Rectal cancer case revised

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Rectal cancer case revised

  1. 1. Rectal Cancer Contouring Speakers : Tz-yu Lin & Shr-Uen Lin Advisor : Dr. Jason Cheng Date : 2013/12/18
  2. 2. • 54 y/o, male, Constipation and bloody stool for one month • Digital rectal exam: cauliflower mass at posterior rectum wall, 3 cm from anal verge. • Biopsy: adenocarcinoma. • MRI Pelvis: – – – – Abnormal thickening and enhancing wall Increased fatty stranding in the perirectal space. Multiple enlarged lymph node in the perirectal space. No evidence of para-aortic lymphadenopathy • Whole Body PET: – intense hypermetabolic lesion at rectum – Mild to moderate hypermetabolic spots at right perirectal and bilateral external iliac nodes • Rectal adenocarcinoma cT3N1M0
  3. 3. DOI: 10.1056/NEJMoa040694
  4. 4. Mesorectal lymph nodes (MLN) : 46% of all patients 87% of patients with positive lymph nodes Risks for Lymph node involvement in N+ patients: Mesorectal : 87% Lateral : 27% External iliac : 9% Inguinal : 1% Posterior pelvic subsite (PPS) recurrence : 22% of all patients Inferior pelvic subsite (IPS) recurrence: 4% of all patients 8% in tumors < 6 cm from anal verge
  5. 5. Rectal Cancer Radiotherapy Contouring Guideline for clinical target volumes (CTV) for neoadjuvant chemoradiotherapy in locally advanced rectal cancer: gross tumor, peri-rectal, pre-sacral, internal iliac and external iliac. NTUH practice: • GTV: main tumor mass + involved lymph nodes • CTV: – GTV with 15 mm expansion – Distal 20 mm margin to GTV for CTV – Vessels with 7 mm expansion – Contour CTV to include mesorectum and pre-sacrum – Avoid bone and small bowel Int J Radiat Oncol Biol Phys. 2009 Jul 1;74(3):824-30. doi: 10.1016/j.ijrobp.2008.08.070.
  6. 6. Lowest boundary of GTV
  7. 7. Lymph node metastasis
  8. 8. Lymph node metastasis
  9. 9. Lower boundary of CTV
  10. 10. Lymph node metastasis, bifurcation of iliacs
  11. 11. Common iliacs
  12. 12. Summary • Pre-op CCRT is the standard treatment for locally advanced rectal cancer • Contouring guideline – GTV: main tumor mass + involved lymph nodes – CTV: • • • • • GTV with 15 mm expansion Distal 20 mm margin to GTV for CTV Vessels with 7 mm expansion Contour CTV to include mesorectum and pre-sacrum Avoid bone and small bowel
  13. 13. THE END THANKS FOR YOUR ATTENTION!!!
  14. 14. Abdominoperineal resection (APR) sphincter preserving surgery Total mesorectal excision

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