The document provides a comprehensive overview of colorectal cancer, including its epidemiology, clinical presentation, risk factors, staging, and management strategies. It highlights the importance of screening and early diagnosis and discusses findings from a case presentation of a patient with symptoms indicative of potential colorectal cancer. Additionally, the document outlines surgical principles, prognostic factors, and the differing survival rates associated with various stages of colon and rectal cancer.

1. colorectal
cancer
By Dr. Ryan Al.Ghanemi

2. overview of the lecture
case presentation.
epidemiology of colorectal cancer.
clinical presentation of colorectal cancer.
staging of colorectal cancer.
management of primary colon tumor.
management of rectal tumor.

3. case presentation
A 65 years old man present with dyspnea on exertion and angina for 3-
4 weeks.
He denies any cough, weight loss, git symptoms.
His past medical history is significant for hypertension, stable angina,
and colonic polyps
Those were removed 7 to 8 years ago by colonoscopy.

4. The physical examination reveals a well-nourished man.
The finding from head and neck, cardiopulmonary, and
neurologic examinations are Unremarkable.
Examination of the abdomen reveals an obese abdomen
without tenderness or Palpable masses .
The rectal examination reveals no masses , a smooth
enlarged prostate

5. Strongly hemoccult positive stool in the vault .
Cbc : hb of 8.7 g/dl hct 29 % and low mcv .
Ecg : normal sinus rhythm and mild lvh.
Normal chest radiograph.

6. What is the most likely mechanism causing this process?
How would you confirm the diagnosis ?
What is the initial treatment for this pt ?

7. Most likely mechanism: anemia caused by occult GI tract
bleeding .
Confirmation of the diagnosis : EGD and colonscopy.
Initial treatment: blood transfusion.

8. Epidemiology:
Approximately 148,810 new cases of large bowel cancer are
diagnosed each year in the United States, of which 108,070
are colon and the remainder rectal cancers.
Annually, approximately 49,960 Americans die of CRC,
accounting for approximately 9 percent of all cancer deaths.

9. Incidence
Age is a major risk factor for sporadic CRC. It is a rare
diagnosis before the age of 40, the incidence begins to
increase significantly between the ages of 40 and 50, and
age-specific incidence rates increase in each succeeding
decade thereafter).

10. The lifetime incidence of CRC in patients at average risk is
about 5 percent, with 90 percent of cases occurring after age
50.
The incidence is higher in patients with specific inherited
conditions that predispose them to the development of CRC.

11. A gradual shift toward right-sided or proximal colon cancers
has been observed both in the United States and
internationally.
The greatest increase in incidence is in cecal primaries.

12. why this changes?
This change in the anatomic distribution of CRCs may be, in
part, related to improvements in diagnosis and treatment.
and increased screening by flexible sigmoidoscopy with
removal of adenomatous polyps in the descending colon .
but there also appears to be a true increase in the incidence
of ascending colon and cecal cancers .

13. Consistent with this hypothesis, five-year survival rates have
improved significantly for left and transverse colon cancers,
but not for right-sided tumor.

14. Risk factors :
Environmental and genetic factors can increase the
likelihood of developing CRC.
Although inherited susceptibility results in the most striking
increases in risk.
the majority of CRCs are sporadic rather than familial .

15. Personal or family history of sporadic cancers or
adenomatous polyps — Patients with a personal history of
CRC or adenomatous polyps are at risk for the development
of a future large bowel cancer

16. FAP
Hereditary nonpolyposis colorectal cancer
A personal history of large (>1 cm) adenomatous polyps and
polyps with villous or tubulovillous histology also increase
the risk of CRC, particularly if multiple . The relative risk
ranges from approximately 3.5 to 6.5 in such patients

17. Family history is also an important risk factor in sporadic
disease, with a single affected first-degree relative (parent,
sibling, or child) increasing the risk 1.7-fold of that in the
general population
A family history of a large (>1 cm) or histologically advanced
colonic adenoma appears to carry the same significance as a
positive family history of colorectal cancer

