Carcinoma Rectum - Workup and management

1. Carcinoma Rectum
Dr.Narayan
PGY2
General Surgery

2. • Work Up
• Management

3. Work Up
• DRE
• Colonoscopy / Colonography (CT Virtual Colonscopy)
• ERUS
• MRI Pelvis
• S.CEA
• CT Chest and CECT Abdomen
• Occult Faecal Blood Test

4. Digital Rectal Examination
• Assessment of
– Tumor size ,
– Mobility and fixation,
– Anterior or posterior location,
– Relationship to the Sphincter mechanism
– Distance from the anal verge
DRE useful for evaluation of fixation of low rectal cancers but cannot assess middle and
upper

5. Colonoscopy
• Allows for biopsy or removal of any suspicious lesions and is considered the
gold standard for evaluating colonic pathology.
• Synchronous Lesions
• It also addresses functional aspects such as active bleeding or an imminent
obstruction by cauterisation, laser ablation or placement of SEMS.

6. CT Colonography
• Incomplete Colonoscopy
• Should be able to pass flatus and capable of tolerating the oral preparation
• CT colonography is preferred over barium enema where access to
colonoscopy is limited.

7. Heiken, JP; Peterson CM; Menias CO (November 2005).
"Virtual colonoscopy for colorectal cancer screening: current status: Wednesday 5 October 2005,
14:00–16:00"

8. • A minority of neoplastic lesions are nonpolypoid and relatively flat or
depressed.
• Cancers that arise from nonpolypoid (flat) adenomas may be more difficult
to visualize colonoscopically than polypoid lesions, but colonoscopy has
superior sensitivity to CT colonography in this situation.

9. PILL CAM 2 COLON
• A colon capsule for CRC screening has been approved by the European
Medicines Agency (EMA) in Europe and by the US Food and Drug
Administration (FDA).
• In the United States, it is approved for use in patients who have had an
incomplete colonoscopy.
UpToDate 2023

10. ERUS
• The distance from the tumor to the anal verge is measured,
• The location of the tumor on the rectal wall and
• The size of the rectal lumen through the tumor are noted.

11. Shackelford's Surgery of the Alimentary Tract, 9th
editio

12. • The accuracy of ERUS is operator dependent but has been reported to be as
high as 95% for T staging and 80% for staging of lymph node metastases.
• The accuracy of nodal staging with ERUS requires the nodes to be larger
than 5 mm.
Zhou Y, Shao W, Lu W. Diagnostic value of endorectal ultrasonography for rectal
carcinoma: a meta-analysis. J Cancer Res Ther. 2014;10(suppl):319

13. Shackelford's Surgery of the Alimentary Tract, 9th
editio

15. Limitations
• Operator dependent
• Stool and liquid within the rectal vault may produce artifacts
• Biopsies of the lesion prior to ERUS may cause the lesion to be overstaged
It is recommended that the ERUS be done prior to biopsy for improved
accuracy
• The specificity of N staging was high, but the sensitivity was low.

16. MRI Pelvis
• Diatance from anal verge to lower aspect of tumour
• Tumour length
• Accurately define the T category
• The circumferential radial margin (CRM) status
• The extramural vascular invasion (EMVI)
• Sphincteric complex
• Morphologic pattern of tumour growth, and
• The lymph node involvement.

17. MRI of Rectal Cancer: Tumor Staging, Imaging Techniques, and Management
Natally Horvat , Camila Carlos Tavares Rocha, Feb 15 2019https://doi.org/10.1148/rg.2019180114

18. MRI of Rectal Cancer: Tumor Staging, Imaging Techniques, and Management
Natally Horvat , Camila Carlos Tavares Rocha, Feb 15 2019https://doi.org/10.1148/rg.2019180114

19. S.CEA
• American Society for clinical oncology(ASCO) recommend that S.CEA levels
be obtained preoperatively in patients with rectal cancer to aid in staging,
surgical treatment planning, and assessment of prognosis.
• Preoperative CEA levels greater than 5 ng/mL signify a worse prognosis,
stage for stage, than those with lower levels.

