This document discusses updates in the management of rectal cancer. It covers the anatomy, risk factors, staging, clinical features, investigations, and various treatment modalities for rectal cancer including surgery, chemotherapy, and radiotherapy. It describes in detail the different surgical procedures like local excision, anterior resection, abdominoperineal resection, and total mesorectal excision. It discusses the importance of clear circumferential resection margins and vascular ligation. Neoadjuvant chemoradiotherapy is emphasized for locally advanced tumors to downstage the cancer before surgery.

1. Updates In Management
Of
Ca Rectum
Dr. Nabarun Biswas
Indoor Medical Officer
Surgery Dep. MMCH

2. ANATOMY

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

8. Rectal cancer
• 2nd most common malignancy in female & 3rd
most common in male
• 4th most common cause of cancer death after
lung, stomach & liver

9. Risk factor
• Red meat and saturated fatty acids
• Obesity
• Sedentary lifestyle
• Old age
• Alcohol and Smoking
• FAP - defect in APC gene on chromosome
5q21
• HNPCC - MSH2 & MLH1 gene defect
• Family history – 2 or more first degree relatives
• Inflammatory bowel disease – Ulcerative Colitis
• Adenomatous polyp

10. Premalignant conditions
1. Adenoma
2. Chronic IBD
3. Hereditary
 FAP

11. Pathogenesis
CRC
Hereditary
5%
Genetic
mutation
FAP,HNPCC,
PJS
Sporadic
95%
Adenoma
carcinoma
sequence
APC
K-ras
P 53

12. Adenoma - Carcinoma sequence
• Accounts for upto 75-95% of sporadic colo-rectal tumours and
typically arise form adenomatous polyp
•Mutation in wnt signaling pathway
1.APC mutation  activation of proto-oncogene (required
for normal cell renewal) over expression
2.Activation of oncogene k-ras  increase cell proliferation.
3.Suppression of P 53 (for apoptosis)  immortal cell

13. Staging
• Duke’s
• Astler-Coller
• TNM

14. Duke’s Staging
A B C1 C2 D
MUCOSA
SUBMUCOSA
MUSCULARIS
PROPRIA
SEROSA
LYMPHNODE

15. TNM Staging
N 0 N 1 N 2
T1 T2 T3 T4a T4b
MUCOSA
SUBMUCOSA
MUSCULARIS
PROPRIA
SEROSA/
Perirectal tissue
LYMPHNODE

16. AJCC Staging
• Stage I  100, 200 (T1 or 2 N0 M0)
• Stage II  300, 400 (T3 or 4 N0 M0)
• Stage III  any T, any N, M0
• Stage IV any T, any N, M1

17. Correlation between TNM, Duke’s &
DRE
Status Duke’s TNM DRE
Early A S-I (T1,N0,M0) Freely mobile over
rectal muscle
A S-I (T2,N0,M0) Moves with rectal
wall
Locally
advanced
B or C S-II, S-III
(T3/T4
or
N1/N2)
Slightly moves along
with pararectal fat
Advanced C or D S- IV (M1a/M1b) Fixed

18. Clinical features
• Early symptoms
1. Per rectal bleeding
3. Early morning diarrhoea
 Alteration of bowel habit
 Change to loose stool is common
 Stenosing ca may cause constipation
2. Tenesmus
 Lower half of rectum
 Spurious diarrhoea
 Bloody slime

19. Clinical features
• Late symptoms
1. Pain
 Colicky
 Severe , intractable
2. Weight loss
 Associated with metastatic disease

20. Examination
• Abdominal:
– Normal in early stage
– Obstructive feature in stenosing
recto-sigmoid tumour
• Rectal:
– Assessment of tumor size,
mobility and fixation, anterior
or posterior location,
relationship to sphincter
mechanism and the distance
from the anal verge.

21. 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

22. Colonoscopy
Torule out
synchronous
cancers - which
occur 2 - 8% of the
time.

23. Virtual/ CT Colonoscopy

24. Transrectal Endoluminal
Ultrasound
Permits accurate characterization of the
primary tumor and the status of the
perirectal lymph nodes

25. MRI
• Investigation of choice for T staging

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

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

28. Treatment

29. Management Protocol
1. Preoperative workup
2. Operative procedure
3. Post operative
management
4. Surveillance program
1. Counseling &
consent
2. Tumour board
formation
3. Correction of
co-morbidities
4. Prophylaxis
5. Bowel
preparation

30. Principle of Treatment
1. Surgery is the mainstay of curative Rx
2. Aim: radical excision of rectum + mesorectum+
lympho-vascular clearance
3. Widespread metastasis: palliative Rx 
stenting/RT/palliative resection
4. Liver/Lung metastasis: single/well localized 
resection with curative intent
5. Locally advanced (T3/4 or N1/2): neoadjuvent
CRT  surgery