18. Inflammatory bowel disease
Diabetes mellitus and insulin resistance obesity
Cholecystectomy - Alcohol
A history of radiation therapy for prostate cancer was
associated with an increased risk of rectal cancer in a large
database study . The magnitude of risk was similar to that
observed in patients with a family history of colonic
adenomas

19. protective factors
Diet
Fiber
Calcium supplementation has been recommended for the
primary or secondary prevention of colonic adenomas by the
American College of Gastroenterology

20. Aspirin and NSAIDs
Hormone replacement therapy

21. Omega 3 fatty acids — Consumption of omega 3 fatty acids
(mainly as fish oil) has been associated with a reduced
incidence of colorectal cancer in observational studies

22. Screening:
Patient surveillance can most effectively be accomplished by
colonoscopy.
For average risk individuals ACG colonoscopy every 10 years
beginning at 50 years of age .
If adenomatous polyp is identified and removed repeat
colonoscopy should be done every 3 years when the colon is
clear every 5 years .
What if he has high risk factor , eg early family history ?

23. Clinical presentations:
• Abdominal pain — 44 percent
• Change in bowel habit — 43 percent
• Hematochezia or melena — 40 percent
• Weakness — 20 percent
• Anemia without other gastrointestinal symptoms — 11
percent
Weight loss — 6 percent

24. A meta-analysis of 15 studies concluded that the sensitivity of
alarm features (such as weight loss) was poor (ranging from
5 to 64 percent).
However, the specificity for some alarm symptoms (including
dark red rectal bleeding and abdominal mass) was greater
than 95 percent.

25. Abdominal pain can be caused by a partial obstruction,
peritoneal dissemination, or intestinal perforation leading to
generalized peritonitis.
tenesmus caused by a rectal cancer may involve pelvic floor
muscles.
a locally advanced lesion may involve the sciatic or obturator
nerve, leading to a neuropathic pain syndrome

26. Hematochezia is more often caused by a rectal rather than
colon cancer
A change in bowel habits is a more common presenting
symptom for left-sided cancers because fecal contents are
liquid in the proximal colon and are therefore less likely to be
associated with obstructive symptoms

27. Metastatic disease — Approximately 20 percent of patients
have distant metastatic disease at the time of presentation
The presence of right upper quadrant pain, abdominal
distention, early satiety, supraclavicular adenopathy, or
periumbilical nodules usually signals advanced disease.

28. Because the venous drainage of the intestinal tract is via the
portal system, the first site of hematogenous dissemination
is usually liver
tumors arising in the distal rectum may metastasize initially
to the lungs because the inferior rectal vein drains into the
inferior vena cava rather than into the portal venous system.

29. Unusual presentations — There are also a variety of unusual
presentations of CRC. These include:
Local invasion or a contained perforation causing malignant
fistula formation into adjacent organs
Fever of unknown origin
CRC ultimately proves to be the origin of approximately 6
percent of adenocarcinomas of unknown primary sites

30. Impact of symptoms on prognosis
— The presence of symptoms and their particular type
appear to be of some prognostic importance:

31. • Patients who are symptomatic at diagnosis have a
somewhat worse prognosis . In one report, the five-year
survival rate for symptomatic and asymptomatic patients
was 49 versus 71 percent.
the duration of symptoms is not an accurate predictor of
prognosis.

32. • Obstruction and/or perforation, although uncommon,
carry a poor prognosis, independent of stage .
• Tumors presenting with hemorrhage have been
thought to have a better prognosis because of their tendency
to be diagnosed earlier; however, bleeding is not an
independent predictor of outcome .

