 CAREFUL ASSESSMENT OF SxS

EARLY DIGNOSIS WITH

ACCURATE STAGING

CH/RT - FOR SELECTED PTS
- PROCTOSCOPY
- SIGMOIDOSCOPY
- DRE
- ERUS
- MRI

36. OUR SCENARIO
LATE PRESENTATION
ADVANCED TUMORS
ANATOMICAL DISTORTION
LACK OF NEOADJUVENTS
SURGERY MORE DIFFICULT
RESULTS POORER

37. COMMON PROBLEMS FACING
SURGERY IN AFRICA
• LACK OF GUIDELINES
AND STANDARDS
• INADEQUATE
SUPERVISION

40. THANK YOU

41. VEINS OF SMALL & LARGE
INTESTINES

42. CAECAL CANCER RESECTION

43. GOALS OF THERAPY FOR RECTAL
CARCINOMA
 DECREASE LOCAL RECURRANCE
 OPTIMISE Q.O.L. AVOID
COLOSTOMY

44. CA. RECTAM (ESP. LOWER
TUMORS)
 SHOULD BE DIAGNOSED EARLY
 SHOULD GIVE GOOD RESULTS
WITH EARLY THERAPY

45. LOCAL EXPERIENCE
 31 CASES OF RECTAL CA
 25 APR DONE
 6 LOW ANT RESECTIONS (2 Local Rec.)

46. SYMPTOMS
 RECTAL BLEEDING
LOWER RECT.
 TENESMUS
 ALT. OF BOWEL HABITS
UPPER.
 ANY G.I. SxS (dyspepsia)

47. RECTAL CANCER