31. Principle of Treatment
6. Watch & wait policy: after long course CRT if
CCR & CPR is found  intense surveillance
7. Early cancer(T1,T2 & N0): organ preserving
surgery by Local excision /TEMS (for T1)
8. If radical excision possible : APR or AR (High,
Low, Ultra low)
9. Sphincter saving possible if tumour margin ≥2
cm from ano-rectal junction
10. Defunctioning stoma: if tumour below
peritoneal reflection

32. Treatment modalities
• Surgery
• Chemotherapy
• Radiotherapy
• Targeted therapy
• Immuno therapy
• Alternative treatment

33. Surgery
• Surgery is the mainstay of treatment
• Radiation and chemotherapy are given before
or after surgery
• The type of surgery depends on the stage of
the cancer

34. Types of surgery
1. Local excision / TEMS / TAMIS
2. Anterior resection
 High AR
 Low AR
 Ultra Low AR
3. TME / Modified TME
4. APR
5. Surgery in advanced carcinoma

35. Approach
• Open
• Laparoscopic
• Robotic
• Trans anal

36. Trans anal endoscopic micro surgery:
TEMS
• For mid and lower rectal tumor
• For rectal adenomas and early rectal cancers
• Must below peritoneal reflection

37. TEMS
• Indication:
– Well differentiated
– Grade 1 or 2
– Not mucinous adenoma
– Lymphnode –ve
– Diameter < 3cm
– Tumor invades only
submucosa

38. Anterior Resection
• It is a sphincter saving operation
• Approach: open / laparoscopic / robotic
assistance
• Two terms: TME & CRM

39. Total Mesorectal Excision: TME
• Introduced by RJ Heald
in 1979
• For middle and lower third
rectal carcinoma
• Mesorectum: perirectal
fascia containing fat and
perirectal lymph nodes,
lymphatic
• Spread of carcinoma
rectum occurs in this area.

40. TME

41. Modified TME
• Distal spread of adenocarcinoma either in the
rectal wall or mesorectum greater than 2-3 cm
is rare.
• So the dissection continues to pelvic floor up to
ano-rectal junction (low AR) or 5 cm (3cm)
below the tomour margin (High AR) 
Modified TME
• Top to down manner

42. Modified TME
5 cm
5 cm

43. Ta TME
• Low anterior resection can be a challenging operation,
especially in obese male patients and in particular
after radiotherapy.
• Transanal total mesorectal excision (TaTME) might
offer technical advantages over laparoscopic or open
approaches particularly for tumors in the distal third
of the rectum.
• Defines the radial and distal margins more clearly.
• Bottom up manner
• TAMIS: modification of TaTME where SILS instruments
are used

44. TaTME

45. TaTME

46. Circumferential Resection Margin:
CRM

47. Circumferential Resection Margin:
CRM
• It is the radial distance between cancer tissue and
the non peritonalized margin of the resected
specimen
• CRM +ve when distance is ≤1 mm
• CRM –ve when distance is >1 mm
• CRM is an important prognostic factor for
recurrence
• CRM can be predicted preoperatively by thin slice
high resolution MRI
• In predicted CRM positivity neoadjuvant CRT is
indicated

48. Circumferential Resection Margin:
CRM

49. Anterior resection
• 3 types of 3 anterior resection
1. High  10cm from anal verge
2. Low  8 cm from anal verge
3. Ultra low  6cm from anal verge
• TME /modified TME is incorporated with AR
• Gastrointestinal continuity is maintained by
stapled anastomosis or hands sewn

50. Steps/ Technique in AR
• Lloyd-Davies position
• Good assistance
• Long midline incision
• Wide retraction
• Small bowel packed
out of the way
• Full laparotomy

51. Steps/ Technique in AR
• Assess for synchronous
lesion or spread
• Sigmoid and descending
colon mobilization lateral to
medial (in laparoscopic
method medial to lateral
after ligation of vessels)
• Protect left ureter and
gonadal vessel
• Splenic flexure mobilization

52. Colonic mobilisation

53. Steps/ Technique in AR….cont.
• next step is vascular
ligation
• High ligation and low
ligation of IMA
• High for proper
lymphatic clearance
& low for improve
vascularity
• 2 step ligation of IMV
for tension free
anastomosis
• Mesocolon divided &
lymphovascular
pedicle prepaired

54. Importance of vascular ligation in LN
+ve

55. Steps/ Technique in AR….cont.
• Next step is rectum &
mesorectal excision
• sharp dissection under direct
vision
• Preservation of hypogastric
nerve in 10 and 2 o’clock
position
• Retraction and counter
retraction given

56. Steps/ Technique in AR….cont.
• Posterior dissection
started 1st through holy
plane between presacral
fascia and waldayer’s
fascia
• middle rectal vessel is
ligated (20%)
• After completing
posterior dissection
anterior dissection
started in denonvillier’s
fascia between seminal
vesicle and rectum

57. Steps/ Technique in AR….cont.
• Next step is rectal
dissection &
anastomosis
• Rectum cross clamped
• Rectal wash given
• Dissection & specimen
removed
• Gut continuity
maintained by circular
stapler or hand sewn.