33. LOCATION OF COLORECTAL
MALIGNANCIES
Synchronous cancers — Synchronous CRCs:
defined as two or more distinct primary tumors separated by
normal bowel and not due to direct extension or metastasis,
occur in 3 to 5 percent of patients with colon cancer

34. Metachronous cancers :
Metachronous CRCs, defined as nonanastomotic new tumors
developing at least six months after the initial diagnosis.
develop in 1.5 to 3 percent of patients in the first five years
postoperatively, rising to up to 9 percent after several
decades in survivors of the primary cancer

35. DIAGNOSIS
CRC may be suspected from one or more of the symptoms
and signs described above or may be asymptomatic and
discovered by routine screening of average and high risk
subject

36. Colonoscopy and BE
The vast majority of colon and rectal cancers are
endoluminal adenocarcinomas that arise from the mucosa.
Colonoscopy is the single best diagnostic test in symptomatic
individuals, since it can localize lesions throughout the large
bowel, biopsy mass lesions, detect synchronous neoplasms,
and remove polyps
The air contrast barium enema (BE), supplemented with
flexible sigmoidoscopy, is also used to evaluate symptomatic
patients

37. A direct evaluation of the total colonic mucosa is necessary to
exclude carcinoma with certainty

39. staging
Tx: No description of the tumor's extent is possible because
of incomplete information.
Tis: The cancer is in the earliest stage. It involves only the
mucosa. It has not grown beyond the muscularis mucosa
(inner muscle layer).
T1: The cancer has grown through the muscularis mucosa
and extends into the submucosa.
T2: The cancer has grown through the submucosa and
extends into the muscularis propria (outer muscle layer).

40. T3: The cancer has grown through the muscularis propria
and into the subserosa but not to any neighboring organs or
tissues.
T4: The cancer has grown through the wall of the colon or
rectum and into nearby tissues or organs.

41. N categories for colorectal cancer
N categories indicate whether or not the cancer has spread
to nearby lymph nodes and, if so, how many lymph nodes
are involved.
Nx: No description of lymph node involvement is possible
because of incomplete information.
N0: No lymph node involvement is found.
N1: Cancer cells found in 1 to 3 nearby lymph nodes.
N2: Cancer cells found in 4 or more nearby lymph nodes.

42. M categories for colorectal cancer
M categories indicate whether or not the cancer has spread
to distant organs, such as the liver, lungs, or distant lymph
nodes.
Mx: No description of distant spread is possible because of
incomplete information.
M0: No distant spread is seen.
M1: Distant spread is present.

43. Stage 0
Tis, N0, M0: The cancer is in the earliest stage. It has not
grown beyond the inner layer (mucosa) of the colon or
rectum. This stage is also known as carcinoma in situ or
intramucosal carcinoma.
Stage I
T1, N0, M0 or T2, N0, M0: The cancer has grown through the
muscularis mucosa into the submucosa (T1) or it may also
have grown into the muscularis propria (T2). It has not
spread to nearby lymph nodes or distant sites.

44. Stage IIA
T3, N0, M0: The cancer has grown into the outermost layers
of the colon or rectum but has not reached nearby organs. It
has not yet spread to the nearby lymph nodes or distant
sites.
Stage IIB
T4, N0, M0: The cancer has grown through the wall of the
colon or rectum and into other nearby tissues or organs. It
has not yet spread to the nearby lymph nodes or distant
sites.

45. Stage IIIA
T1, N1, M0 or T2, N1, M0: The cancer has grown through the mucosa
into the submucosa (T1) or it may also have grown into the
muscularis propria (T2). It has spread to 1 to 3 nearby lymph nodes
but not to distant sites.
Stage IIIB
T3, N1, M0 or T4, N1, M0: The cancer has grown into the outermost
layers of the colon or rectum but has not reached nearby organs (T3)
or the cancer has grown through the wall of the colon or rectum and
into other nearby tissues or organs (T4). It has spread to 1 to 3
nearby lymph nodes but not distant sites.