20. • In addition, elevated preoperative CEA levels that do not normalize
following surgical resection imply the presence of persistent disease and
the need for further evaluation.
• CEA is most helpful in identifying recurrent disease with an overall
sensitivity rate of 70% to 80%.
UpToDate 2023

21. CECT Abdomen
• Demonstrate regional tumor extension, lymphatic and distant metastases,
and tumor related complications such as perforation or fistula formation.
• CT is useful for evaluating distant metastatic lesions and involvement of
contigous organs but is less accurate for t staging.

22. PET CT
• Current guidelines recommend that PET scans not be used routinely in the
standard workup of a rectal cancer.
If potentially surgically curable M1 disease in selected cases.
NCCN Guidelines Version 3.2023 Rectal Cancer

23. • Clinical evaluation including digital rectal examination
• Complete colonoscopy to rule out the presence of synchronous colonic lesions
• Rigid proctoscopy to locate the lesion along the circumference and to measure the
distance of the upper and lower limits from the anal verge
• Endoscopic ultrasound (EUS) to assess the depth of invasion of the tumor in the rectal
wall
• Pelvic magnetic resonance imaging (MRI) to detect potential lymph node metastases
• Chest and abdominal computed tomography to rule out distant metastases
• Serum carcinoembryonic antigen (CEA) assay

24. TNM Staging

28. Staging
• Stage I: T1 N0 M0; T2 N0 M0
• Stage II: T3 N0 M0; T4 N0 M0
• Stage III: any T, N1-2, M0
• Stage IV: any T, any N, M1

29. Poor Prognostic Factors
• Distal cancers
• Poorly differentiated cancers
• Direct tumor extension into adjacent structures (T4 lesions), lymph node
metastases, lymphatic, vascular, or perineural invasion, and bowel
obstruction.

30. UpToDate 2023

31. Management

32. Stage 1 (T1-2, N0, M0)

33. UpToDate 2023

34. Early Rectal Cancer
ERC is a rectal cancer with good prognostic features that might be safely
removed preserving the rectum, and that will have a very limited risk of
relapse after LE.
. Morino M, Risio M, Bach S, et al. Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference. Surg Endosc. 2015;29:755-773.

35. Shackelford's Surgery of the Alimentary Tract, 9th
editio

36. Local Excision
– Endoscopic
• Polypectomy
• Endoscopic mucosal resection
• Endoscopic submucosal resection
– Surgical
• Transanal excision
• TEM
• TAMIS

37. ENDOSCOPIC Management is not indicated :-
• Poorly differentiated histology
• Lymphovascular or perineural invasion
• Tumor budding (foci of isolated cancer cells or a cluster of five or fewer
cancer cells at the invasive margin of the polyp)
• Submucosal invasion depth ≥1 mm

38. • Major risk factors for local recurrence
– Positive surgical margins,
– Transmural extension,
– Lymphovascular invasion, and
– Poorly differentiated/high grade histology.

39. Superficial T1 cancer, limited to the submucosa
●No radiographic evidence of metastatic disease to the regional nodes
●Tumor <3 cm in diameter
●Well-differentiated histology, no lymphovascular or perineural invasion
●Mobile, non-fixed
●Margin clear (>3 mm)
●Involving <30 percent of the bowel lumen circumference
●Patient is able to comply with frequent postoperative surveillance

40. Trans Anal Excision
• Approach to transanal excision of a rectal tumor.
• A. A 1- to 2-cm margin is marked circumferentially with electrocautery on the rectal mucosa.
• B. Full-thickness excision down to perirectal fat is performed.
• C. The specimen is oriented for the pathologist
Local excision of rectal cancer, World J Surg 1997:Sept;21(7):706-714.

41. • can be done either as an outpatient
• Potential complications
Rectal bleeding
• Perirectal infection
• Pain in case of resection reaching the dentate line
• Anorectal stenosis
• Prostate or vagina injury in case of anterior rectal tumors

42. TEM Transanal Endoscopic Microsurgery

43. Shackelford's Surgery of the Alimentary Tract, 9th
edition

44. • TEM resection of low-risk T1 rectal adenocarcinoma results in a 0% to 11%
local recurrence rate, whereas local recurrence for T2 lesions without
adjuvant therapy is approximately 19% to 35%.
• When T2 and T3 lesions are treated with adjuvant or neoadjuvant therapy
and TEM resection, the local recurrence rates decrease to 14% and 3%,
respectively.