58. APR
• Tumour of the lower 3rd
having no adequate free
margin
• Sphincter involved
• 2 surgeon in 2 route
• Morbidity - 61%
• Mortality - 0 - 6.3%
• Urinary complications - 50%
• Perineal wound infections - 16%

59. APR technique
• Abdominal route 1st done by open / laparoscopic
& same way as AR except that the dissection
stops before pelvic floor is reached
• Perineal excision started with circum anal incision
• Depend into ischio-rectal fossa & out towards
levator muscles of pelvic side wall
• Extended posteriorly by incising waldeyer’s fascia
and anteriorly between rectum and prostate or
vagina
• Specimen delivered through perineal route

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

61. 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

62. 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

63. Advanced Ca Of The Rectum

64. En block resection
• in male cystectomy or prostatectomy and in
female posterior vaginectomy or hysterectomy
can be undertaken in combination with AR
• to achieve oncological clearance

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

66. Pelvic Exenteration
•Morbidity - 20 - 40 %
•Mortality - 0 - 20%
• Aim is to remove pelvic
organs involved in the
malignant process
• Two types
 partial
 complete
• indication
 locally advanced
 recurrence

67. liver and lung resection
• Single or multiple well
localised metastasis
• long-term survival can be
achieved (40%)
• Performed synchronously at
the time of AR

68. Palliative resection
• Indication - stage IVb
• 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

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

70. Radiotherapy
• Neoadjuvant ,adjuvant or palliative setting
• Neoadjuvant is short course and long course
chemoradiation
• Long course RT 45-50 Gy for 6 weeks + 1st & last
week chemo  6 weeks interval  surgery (down
staging)
• Short course RT 25 Gy for 5 day + 1st & 2nd day
chemo  surgery within 7-10 days (sterilize
tumour) or, 12 weeks later (down staging)
• Adjuvant is EBRT or IORT/ contact RT

71. Neoadjuvant CRT
Short course
Long course

72. External Beam Radiotherapy

73. Chemotherapy
• As Neoadjuvant with RT or adjuvant to reduce the
risk of disseminated disease
• 5 FU remain the 1st line therapy
• Oxaliplatin & Irinotcan is 2nd line

74. Targeted Therapy
• Target specific type of cancer cells
• Different targeted therapy work in different way
• one type stops the growth of new blood vessel
into rectal tumour
• second type stops the cancer cells from receiving
signal to grow
• less likely to harm normal cells than
chemotherapy
• not everyone will benefited from targeted
therapy

76. Immunotherapy
• increases the activity of immune system
• Improves body’s ability to find and destroy cancer
cell
• drugs are called checkpoint inhibitor

77. NCCN Guideline for the treatment
of Rectal Cancer
according to stage

78. Stage I (T1, T2, N0,M0 or Polyp)
High risk are
Fragmented
specimen
Poorly
differentiated
High grade (3)
Mucinous
adenoma
+ve margine
Lympho-
vasular invasion
Size >3 cm

79. Treatment After Transanal Local Excision And
Staging Update

80. Treatment After Transanal Local Excision And
Staging Update

81. Treatment After Abdominal Resection and
Staging Update
(T3,N0,M0)

82. Treatment After Abdominal Resection and
Staging Update
(T4 or N1, Mo)

83. Stage II & III
Less invasive:
1.T1 or T2 but LN +ve
2.T3 but CRM -ve

84. Stage II & III…..cont

85. Stage II & III…..cont
• More invasive:
– T3 + CRM +ve
– T4
– Cancer can not be removed with surgery
Option 1
Long course CRT then
After 6 wk imaging,
If CRM –ve then
Surgery
If surgery not possible, then
Systemic therapy
Option 2
12-16 wks of chemotherapy
(FOLFOX/CAPEOX/5FU-LV)
Then CRT
Next imaging
If possible  surgery
No further treatment
If surgery not possible
Then systemic therapy

86. Follow-up care

87. Follow-up care

88. Treatment for local recurrence

89. Treatment for metastatic cancer: Stage IV

90. Treatment for metastatic cancer: Stage IV

91. Treatment for Recurrence

92. Stage I (T1 or 2, N0, M0)

93. Stage II : (T3or4, N0, M0) &
Stage III: (any T, any N, M0)

94. Stage VI: (any T, any N, M1)
Metastatic Ca
Systemic chemotherapy

95. Stage VI: (any T, any N, M1)
Metastatic Ca

96. Recurrent Cancer

97. Conclusion
At present with the advancement in diagnostic
procedure and improvement of surgical
technique Rectal Carcinoma is regarded as
extremely curable malignant disease.

98. References
• Bailey’s And Love short practice of surgery 27th edi
• Cuschieri’s Essential Surgical practice 5th edi
• Current surgical Diagnosis & Treatment 14th edi
• American Cancer Society guideline
• National comprehensive Cancer Network (NCCN)
guideline