This is a presentation regarding carcinoma rectum including its etiology, prognosis,tages and treatment along with surgical anatomy of rectum , details presentation with pictures and description,useful for medical students

1. Carcinoma rectum
BY DR.SAI LIKHITHA
,2ND YEAR POST GRADUATE,
S-2 UNIT, DEPARTMENT OF GENERAL SURGERY,
UNDER THE GUIDANCE OF DR.Y.KIRAN KUMAR,PROFESSOR OF GENERAL SURGERY

2. INTRODUCTION
 EPIDEMIOLOGY
 ETIOLOGY
 DIAGNOSIS
 STAGING
 TREATMENT
surgical anatomy of rectum
surgeries
chemotherapy
radiotherapy
 OUTCOMES
 PROGNOSIS

3. EPIDEMIOLOGY
 More prevalent in western countries.
 Incidence- 12,00,000 new cases every year
 Mortality-6,09,000 cases every year
 Accounts for nearly 10% of cancer related mortality in US.
 Second most common malignancy
 Second most common in females, third most common in males
 Prevalence estimates- in unscreened individuals(>50yrs) are 0.5 – 2.0% of invasive CRC, 1.0-
1.6%of an insitu carcinoma , 7-10% of large adenomas and 25-40% of adenoma of any size.
 Rectum is most commonly involved site.
 Men>women
 Age is the most important demographic factor
 Tends to me more advanced in younger patients.

4. EPIDEMIOLOGY(continued)
 Adenomatosis polyposis coli gene(I1307K) mutation in Ashkenazi jewish families.
 SEER program, Emmigration patterns, Anatomic shift.

5. ETIOLOGY
 Genetic factors:
atleast 1 first degree relative with CRC(<60yrs)
dominantly inherited susceptibility factors- glutathione S-transferase, ethylene
tetrahydrofolate reductase, N-acetyltransferases(NAT1 &2)
BRCA1 mutation
APC gene mutation
MMR gene mutation,
TGF-beta, DCC, KRAS, RAF, PI3K, PTEN
familial syndromes- FAP, TURCOT syndrome, HNPCC, Muire-Torre, hamartomatous
polyposis syndromes.
epigenetic factors.

6. ADENOMA – CARCINOMA SEQUENCE

8.  Environmental factors:

9.  Diet:
red meat, coffee, fibre, vegetables and fruits, antioxidant vitamins, folate, thioethers,
terpenes, plant phenols, dietary methionine, calcium, magnesium, vitamin D.
 Only proximal colon cancer retained a significant risk association with elevated DII score.
 Life style:
physical inactivity, alcohol, smoking, diabetes(insulin therapy)
 Drugs:
aspirin, NSAIDS, bisphosphonates, statins( simvastatin, lovastatin)
 HPV VIRUS, ESCHERISCHIA COLI( muscosa adherent and mucosa internalized strains)

10.  Biomarkers:
CRP
Sr. Amyloid A
Soluble leptin receptor levels
IGF-1 and 2
C-peptide levels

11. DIAGNOSIS
 Symptoms:
tenesmus, bleeding PR,
altered bowel habits- spurious diarrhoea,bloody slime, loose stools, early
morning diarrhoea.
pain, weight loss
 Examination:
DRE, rigid sigmoidoscopy, colonoscopy, ct colonography, barium enema.
 Laboratory investigations:
iron deficiency anemia, electrolyte derangements, lft , CEA levels,
 CT scan, MRI scan, EUS, PET-CT.

12. STAGING
 DUKES staging:

13.  ASTLER-COLLER staging:

14. TNM staging

15. STAGE GROUPING

16.  HISTOLOGICAL GRADING:
well differentiated
moderately differentiated
poorly differentiated

17. TREATMENT
SURGICAL CHEMOTHERAPY RADIOTHERAPY

18. SURGICAL ANATOMY OF RECTUM

51. SURGICALMANAGEMENT
 PREOPERATIVE PREPARATION:
counselling and siting of stomas
correction of anemia and electrolyte disturbances
type and screen for blood transfusion
bowel preparation
deep vein thrombosis
prophylactic antibiotic prophylaxis.- ( neomycin and metronidazole)

53.  LOCAL OPERATIONS:
early rectal cancers( T1 and good prognosis T2)
using trans anal laparoscopic procedures and taTME procedure.
Adequacy of resection is assessed with histological analysis of specimen
 ANTERIOR RESECTION:
sphincter saving procedure
laparoscopic/open/ robotic surgery- da Vinci surgical system.
radical excision of cancer along with its complete mesorectal envelope,
combined with high proximal ligation of the IM lymphovascular
pedicle.

57.  TRANS ANAL TOTAL MESORECTAL EXCISION:
purse string suture is placed below distal level of tumor and bowel wall is incised
to enter mesorectal plane
bottom-up approach is accomplished.
usually combined with synchronous top-down laparoscopic resection by an
abdominal operator.
increased incidence of urethral injuries and concerned with development of
multifocal local recurrences.
 HARTMANN’S PROCEDURE:
in elderly and frail patients

59.  ABDOMINO PERINEAL RESECTION OF THE RECTUM:
in lower third rectal tumors.
Trendelenburg lithotomy position/ Lloyd Davies position/ Jack knife position
complete resection of rectum and mesorectum along with cylindrical excision
of extralevator component.
dissection stoped before reaching pelvic floor to prevent coning down
posterior wall of vagina can be excised if an advanced anterior tumor is
present
end colostomy is placed in left iliac fossa.

63.  ENDOLUMINAL STENTING
 PALLIATIVE COLOSTOMY
 PELVIC EXENTERATION
additional cystectomy/ prostatectomy/hysterectomy….
 Liver resection

65. Chemotherapy
 NEO ADJUVANT:
to down stage the disease.
5-FU based regimen
oxaliplatin, irinotecan, cetuximab are second line drugs
 ADJUVANT:
to reduce risk of disseminated disease.

66. radiotherapy
 NEOADJUVANT:
long course- 5 fractions of chemo radio therapy over 6 weeks with 6 wks
gap
short course- over 5 days with 7-10 days or 12 weeks gap
brachytherapy, contact radiotherapy(Papillon)
“ wait and watch policy”
 occasionally palliative use.

67. OUTCOMES
 95% resectability
 <5% operative mortality
 50% 5 yr survival rate
 Local recurrence rate – 2 to 25%
surgical exenteration is the only hope of cure

68. PROGNOSIS
 GOOD PROGNOSTIC FACTORS
old age
female gender
asymptomatic patients
polypoidal lesions
diploid
 BAD PROGNOSTIC FACTORS
obstruction
perforation
ulcerative lesion
adjacent structures involvement
positive margins
LVSI
signet cell carcinoma
high CEA
tethered and fixed carcinoma

69. STAGE AND PROGNOSIS