46. Stage IIIC
Any T, N2, M0: The cancer may or may not have grown through
the wall of the colon or rectum, but it has spread to 4 or more
nearby lymph nodes. It has not spread to distant sites.
Stage IV
Any T, Any N, M1: The cancer may or may not have grown through
the wall of the colon or rectum, and it may or may not have
spread to nearby lymph nodes. It has spread to distant sites such
as the liver, lung, peritoneum (the membrane lining the
abdominal cavity), or ovary.

48. An increase in colorectal cancer screening has been
associated with an earlier stage at which colorectal cancer is
diagnosed. The following results were observed in a large
database study
• Localized — confined to the primary site and to the
mucosa, submucosa, and muscle layer (Dukes' A or B or TNM
stage I or II ) — 40 percent
• Lymph node involvement (Dukes' C or TNM stage III) —
37 percent
• Distant metastases (Dukes' D or TNM stage IV) — 19
percent

49. As a general rule, the stage of rectal cancer at diagnosis
tends to be slightly earlier than the stage in the colon
probably because rectal cancers are more likely to cause
symptoms.

50. In patients with four or fewer hepatic lesions, resection may
be curative, with five-year relapse-free survival rates of 24 to
38 percent

51. Intraoperative evaluation — Even if preoperative clinical
staging evaluation fails to show evidence of metastatic
spread.
intraoperative evaluation is an essential component of the
clinical staging process.
CT scan is not a reliable diagnostic test for low volume tumor
on peritoneal surfaces.

52. EUS for rectal cancer — Preoperative knowledge of the depth
of invasion and nodal status is critically important for
planning therapy of a rectal cancer.
Neoadjuvant combined modality approaches utilizing both
chemotherapy and radiation are associated with less toxicity
and a higher likelihood of sphincter preservation, particularly
for distal transmural tumors.

53. Tumor markers :
An expert panel on tumor markers in breast and colorectal
cancer convened by the American Society of Clinical
Oncology (ASCO) recommended that serum CEA nor CA 19-9
levels not be used as a screening test for colorectal cancer . A
similar recommendation has been made by the European
Group on Tumor Markers .
However, serum levels of CEA do have prognostic utility in
patients with newly diagnosed CRC. Patients with
preoperative serum CEA >5 ng/mL have a worse prognosis,
stage for stage, than those with lower levels

54. PROGNOSIS :
Colon cancer — Five-year survival rates in a contemporary series of over 119,000
patients treated between 1991 and 2000 stratified according to the most recent
modification of the TNM staging system were as follows:
• Stage I (T1-2N0) — 93 percent
• Stage IIA (T3N0) — 85 percent
• Stage IIB (T4N0) — 72 percent
• Stage IIIA (T1-2 N1)— 83 percent
• Stage IIIB (T3-4 N1) — 64 percent
• Stage IIIC (N2) — 44 percent
Stage IV — 8 percent

55. Survival rates in patients with stage II and III disease are
variable and depend on the number of lymph nodes
analyzed .
Rectal cancer — Five-year survival rates for rectal cancer tend
to be somewhat lower and are heavily dependent upon case
mix .

56. In particular, the survival of patients with stage III disease is
variable and depends upon the T stage (ie, T1-2 versus 3-4)
and the extent of nodal disease. As an example, when data
from the National Cancer Database were stratified according
to subsets of stage III disease, the following five-year survival
rates were reported :

57. • Stage IIIA (T1-2, N1) — 55.1 percent (n = 1043 patients)
• Stage IIIB (T3-4, N1) — 35.3 percent (n = 2856 patients)
• Stage IIIC (Any T, N2) — 24.5 percent (n = 2088 patients)

58. Surgical management of primary colon cancer
Surgery is the only curative modality for localized colon
cancer. Surgery also provides a potentially curative option for
selected patients with limited metastatic disease in liver
and/or lung.