45. • TEM offers better visualization, almost complete intact excision, and access
to lesions that are higher in the rectum and otherwise would need radical
surgery.

46. TAMIS(TransAnal Minimally Invasive Surgery)

47. Shackelford's Surgery of the Alimentary Tract, 9th
editio

48. • Bleeding is the most common complication associated with TAMIS and is
usually self-limited.
• Suture line dehiscence after peritoneal entry has the obvious potential to lead
to more significant complications such as pelvic sepsis.
• TAMIS following neoadjuvant therapy is associated with a high incidence of
wound breakdown, severe pain, readmission, and may even require fecal
diversion.

50. NCCN Guidelines V.3.2023
• In accordance with the NCCN guidelines for ERC undergoing local excision,
• Patients should undergo a history, physical examination, rigid proctoscopy, and
serum carcinoembryonic antigen (CEA) level every 3 months for 2 years and then
every 6 months for a total of 5 years after excision of a malignant lesion.
• A full colonoscopy at 1 and 3 years following resection should be performed and
every 5 years thereafter to identify metachronous lesions

51. • Surgery alone was adequate for T1 lesions, and surgery combined with
chemoradiation was appropriate for T2 lesions excised with negative
margins.
• Radical resection was and still is appropriate for tumors with positive
margins after local excision or for T3 cancers.

53. Stage II(T3- T4 N0 M0)
Stage III (any T, N1-2, M0)

54. UpToDate 2023

55. Neo Adjuvant Treatment
• Standard treatment of clinical stage II and III mid and lower rectal cancer
includes neoadjuvant treatment with either long course chemoradiation
therapy (CRT) or preoperative short-course radiotherapy (SCRT)

56. • Long-course CRT
– 5-fluorouracil-based chemotherapy and concomitant 50.4 Gy of radiation delivered over 5
weeks can achieve up to 20% rates of complete pathologic response.
– Radical resection with TME is typically performed 6 to 12 weeks after completion of CRT,
which allows for additional downstaging of chemosensitive tumors.
• SCRT
– Alternative to long-course CRT when chemotherapy cannot be administered or in special
situations such as resectable synchronous metastases or synchronous tumors in the
colon.
– TME is typically performed 1 week after completion of SCRT.
Shackelford's Surgery of the Alimentary Tract, 9th
editio

57. • CRT with capecitabine was not found to be inferior to CRT with CVI 5-FU
with respect to 5-year OS; it was even superior to CRT with CVI 5-FU in 3-
year OS.
. Bujko K, Nowacki MP, Nasierowska-Guttmejer A, Michalski W, Bebenek M, Kryj M. Long-term results of a randomized trial comparing preoperative
short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg. 2006;93(10):1215-1223.

58. • Large bulky,
• Locally unresectable tumors (i.e, clinical T4 disease), clinical N2 disease, or
other high-risk features such as a low-lying rectal tumor,
• an involved or threatened mesorectal fascia, or extramural venous
invasion (EMVI) on staging MRI.

59. Principles of Surgery
• Aimed at removing the with adequate margins and excising en bloc the
mesentery containing the feeding vessels and regional lymph nodes.
• The extent of the resection depends on the location of the primary tumor,
which determines lymphatic drainage.

61. • Since longitudinal lymphatic flow is primarily upward in the rectum, cancer
cells do not generally spread distally along the bowel wall more than 1 cm
from the macroscopic distal end of the tumor.

62. • Radial-involvement of the circumferential margin has been shown to be an
independent predictor of both local recurrence and survival.
• Therefore, in proximal rectal cancers, distal mesorectal excision 5 cm below the
lower border of the tumor should be the goal.
• There is ample evidence, however, that in more distal tumors where there is
less mesorectum, a 1- to 2-cm margin is acceptable to achieve sphincter
preservation.

63. • For rectal cancer, a total mesorectal excision (TME) using sharp dissection along
normal anatomical planes to remove the rectum along with its mesorectal
envelope is associated with a low risk of local tumor recurrence.
• TME involves sharp dissection under direct vision in the avascular, areolar plane
between the fascia propria of the rectum, which encompasses the mesorectum,
and the parietal fascia overlying the pelvic wall structures.
• This procedure emphasizes autonomic nerve preservation (ANP) and complete
hemostasis and avoids violation of the mesorectal envelope.

