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Management of Rectal cancer.pptx
- 1. Management of rectal cancer Adewunmi Olayinka Lukman Division of General Surgery UMTH Maiduguri 25th January, 2021
- 2. Outline • Introduction • Epidemiology • Relevant anatomy • Pathology and Genetic pathway • Clinical features • Investigations • Treatment • Complications • Prognosis • Screening • Summary • References
- 3. Introduction • Cancer of the rectum, defined as a tumour within 15cm from the anal verge, accounts for approximately 30% of all colorectal malignancies. • There were 14440 new cases of rectal cancer registered in the UK in 2008.
- 8. Risk factor • Genetic • Environment low fibre diet/high fat diet previous surgery- ureterosigmoidostomy, RT hemicolectomy Family history Inflammatory bowel disease- 8% at 10yrs obesity Smoking etc.
- 9. Genetic pathway • Loss of heterozygosity (LOH) 80% • Microsatellite instability (MSI) 10-15% • Cp island methylation pathway 0-5%
- 10. Histology • Adenocarcinoma Mucinous signet ring papillary • Carcinoid • GIST • Lymphoma • Sarcoma
- 11. Clinical presentation • Elective • Emergency
- 12. Clinical features- Elective • Tenesmus • Bleeding per rectum • Change in bowel habit • Passage of pellet-like stool • Chronic constipation • Weight loss • +/- per rectal Findings • Bright red stool • Advanced dx rectovaginal fistula pain with defecation anal incontinence Distant metastasis
- 13. Investigations • Proctoscopy + biopsy • Sigmoidoscopy + biopsy about 60% of tumors • Colonoscopy Synchronous tumor, polyps, etc • Barium enema (double contrast) • CT colonography (virtual colonoscopy) • Tumor marker: CEA • Computed Tomography: Chest, Abdomen • Magnetic Resonant Imaging (MRI): Pelvis • PET scan
- 14. Investigations- proctoscopy • Indication confirm tumor allow for biopsy confirm rectal polyps
- 15. Investigations- Sigmoidoscopy • Indications bright red bleeding rectal mass left iliac fossa pain/mass change in bowel habit surveillance for polyps • Clinic procedure
- 16. Investigation- colonoscopy • Indications Dark red blood Rt iliac fossa mass iron def. anaemia change in bowel habit abnormal imaging findings • Detect synchronous tumor- 2-8% • Polyps • Sensitivity- 90-95%
- 17. Investigations- Barium enema (double contrast) • Indications Incomplete colonoscopy absent colonoscopy less invasive procedure in elderly patients • Disadv no biopsy • Sensitivity- 90%
- 18. CT colonography (virtual colonoscopy) • Indications absent colonoscopy less invasive procedure incomplete colonoscopy • Disadv no biopsy • Sensitivity- 90%
- 19. Investigations- loco-regional staging • Endo-luminal/Endo-rectal ultrasound T-staging- 80-95% peri-rectal LN- 70-75%
- 20. Investigations- loco-regional staging • Pelvic MRI- gold standard T staging (75-85%) and depth of invasion peri-rectal LN (90-95%) Circumferential resection margin (CRM)- (90-95%)
- 21. Investigations- loco-regional staging • Circumferential resection margin (CRM) in rectal cancer has been defined as the non-peritonealized surface of a resection specimen created by dissection of the subperitoneal aspect at surgery • Many studies have demonstrated that CRM involvement is able to predict local recurrence and poor prognosis in patients with rectal cancer. 1-5
- 22. Investigations- systemic staging • Computed Tomography (CECT)- 80-90% sensitive Abdomen Chest • Positron Emission Tomography (PET) scan
- 23. Investigations- laboratory • Tumor makers CEA- Carcinoembryonic Antigen • Hematology CBC, ESR • Blood Chemistry EUC, LFT, Urine analysis • Clotting profile: PT, PTTK, INR
