RECTAL CANCER PRESENTATION

1. Rectal Cancer
Presenter. DR. ALEX ELIFURAHA MSOKA(TANZANIA)
Prepared byDR.NOORA HASSAN ABDULKAWY (EGYPT)
DR.ABDULLAHI HAJI ADEN(KENYA)
GENERAL SURGERY RESIDENTS PRESENTATION

2. Clinical Anatomy
• 12-15 cm from anal verge.
• Diameter
▫ 4 cm (upper part)
▫ Dilated (lower part)
• Posterior part of the
lesser pelvis and in front
of lower three pieces of
sacrum and the coccyx
• Begins at the
rectosigmoid junction, at
level of third sacral
vertebra
• Ends at the anorectal
junction, 2-3 cm in front
of and a little below the
coccyx

3. • Divided into 3 parts
• Upper third
• Middle third
• Lower third
• 3 distinct intraluminal
curves ( Valves of
Houston)

4. • Superior 1/3rd of the rectum
▫ Covered by peritoneum on the
anterior and lateral surfaces
• Middle 1/3rd of the rectum
▫ Covered by peritoneum on the
anterior surface
• Inferior 1/3rd of the rectum
▫ Devoid of peritoneum
▫ Close proximity to adjacent
structure including boney pelvis.
Note: - Distal rectal tumors have no
serosal barrier to invasion of
adjacent structures and are more
difficult to resect given the close
confines of the deep pelvis.
Peritoneal Relations

5. Arterial supply
• Superior rectal A – fr. IMA; supplies
upper and middle rectum
• Middle rectal A- fr. Internal iliac A.
(supplies lower rectum)
• Inferior rectal A- fr. Internal pudendal A.
Venous drainage
▫ Superior rectal V- upper & middle third
rectum
▫ Middle rectal V- lower rectum and upper
anal canal
▫ Inferior rectal vein- lower anal canal
Innervations
• Sympathetic: L1-L3, Hypogastric
nerve
• ParaSympathetic: S2-S4

6. Lymphatic drainage
• Upper and middle rectum
▫ Pararectal lymph nodes,
musclelocated directly on the
layer of the rectum
▫ Inferior mesenteric lymph
nodes, via the nodes along the
superior rectal vessels
• Lower rectum
▫ Sacral group of lymph nodes or
Internal iliac lymph nodes
• Below the dentate line
▫ Inguinal nodes and external iliac
chain

7. Epidemiology
• Colorectal cancer is the third most frequently diagnosed
cancer in the US men and women.
• 108,070 new cases of colon cancer and 40,740 new cases of
rectal cancer in the US in 2008. Combined mortality for
colorectal cancer 49,960 in 2008.
• Worldwide approx. 1 million new cases p.a. are diagnosed,
with 529,000 deaths.
• In Egypt colorectal cancer is the fourth most commonly
diagnosed cancer in both men and women.
• Incidence rate increase with age with predominant male sex.
• Median age- 7th decade but can occur any time in adulthood.

8. • Cecum 14 %
• Ascending colon 10 %
• Transverse colon 12 %
• Descending colon 7 %
• Sigmoid colon 25 %
• Rectosigmoid junct 0.9 %
• Rectum 23 %

9. Rectal cancer
Any cancer whose distal margin is 15 cm or less from anal verge using a rigid
sigmoidoscope should be classified as rectal.
It is the disease in which cancer cells form in the tissues of the rectum; colorectal cancer
occurs in the colon or rectum.
Adenocarcinomas comprise the vast majority (98%) of colon and rectal cancers; more
rare rectal cancers include lymphoma (1.3%), carcinoid (0.4%), and sarcoma (0.3%)

10.  Etiological agents
 Environmental & dietary factors
 Chemical carcinogenesis.
 Associated risk factors
 Male sex
 Family history of colorectal cancer
 Personal history of colorectal cancer, ovary, endometrial, breast
 Excessive BMI
 Processed meat intake
 Excessive alcohol intake/smoking
 Low folate consumption
 Neoplastic polyps.
 Hereditary Conditions /Genetic syndromes
(FAP, HNPCC,IBD,LS)

11. Clinical Presentations
• Symptoms
▫ Asymptomatic
▫ Change in bowel habit 43% (diarrhoea, constipation, narrow
stool, incomplete evacuation, tenesmus).
▫ Blood PR(60%)
Occult bleeding (26%)
▫ Abdominal discomfort (20%) (pain, fullness, cramps,
bloating, vomiting).
▫ Weight loss, tiredness.
• Acute Presentations
▫ Intestinal obstruction.
▫ Peritonitis from Perforation (03%).
▫ Massive bleeding.