64. • Proctectomy with sphincter preservation:
– Open low anterior resection (LAR),
– Laparoscopic LAR, Robotic LAR
– Laparoscopic-assisted taTME
• APR (Abdomino Perineal Resection)

65. Gordon’s Principles and Practice of surgery
Colon, Rectum and anal canal 3rd
edition

66. Sabiston Textbook of Surgery 21st
edition

67. Low AR with TME

68. Proper Excision along anatomic
plane is essential
• To obtain free circumferential
radial margins
• Reducing local recurrance by 5%
• Decrease in frequency of urinary
and sexual dysfunction.
Sabiston Textbook of Surgery 21st
edition

69. Erectile Dysfunction ,
Impotence and Atonic
Bladder
Retrograde Ejaculation
Sexual and Bladder
Dysfunction

70. Gordon’s Principles and Practice of surgery
Colon, Rectum and anal canal 3rd
edition

71. Sphincter Sparing Surgery Procedures for Low Rectal
Cancers
In Young and fit patients with
good preoperative sphincter
function.
Transanal Approach.
Sabiston Textbook of Surgery 21st
edition

72. Ta-TME
• Port similar to TAMIS
• Rectal dissection from
bottom upward(narrow to
wide space)
• Posterior first then
anteriorly detached
Sabiston Textbook of Surgery 21st
editio

73. Gordon’s Principles and Practice of surgery
Colon, Rectum and anal canal 3rd
edition

74. Abdomino Perineal Resection
• Tumour Infiltrating sphincters
• Elderly Patients with distal rectal cancer and with poor sphincter function
• Specimen
– Origin of IMA
– Mesorectum with haemorrhoidal vessels
– Naked portion of ultra distal rectum with anal sphincters

76. Sabiston Textbook of Surgery 21st
edition

77. LAR Syndrome
• 80% of patients undergoing a low anterior resection.
• Mixture of multiple symptoms that include frequency, multiple fragmented bowel
movements, a sensation of incomplete emptying, incontinence, constipation, and
diarrhea.
• Cause of LARS is multifactorial.
• Preventive technical mechanisms are currently used to improve LARS symptoms that
aim to increase the capacity of the neorectum: anastomosis with a 5 to 6-cm colonic
J-pouch or with a transverse coloplasty or side-toend colorectal anastomosis

78. • The treatment of LARS is often empirical, based on diet control, balanced
use of loperamide associated with fiber products, physical therapy
including biofeedback, and transanal irrigation.

79. ADJUVANT THERAPY
• STAGE II
– MSI-H condition (deficient expression of MMR genes) is more frequent in stage II disease
(22%) than in stages III (12%) and IV (3%) and does appear to have a favorable prognostic
significance in stage II. Moreover, adjuvant 5-FU treatment seems to have a detrimental
effect on survival in stage II but not stage III colon cancer patients

80. • STAGE III
– 5-FU and FA are combined with oxaliplatin in the FOLFOX protocol
– CAPOX regimen, oral capecitabine is used instead of 5-fluorouracil
folinic acid (5-FUFA)

81. • In low-risk patients (pT3pN1), 3 months (four cycles) of CAPOX was not inferior to 6
months of the same regimen (3 years DFS: 85.0% vs. 83.1%, 3 months vs. 6 months).
In high-risk patients, 3 months of the CAPOX regimen was sufficient (3 years DFS:
64.1% vs. 64.0%, 3 months vs. 6 months).
• With regard to the FOLFOX regimen, 6 months seems superior to 3 months, regardless
of the risk group (3 years DFS in high-risk: 61.5% vs. 64.7%, 3 months vs. 6 months).
Sabiston Textbook of Surgery 21st
edition

83. • Five-year survival rate for patients with stage I cancer is approximately
90%; for stage II, 75%; and for stage III (with positive lymph nodes), 50%.
Sabiston Textbook of Surgery 21st
edition

85. Stage IV T any N any M1

88. Refferences
• Bailey and Love’s short practice of Surgery 28th
Edition.
• Sabiston Textbook of Surgery 21st
edition.
• Shackelford's Surgery of the Alimentary Tract, 9th
edition.
• Gordon’s Principles and Practice of surgery Colon, Rectum and anal canal 3rd
edition
• UpToDate 2023
• NCCN Guidelines V.3.2023