59. PREOPERATIVE EVALUATION :
A complete history and physical examination should be
performed in all patients presenting with a newly diagnosed
colon cancer
The preoperative evaluation should also include a complete
blood count, serum electrolytes, liver enzymes, and
carcinoembryonic antigen (CEA), urinalysis, coagulation
profile, electrocardiogram, chest x-ray, and computed
tomography (CT) scan of the abdomen and pelvis
Ideally, each patient should have a colonoscopic examination
of the entire colon prior to surgery.

60. Endoscopic ultrasound — Endoscopic ultrasound (EUS) is not
routinely used in the preoperative or staging workup of colon
cancer (in contrast to rectal cancer, where it is routinely
used).

61. GENERAL SURGICAL PRINCIPLES
The goal of colon cancer surgery is complete removal of the
tumor along with the major vascular pedicle feeding the
affected colonic segment and the lymphatic drainage basin
En bloc resection of contiguous structures is indicated if
there is attachment or adhesion of the tumor to any organ or
structure.

62. Bowel preparation
Preoperative mechanical bowel preparation (MBP) reduces
both the fecal content and bacterial count in the bowel
lumen . The use of MBP in conjunction with prophylactic
antibiotics has been reported to decrease the incidence of
wound infection and intraabdominal abscess after colorectal
surgery .
Some have questioned the need for routine MBP prior to
elective colon cancer surgery.

63. In an early systematic review of randomized trials of
preoperative MBP versus no MBP in 1592 patients (nine
trials) undergoing elective colorectal surgery, there was no
significant difference in the anastomotic leakage rate
between patients who had versus did not have MBP (2.9
versus 1.6 percent, respectively) .
Furthermore, there was a nonsignificant trend toward a
higher incidence of wound infection in patients who received
MBP (7.4 versus 5.4 percent).

64. Resection margins — Proximal and distal resection margins
should be at least 5 cm from the tumor .
Regional lymphadenectomy — Regional lymphadenectomy
provides important prognostic information that guides
adjuvant treatment and is of therapeutic value as well.

65. SURGICAL TECHNIQUES
Right hemicolectomy : A right hemicolectomy is usually
performed for tumors of the cecum and ascending colon,
and for some hepatic flexure. In a classic right
hemicolectomy, the ileocolic, right colic, and right branch of
the middle colic vessels are divided and removed with the
contiguous mesentery.
Care must be taken to identify the right ureter, the ovarian or
testicular vessels, and the duodenum. If the omentum is
attached to the tumor, it should be removed en bloc with the
specimen.

66. Extended right hemicolectomy
An extended right hemicolectomy can be performed for
proximal, mid, or even distal transverse colon cancers,
although tumors of the distal transverse colon are more
often resected with a left hemicolectomy.
In the extended right hemicolectomy, the ileocolic, right colic,
and middle colic vessels with their contiguous mesentery are
divided and removed. The inferior mesenteric vein may be
divided and included in the specimen. Care must be taken to
protect the duodenum and the pancreas

67. Transverse colectomy
A transverse colectomy may be undertaken for mid
transverse colon cancers as long as satisfactory resection
margins and an adequate lymphadenectomy can be
obtained. The transverse colon is resected along with the
middle colic vessels and its mesentery. At times, the inferior
mesenteric vein is also divided and included in the resected
specimen. Both the hepatic and splenic flexures may need to
be mobilized in order to achieve a tension-free anastomosis.
When mobilizing the splenic flexure, care must be taken not
to apply much traction to the omentum or colon, as this will
invariably result in splenic capsule tears.

68. Left hemicolectomy
A left hemicolectomy is appropriate for tumors in the distal
transverse or descending colon and for selected patients
with proximal sigmoid colon cancer. The left branch of the
middle colic vessels, the inferior mesenteric vein, and the left
colic vessels along with their mesenteries are included with
the specimen.
In some cases, a segmental colectomy may be performed as
long as adequate resection margins and lymphadenectomy
are achieved .