12. • Signs
▫ Pallor
▫ Abdominal mass
▫ PR mass
▫ Jaundice
▫ Nodular liver
▫ Ascites
▫ Rectal metastasis travel along portal drainage to liver via
superior rectal vein as well as systemic drainage to lung via
middle inferior rectal veins.

13. Rectal cancer is a challenging disease because:
1.Common malignancy
2.Difficult dissection
3.Treatment not infrequently entails a permanent stoma
4.Sexual and urinary morbidity
5. Local recurrence.
Histopathologic features such as poor differentiation, lymphovascular and/or
perineural invasion, T4 tumor stage, and clinical findings such as obstruction
or perforation, and elevated preoperative CEA levels are all associated with
increased recurrence rates and worse survival

14. Dukes classification-
Dukes A: Invasion into but not through the bowel wall.
Dukes B: Invasion through the bowel wall but not involving lymph
nodes.
Dukes C: Involvement of lymph nodes
Dukes D: Widespread metastases
Modified astler coller classification-
Stage A : Limited to mucosa.
Stage B1 : Extending into muscularis propria but not penetrating
through it; nodes not involved.
Stage B2 : Penetrating through muscularis propria; nodes not
involved
Stage C1 : Extending into muscularis propria but not penetrating
through it. Nodes involved
Stage C2 : Penetrating through muscularis propria. Nodes
involved
Stage D: Distant metastatic spread

15. Tis T1 T2 T3 T4
Extension to an adjacent organ
Mucosa
Muscularis mucosae
Submucosa
Muscularis propria
Subserosa
Serosa
TNM Classification
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ: intraepithelial or invasion of lamina propria
T1 Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades through the muscularis propria into pericolorectal tissues
T4a Tumor penetrates to the surface of the visceral peritoneum
T4b Tumor directly invades or is adherent to other organs or structures

16. TNM Classification

17. Stage Grouping

18. Diagnostic Workup
• History—including family history of colorectal cancer or polyps
• Physical examinations including DRE and complete pelvic
examination in women: size, location, ulceration, mobile vs.
tethered vs. fixed, distance from anal verge and sphincter
functions.
• Proctoscopy—including assessment of mobility, minimum
diameter of the lumen, and distance from the anal verge
• Biopsy of the primary tumor

19. .

20. Routine laboratory studies should include a complete blood count (CBC); serum
chemistries, including liver and renal function tests; and a carcinoembryonic antigen
(CEA) test. A cancer antigen (CA) 19-9 assay, if available, may also be useful to monitor
the disease.
Screening CBC may demonstrate a hypochromic, microcytic anemia, suggesting iron
deficiency. The combined presence of vitamin B-12 or folate deficiency may result in a
normocytic or macrocytic anemia. All men and postmenopausal women with iron
deficiency anemia require a GI evaluation. Liver function tests are usually part of the
preoperative workup. The results are often normal, even in patients with metastases to
the liver.
Perform a CEA test in all patients with rectal cancer. A baseline level is obtained before
surgery and a follow-up level is obtained after surgery. If a previously normalized CEA
begins to rise in the postoperative period, this suggests possible recurrence. A CEA level
higher than 100 ng/mL usually indicates metastatic disease and warrants a thorough
investigation.

22. A multidisciplinary approach that includes surgery, medical oncology, and
radiation oncology is required for optimal treatment of patients with rectal
cancer.
Surgical technique, use of radiotherapy, and method of administering
chemotherapy are important factors.
Strong considerations should be given to the intent of surgery, possible
functional outcome, and preservation of anal continence and genitourinary
functions.
The first step involves achievement of cure, because the risk of pelvic
recurrence is high in patients with rectal cancer, and locally recurrent rectal
cancer has a poor prognosis .
resection margin is determined by blood supply consideration.For upper
third rectal cancers both the rectum and mesorectum are divided not loss
than 5cm below the lower margin of the tumor.A 2cm distal margin is
adequate for most low rectal cancers. In smaller cancers of the low rectum
without adverse histopathological features,a 1 cm distal margin is acceptable.

