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Carcinoma rectum


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Carcinoma rectum

  1. 1. Carcinoma rectum Dr. vinayak lokare JMMC & RI
  2. 3. Etiology <ul><li>average lifetime risk - 6% </li></ul><ul><li>risk increases two- to fourfold history of or a first-degree relative with colorectal cancer. </li></ul><ul><li>Inflammatory bowel disease (IBD) </li></ul><ul><li>Genetics – </li></ul><ul><ul><li>familial adenomatous polyposis (FAP) - APC gene on chromosome 5q21 </li></ul></ul><ul><ul><li>hereditary nonpolyposis colorectal cancer (HNPCC) </li></ul></ul>
  3. 4. Anatomy <ul><li>divided into three portions </li></ul><ul><li>lower rectum -3 to 6 cm from the anal verge </li></ul><ul><li>midrectum - 5 to 6 to 8 to 10 cm </li></ul><ul><li>upper rectum - 8 to 10 to 12 to 15 cm </li></ul><ul><li>determination of the location of the boundary between rectum and sigmoid colon is important in defining adjuvant therapy </li></ul>
  4. 5. anatomy <ul><li>upper extent of the rectum can be identified where the tenia spread to form a longitudinal coat of muscle </li></ul><ul><li>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 </li></ul>
  5. 7. Lymphatic drainage <ul><li>Upper rectum - follows the course of the superior hemorrhoidal artery toward the inferior mesenteric artery </li></ul><ul><li>Middle rectum - follow the middle hemorrhoidal artery </li></ul><ul><li>lesions occur below the dentate line, the lymphatic drainage is via the inguinal nodes and external iliac chain </li></ul>
  6. 8. Types <ul><li>Macroscopic </li></ul><ul><ul><li>Proliferative </li></ul></ul><ul><ul><li>Ulcerative </li></ul></ul><ul><ul><li>Tubular </li></ul></ul><ul><li>Microscopic </li></ul><ul><ul><li>Adenocarcinoma </li></ul></ul><ul><ul><li>Colloid carcinoma </li></ul></ul><ul><ul><li>Squamous cell carcinoma </li></ul></ul>
  7. 9. Clinical features <ul><li>Bleeding per rectum – mucous +/- </li></ul><ul><li>Alteration of bowel habits – increasing constipation, early morning diarrhoea </li></ul><ul><li>Sense of incomplete defeacation </li></ul><ul><li>Intestinal obstruction </li></ul><ul><li>Pain </li></ul><ul><li>Loss of appetite ,weight loss , joundice , ascitis </li></ul>
  8. 10. Investigations <ul><li>USG abdomen </li></ul><ul><li>Proctosigmoidoscopy / biopsy </li></ul><ul><li>Colonoscopy </li></ul><ul><li>contrast CT of the pelvis and the abdomen </li></ul><ul><li>Endoscopic USG </li></ul>
  9. 11. <ul><li>Chest X-ray </li></ul><ul><li>Liver function tests </li></ul><ul><li>Renal function tests </li></ul><ul><li>Baseline CEA levels </li></ul>
  10. 12. staging <ul><li>Dukes’ staging </li></ul><ul><li>A- limited to bowel wall </li></ul><ul><li>B-spread outside the bowel wall </li></ul><ul><li>C-involvement of lymph nodes </li></ul><ul><li>Astler- Coller modification </li></ul><ul><li>B1-infiltration into muscularis propria </li></ul><ul><li>B2- infiltration beyond muscularis propria into serosa </li></ul>
  11. 13. <ul><li>C1- lymph node involvement but did not penetrate the entire bowel wall </li></ul><ul><li>C2- tumors that invaded lymph nodes and did penetrate the entire wall (C2). </li></ul>