69. Sigmoid colectomy
For sigmoid colon cancers, segmental or sigmoid colectomy
is appropriate. The inferior mesenteric artery is divided at its
origin, and dissection proceeds just under the superior rectal
vessels toward the pelvis until adequate margins are
obtained.
As with right-sided tumors, care must be taken while
mobilizing the sigmoid and descending colon to identify the
left ureter and the left ovarian or testicular vessels.

70. Subtotal and total colectomy
A subtotal or a total abdominal colectomy is indicated if
there are synchronous neoplasms on the right and left sides
of the colon. Occasionally these procedures are performed in
patients presenting with obstructing-left sided tumors.
For patients with hereditary nonpolyposis colorectal cancer
(HNPCC) who present with a colon cancer, total abdominal
colectomy is the procedure of choice. .

71. Locally advanced primary lesions — Approximately 10
percent of patients with colon cancer have invasion of
contiguous organs or inflammatory adhesions involving
neighboring structures

72. Benefit of postoperative RT
There is a paucity of high-quality evidence addressing the
role of adjuvant RT (with or without concurrent
chemotherapy) in patients with resected locally advanced
colon cancer

73. current treatment recommendations suggest that adjuvant
RT be offered to the following subgroups of patients who
have an estimated risk of local recurrence that is 30 percent
or higher: T4 disease, positive resection margins, disease
complicated by perforation or abscess formation

74. Neoadjuvant chemoradiotherapy
Neoadjuvant (preoperative) chemoradiotherapy may
represent an alternative approach for selected patients with
locally advanced colon cancer invading into adjacent organs.
However, there is no consensus as to which patients are
suitable for this approach.
Although commonly used for locally advanced rectal
cancers.

75. patients with obstruction
Optimal management for an obstructing cancer depends
upon the condition of the patient and the tumor location.
If the patient is a candidate for surgery, surgical treatment
alternatives for obstructing colon cancers include resection
of the tumor with a primary anastomosis with or without a
temporary proximal diversion, resection without an
anastomosis and with an end colostomy, and proximal
diversion with a mucous fistula or a loop colostomy, to
temporize the situation with an elective definitive resection
at a second operation

76. patients with perforation
The management of perforated tumors has to be
individualized. Treatment alternatives will depend on the
patient's overall condition and whether peritonitis is localized
or generalized. If the patient is stable and peritonitis is not
generalized, tumor resection with a primary anastomosis can
be performed.
As noted above, primary anastomosis is not recommended if
there is diffuse peritonitis or free perforation and/or the
patient is medically unstable.

77. For an unstable patient, percutaneous drainage or a proximal
diverting colostomy can be performed.
Chemotherapy — Obstructed and perforated colon cancers
are considered at high risk for recurrence. Guidelines from
ASCO suggest the use of adjuvant chemotherapy in these
settings, even for node-negative disease.

78. LAPAROSCOPIC COLECTOMY
Laparoscopic-assisted colectomy (LAC) was first described in
1991 . However, because of concerns over port site
recurrences and the adequacy of the oncologic procedure,
LAC was not accepted by the surgical community until the
completion of multiple studies comparing safety and
oncologic equivalency to open colectomy

79. At least six large (100 or more patients) prospective
randomized controlled trials have now been reported, and
none suggest a significant detrimental impact on recurrence
or survival for laparoscopic as compared to open resection
In the earliest trial from Barcelona ( a median follow-up of 94
months, overall and disease-free survival were similar in both
groups institution study),

80. In the largest trial, the United States Intergroup
At a median follow-up of seven years, there were also no
significant differences in the five-year disease-free survival
(69 versus 68 percent in the LAC and open colectomy groups,
respectively) or overall survival (76 versus 75 percent).

81. Both concluded that laparoscopic colectomy provides
oncologic outcomes (cause-specific survival, disease
recurrence, number of lymph nodes harvested) that are
comparable to those achieved with an open approach.