24. Radical resection of the rectum is the mainstay of therapy. The timing of
surgical resection is dependent on the size, location, extent, and grade of
the rectal carcinoma. Operative management of rectal cancer may
include the following:
•Transanal excision: For early-stage cancers in a select group of patients
•Transanal endoscopic microsurgery: Form of local excision that uses a
special operating proctoscope that distends the rectum with insufflated
carbon dioxide and allows the passage of dissecting instruments
•Endocavity radiotherapy: Delivered under sedation via a special
proctoscope in the operating room
•Sphincter-sparing procedures: Low anterior resection, coloanal
anastomosis, abdominal perineal resection.

25. Total mesorectal excision
• local failures are most often due to inadequate surgical clearance of
radial margins.
• conventional resection violates the mesorectal circumference during
blunt dissection, leaving residual mesorectum.
• TME involves precise dissection and removal of the entire rectal
mesentery as an intact unit.
• local recurrence with conventional surgery averages approx. 25-30%
vs. TME 4-7% by several groups (although several series have higher
recurrence)

26. Pelvic Exenteration
15cm
Abdominoperineal Resection (APR)
The surgeon removes the rectum as well as nearby organs such as the
bladder, prostate, or uterus if the cancer has spread to these organs.
A colostomy is needed after this operation. If the bladder is removed,
a urostomy (opening to collect urine) is needed.
High Anterior Resection
Low Anterior Resection
Ultra-low Anterior Resection

27. Complications of Surgery
• Bleeding
• Infection
• Anastomotic Leakage
• Blood clots
• Anesthetic Risks

29. Although radical resection of rectum is the mainstay of therapy,
surgery alone has a high recurrence rates. The local recurrence rate
for rectal cancers treated with surgery alone is 30-50%. Rectal
adenocarcinomas are sensitive to ionizing radiation. Radiation
therapy can be delivered preoperatively, intraoperatively, or
postoperatively and with or without chemotherapy.
Tumor stage, grade, number of lymph node metastasis,
lymphovascular involvement, signet cell appearance, achievement of
negative radial margins, and distance from the radial margin are
important prognostic indicators of local and distant recurrences. Low
anterior (LAR) or abdominal-perineal resection (APR) in
conjunctions with total mesorectal excision (TME) should be
performed for optimal surgical therapy.
Adjuvant medical therapy may include the following:
•Adjuvant radiation therapy
•Intraoperative radiation therapy
•Adjuvant chemotherapy
•Adjuvant chemoradiation therapy

30. Stage Rectal cancer ~5-year LF/OS
I •TME with APR or LAR.
•If pT1-2N0, no adj. treatment.
•Local excision for favorable tumors (<3 cm size, <30%
circumference, within 8 cm of anal verge, well-moderately
differentiated; margin >3 mm, no LVSI/PNI).
 favorable T1 lesions- observation.
 T2 lesions - adjuvant 5-FU/RT
<5% LF
90% OS
II and III • Pre-op 5-FU/RT LAR/APR adjuvant 5-FU-based T3N0 and T1-2N1:
(locally therapy × 3 cycles (preferred) 5–10% LF
resectable) • If surgery initially  then adjuvant 5-FU × 2 cycles  80% OS
concurrent chemoRT  5-FU ×2 cycles T4N0 and T3N1:
10–15% LF
60% OS
T4N1 and T3/4N2:
15–20% LF
40% OS
Treatment Recommendations

31. Stage Rectal cancer ~5-year LF/OS
III
(T4/ Locally
unresectable)
If obstructed, diverting colostomy or stent placed 
definitive treatment. 5-FU/RT  resection if
possible. Consider
IORT for microscopic disease (after 50 Gy EBRT,
give IORT 12.5–15 Gy) or
brachytherapy for macroscopic disease  adjuvant
5-FU-based therapy*
IV Individualized options, including combination 5-FU-
based chemo alone, or chemo ± resection ± RT
Recurrent Individualized options.
If no prior RT, then chemoRT  surgery ± IORT or
brachytherapy.
If prior RT, then chemo surgery ± IORT or
brachytherapy as appropriate.

32. Prognostic factors
 Good prognostic
factors
 Old age
 Gender(F>M)
 Asymptomatic pts
 Polypoidal lesions
 Poor prognostic
factors
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Obstruction
Perforation
Ulcerative lesion
Adjacent structures
involvement
Positive margins
Recurrence
Signet cell carcinoma
High CEA
Tethered and fixed
cancer

33. Stage and Prognosis
Stage 5-year Survival (%)
0,1 Tis,T1;No;Mo > 90
I T2;No;Mo 80-85
II T3-4;No;Mo 70-75
III T2;N1-3;Mo 70-75
III T3;N1-3;Mo 50-65
III T4;N1-2;Mo 25-45
IV M1 <3

34. Thank You !!