- 24. Clinical staging • Dukes (based on histology of resection specimen) • Astler-Coller modification of Dukes • TNM staging
- 25. Clinical staging- TNM • Tumor stage • T0- no evidence of tumor • Tis- carcinoma in situ • T1- submucosa • T2- muscularis propria • T3- serosa or non-peritonealized perirectal tissue • T4- invasion of adjacent tissues • Node N1- 1-3 pericolic LN N2- 4 or more pericolic LN N3- LN along a named vascular trunk • Metastasis Mx- metastasis can’t be assessed M0- no distant metastasis M1- distant metastasis
- 26. Clinical staging STAGE TNM LOCAL RECURRENCE (%) 5YR SURVIVAL (%) I T1-2, N0 <5 93% IIA T3 N0 8 85% IIB T4 N0 15 72% IIIA T1-2, N1 6 83% IIIB T3 N1 8 64% IIIC T3 N2 OR T4 N1-2 11 44% IV any T, any N, M1 19-22 8%
- 27. Treatment of rectal cancer • Surgery- Total Mesorectal Excision (TME) Early disease Primary tumor metastatic dx Late disease • Chemotherapy • Radiotherapy
- 28. Treatment- Surgery • Upper rectum- 12-15cm from anal verge Anterior resection • Middle rectum- 7-11cm from anal verge Low anterior resection using circular staples • Low rectum- 0-6cm from the anal verge Local therapy- TaE, TEM, TAMIS Radical therapy- Abdominoperineal resection (APR)
- 29. Treatment- Surgery • Low rectum- 0-6cm from the anal verge Local therapy: Trans anal Excision Trans anal Endoscopic Microsurgery(TEM) Trans coccygeal excision Trans phincteric excision Radical therapy: Abdominoperineal resection (APR) (Total Mesorectal Resection (TME))
- 30. Trans-anal Excision Indications • T1N0 or T2N0 tumor • <4cm in diameter • <40% of circumference • 3cm from the dentate line • Well to moderately differentiated tumor • No lymphatic or vascular invasion • Advanced dx who required local control
- 31. Trans coccygeal Excision • T1N0 or T2N0 tumor • 4.5-5cm from the dentate like • Popularized by Kraske • Used for both anterior and posteriorly located tumor
- 32. Transanal Endoscopic Microsurgery (TEM/TAMIS) • T1N0 or T2N0 tumor • 6-7cm from the dentate line • Popularized by Gerhard Buess, Germany
- 33. Treatment- Surgery • Upper/middle rectum- sphincter saving procedure TME Anterior resection low anterior resection using staples Local therapy • Lower rectum- non sphincter saving procedure TME Abdominoperineal resection (APR) Miles- abdomen first, perineum later Gabriel- perineum first, abdomen later Lloyd-Davies- synchronized/combined APR
- 35. Treatment- Surgical principles • Pre-op Low residue diet/bowel preparation intravenous urography (IVU)/CT urography ureteric stenting antibiotics prophylaxis PO Neomycin 1g at 1pm, 2pm & 10pm IV Ceftriaxone and Metronidazole DVT prophylaxis- compression stockings, heparin,
- 36. Treatment- Surgical principles • Intra-op assess the abdomen for peritoneal/liver metastasis mobilize the sigmoid from the white line of Toldt high(IMA) or low(Lt colic) ligation of vascular control
- 37. Treatment- Surgical principles • sharp dissection of pelvic peritoneum using scissors or diathermy • no blunt dissection • Preserve the hypogastic plexus and sacral plexus (nerve erigentes)
- 40. Treatment- Surgical principles • Intra-op resection margin Vertical: proximal-5cm, distal-2cm (5cm in poorly diff.) Radial/CRM: 3-5cm of mesorectum excised specimen should be BILOBED shape label proximal and distal segment count the number of lymph nodes (12-15 LN) Close the anal incision primarily or using muscle flap over a perineal drain
- 41. Treatment- Surgical principles • Post-op DVT prophylaxis antibiotics analgesics IVFluid early ambulation • Other therapy Posterior vaginectomy Pelvic exenteration