  12. 14. TNM staging <ul><li>TX- Primary tumor cannot be assessed </li></ul><ul><li>T0 - No evidence of primary tumor </li></ul><ul><li>Tis - Carcinoma in situ: intraepithelial or invasion of lamina propria [*] </li></ul><ul><li>T1 - Tumor invades submucosa </li></ul><ul><li>T2 - Tumor invades muscularis propria </li></ul><ul><li>T3- Tumor invades through the muscularis propria into the subserosa, or into nonperitonealized pericolic or perirectal tissues </li></ul><ul><li>T4 Tumor directly invades other organs or structures and/or perforates visceral peritoneum [†] </li></ul>
  13. 15. <ul><li>NX- Regional lymph nodes cannot be assessed N0- No regional lymph node metastasis </li></ul><ul><li>N1 - Metastasis in 1 to 3 regional lymph nodes </li></ul><ul><li>N2- Metastasis in 4 or more regional lymph nodes </li></ul>
  14. 16. <ul><li>MX Distant metastasis cannot be assessed </li></ul><ul><li>M0 - No distant metastasis </li></ul><ul><li>M1 - Distant metastasis </li></ul>
  15. 17. <ul><li>STAGE T N M DUKES [§] MAC [§] </li></ul><ul><li>0 Tis N0 M0     </li></ul><ul><li>I T1 N0 M0 A A  </li></ul><ul><li> T2 N0 M0 A B1 </li></ul><ul><li>IIA T3 N0 M0 B B2 </li></ul><ul><li>IIB T4 N0 M0 B B3 </li></ul><ul><li>IIIA T1-T2 N1 M0 C C1 </li></ul><ul><li>IIIB T3-T4 N1 M0 C C2 </li></ul><ul><li>IIIC Any T N2 M0 C C1/C2 </li></ul><ul><li>IV Any T Any N M1   D </li></ul>
  16. 18. Treatment <ul><li>Stage 1 </li></ul><ul><li>TEM </li></ul><ul><ul><li>EUS- T1, T2 </li></ul></ul><ul><ul><li><40% circumference involvement </li></ul></ul><ul><ul><li>Well- mod. Differentiated </li></ul></ul><ul><ul><li>HPR – no lymphatic / venous invasion </li></ul></ul>
  17. 19. <ul><li>posterior proctotomy- Kraske procedure </li></ul><ul><ul><li>large posterior lesions </li></ul></ul><ul><ul><li>allows for the mobilization of the rectum and a full-thickness local excision </li></ul></ul><ul><li>T2 lesions- </li></ul><ul><ul><li>Adjuvant chemoradiation </li></ul></ul>
  18. 20. <ul><li>Endocavitary radiation therapy </li></ul><ul><ul><li>T1 or T2 tumors less than 3 cm, </li></ul></ul><ul><ul><li>not poorly differentiated, </li></ul></ul><ul><ul><li>with no evidence of nodal involvement </li></ul></ul><ul><li>four rounds of 2,500 to 3,000 cGy each with 2 to 3 weeks between treatments </li></ul>
  19. 21. Stage 2 and stage 3 <ul><li>Preoperative </li></ul><ul><li>Chemo therapy – 5-FU(350mg/m2/day) for 5 days </li></ul><ul><li>Leucovorin(20mg/m2) for 5 days </li></ul><ul><li>2cycles </li></ul><ul><li>Radiotherapy 5000cGy </li></ul><ul><li>Surgery after 4-6 wks </li></ul>
  20. 22. <ul><li>Surgery </li></ul><ul><li>Upper rectum – anterior resection </li></ul><ul><li>Middle rectum – low anterior resection </li></ul><ul><li>Low rectum - low anterior resection / APR </li></ul><ul><li>Adjuvant chemotherapy </li></ul><ul><li>5-FU + leucovorin – 4 cycles </li></ul>
  21. 23. Stage 4 <ul><li>Preoperative chemo radiation </li></ul><ul><li>APR </li></ul><ul><li>Post operative chemo / RT </li></ul>
  22. 24. radiotherapy <ul><li>Proximal – sacral prmontary </li></ul><ul><li>Distal – 2 cm below primary tumor mass </li></ul><ul><li>Lateral – pelvic wall </li></ul><ul><li>Posterior – sacrum </li></ul><ul><li>Anterior – posterior border of vagina / prostate </li></ul>
  23. 25. <ul><li>5-FU based adjuvant chemotherapy has been the standard of care for advanced rectal cancer </li></ul><ul><ul><li>5-FU treats micrometastases </li></ul></ul><ul><ul><li>– 5-FU acts as a radiosensitizer </li></ul></ul><ul><li>Continuous infusion has shown improved survival and increased time to relapse when compared to bolus therapy </li></ul>