83. MANAGEMENT OF CARCINOMA IN
A POLYP
Endoscopic resection alone is a reasonable approach for
favorable-risk early stage colon cancers arising in a polyp.
The presence of any of the following factors should prompt
consideration of radical surgery, as they indicate a higher risk
of residual cancer and/or nodal metastases:

84. • Poorly differentiated histology
• Lymphovascular invasion
• Cancer at the resection or stalk margin
• Invasion into the muscularis propria of the bowel wall
(T2 lesion)
• Invasive carcinoma arising in a sessile (flat) polyp
• Invasive carcinoma with incomplete polypectomy

85. • Lymphovascular invasion
• Cancer at the resection or stalk margin
• Invasion into the muscularis propria of the bowel wall
(T2 lesion)

86. Surgical management of rectal
cancer
Physical and endoscopic examination — Digital rectal
examination (DRE) and rigid sigmoidoscopy are essential to
the surgical decision-making process
The type of operation offered to a patient with rectal cancer
depends on tumor stage and location

87. If sphincter preservation is to be achieved, the tumor has to
be located high enough above the top of the anorectal ring
to allow for an adequate distal margin.
This is more likely with midrectal and upper rectal tumors
than for distal tumors (within 5 cm of the anal verge),
although preoperative chemoradiotherapy may permit
sphincter preservation in some patients with low-lying
tumors.

88. GENERAL SURGICAL PRINCIPLES
After establishing the diagnosis and completing the staging
workup, a decision is made whether to pursue immediate
resection or attempt preoperative chemoradiotherapy .
The benefits of preoperative chemoradiotherapy were best
demonstrated in the German Rectal Cancer Study Group trial
that randomly assigned 823 patients with rectal cancer to
preoperative versus postoperative chemoradiotherapy .

89. The following results were noted:
• Patients treated preoperatively had similar survival
rates but a significantly lower pelvic relapse rate compared to
those receiving postoperative chemoradiotherapy.
Overall rates of sphincter preservation were similar in both
groups (APR required by 26 and 23 percent of preoperatively
and postoperatively treated patient.

90. Goals of surgery:
The primary goal of surgery is complete removal of the
primary tumor along with the regional lymphatics and the
superior hemorrhoidal artery pedicle. The surgical specimen
should contain at least 12 lymph nodes

91. SELECTION OF APPROPRIATE
SURGERY
The surgeon has three major curative options for rectal
cancer: local excision, sphincter-preserving abdominal
surgery (low anterior resection or LAR), and abdominal
perineal resection (APR).
The depth of tumor invasion into the rectal wall, the presence
or absence of regional lymph node metastases, the size and
macroscopic appearance of the cancer, and tumor location
are all critical in determining the best surgical option

92. Abdominal perineal resection
(APR):
An APR requires incisions in both the abdomen and
perineum. It entails removal of the primary tumor along with
a complete proctectomy, resulting in the need for a
permanent colostomy.
APR has long been considered the gold standard for surgical
therapy of distal rectal cancers.
Oncologic outcomes following LAR are not significantly
different from those after APR .

93. However, compared to LAR, APR is associated with higher
procedure-related morbidity and mortality . and an inferior
quality of life (QOL), mainly related to depression and
changes in body image .

94. Sphincter-sparing procedures : Sphincter-sparing approaches
for distal rectal cancers have evolved along two pathways:
For larger or more invasive tumors of the distal rectum (eg,
T3 or T4 lesions), preoperative or neoadjuvant
chemoradiotherapy may facilitate the conversion of a
planned APR to a LAR by promoting tumor regression
For small rectal cancers that are confined to the rectal wall,
local excision techniques may offer local control and survival
rates that are comparable to APR, while preserving sphincter
function

95. Low anterior resection — Most invasive rectal cancers
involving the upper third of the rectum can be adequately
treated by a LAR, preserving the anal sphincter.
Even for patients with midrectal and some distal (lower third)
rectal cancers, LAR has become increasingly prevalent as the
safety and efficacy has been established

96. THANK YOU Dr. Ryan Al.Ghanemi