- 42. Treatment- Surgical principles • Late disease Permanent diversion followed by chemo-radiation Palliative resection + permanent colostomy + chemotherapy Palliative resection + restoration of GI continuity + chemotherapy
- 43. Emergency presentation • 3 stage procedure colostomy, resection and colostomy reversal • 2 stage procedure Hartmann’s operation Mucus fistula
- 44. Treatment: Chemo-radiotherapy timing • Neoadjuvant Chemotherapy radiotherapy • Adjuvant Chemotherapy
- 45. Treatment: Chemo-radiotherapy timing • Chemotherapy 5-FU alone 5-FU + leucovorin (or Levamisole) FOLFOX-4 (12 cycles every 2 weeks) FOLFOX-6 FOLFIRI FOLFIRINOX/ FOLFOXIRIN
- 46. Complications • Anastomotic leak • Damage to pelvic autonomic nerve plexus: Bladder and erectile dysfunction • Surgical Infection • Local recurrence • Systemic recurrence • Colostomy complications
- 47. Complications • Local recurrence Inadequate/incomplete resection avoid sphincter saving procedure where an APR is required in an attempt to be heroic Quality of life may be far better with APR as compared to sphincter-saving procedure with local recurrence • Tumor size • Positive CRM • Distal location of the tumor • Extramural vascular invasion • Tumor differentiation • Nodal status • Extent of extramural spread • Peritoneal tumor spread
- 48. Follow up: NCCN guidelines • Clinic visit every 3 month until 2yrs DRE, CEA and sigmoidoscopy • 1yr- colonoscopy and abdominopelvic CT scan • After 2yrs, see every 6month until 5yrs CEA and DRE • After 5yrs, yearly visit colonoscopy every 3-5yrs
- 49. Screening- sporadic CRC Test Timing Probabality FOBT Annually 30% reduction Sigmoidoscopy 2-3yrs 50-60% FOBT + Sigmoidoscopy 70-80% Colonoscopy Every 10yrs Barium enema Every 5yrs CT colonography (Virtual colonography) 5-10yrs
- 50. Summary • Rectal cancer is any tumor within 15cm from the anal verge and constitute 30% of colorectal tumors • Classical features include Tenesmus, change bowel habit, bleeding per rectum • Pelvic MRI is now the gold standard for loco-regional staging and detection of CRM • Total Mesorectal Excision(TME) is now the treatment of choice to improve Overall Survival(OS) and Disease Free Survival(DFS)
- 51. References 1. Adam IJ, Mohamdee MO, Martin IG, Scott N, Finan PJ, Johnston D, et al. Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet. 1994;344:707–711. [PubMed] [Google Scholar 2. Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Søreide O Norwegian Rectal Cancer Group. Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum. 2004;47:48–58. [PubMed] [Google Scholar] 3. Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet. 1986;2:996– 999. [PubMed] [Google Scholar]
- 52. References 4. de Haas-Kock DF, Baeten CG, Jager JJ, Langendijk JA, Schouten LJ, Volovics A, et al. Prognostic significance of radial margins of clearance in rectal cancer. Br J Surg. 1996;83:781–785. [PubMed] [Google Scholar] 5. Baik SH, Kim NK, Lee YC, Kim H, Lee KY, Sohn SK, et al. Prognostic significance of circumferential resection margin following total mesorectal excision and adjuvant chemoradiotherapy in patients with rectal cancer. Ann Surg Oncol. 2007;14:462–469. [PubMed] [Google Scholar] 6. Charles F. Brunicardi: Schwartz’s principles of Surgery, 10th edition Chapters 29
- 53. References 7. O. James Garden and Simon Peterson-Brown: Colorectal Surgery, a companion to specialist surgical practice, 5th edition, chapter 5 8. Norman, S. W., Christopher J.K.B., and P.Ronan O’ Connell (2008). Bailey and Love principles and practice of Surgery, 25th edition, chapter 61, 63 and 64 9. Michael J Zinner and Stanley W Ashley: Maingot’s abdominal operations, 12th edition. Chapter 40
- 54. THANK YOU