A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer

1. Management of
Rectal Cancer
by : Dr. Subhash Thakur
JR-RT, 2nd year
Date : 30/05/2018
PGIMER, Chandigarh

2. Introduction
How are rectal cancer different from colon cancer?
Upper Third : anteriorly and
laterally : peritoneal lining But
Posteriorly it is retroperitoneal
without serosal covering
At Rectovesical Pouch rectum
becomes completely
retroperitoneal.
Lack of peritoneal covering for
most of the rectum is a major
cause for higher risk of local
failure after primary surgical
management than for colon
cancer

3. Rectal cancer
Symptoms and signs

4. Examination
Digital Rectal Examination :
Assessed for size, ulceration
and fixation to surrounding
structures
Assess sphincter function

5. Investigations
•For diagnosis
•Proctosignoidoscopy and
•Biopsy from the lesion
•For staging
•EUS
•CT of abdomen
•CT of thorax
•MRI

6. Investigations for staging
•Local Information
•Tumor location
•Depth of invasion
•LN positivity
•Proximity to neighbouring structures
•Integrity of mesorectal envelope
•Lateral margin
•Local peritoneal involvement by tumor and
•Venous invasion
•Metastatic Work up :

7. clinical staging, 80-95% accurate in
tumor staging, 70-75% accurate in
mesorectal lymph node staging
Very good at
Demonstrating layers of rectal
wall
Determining extension of
disease into anal canal : clinical
importance for planning
sphincter preserving surgery
Limitations :
Useful only for lesions < 14 cm
from anus
Not applicable for upper rectum
Figure. Endorectal
ultrasound of a T3 tumor of
the rectum,
through the
extension
muscularis
propria, and into perirectal
fat.
Transrectal Ultrasound

8. CT scan
Part of routine workup of patients
Useful in identifying enlarged pelvic lymph-nodes and
metastasis outside the pelvis than the extent or stage
of primary tumor
Limited utility in small primary cancer
Sensitivity 50-80%
Specificity 30-80%
Ability to detect pelvic and para-aortic lymph
nodes is higher than peri-rectal lymph nodes.

9. Figure: Mucinous adenocarcinoma of the
rectum. CT scan shows a large
heterogeneous mass (M) with areas of
cystic components. Note marked luminal
narrowing of the rectum (arrow).
Rectal cancer with uterineFigure:
invasion. CT
heterogeneous
scan shows a
rectal mass (M)
large
with
compression and direct invasion into the
posterior wall of the uterus (U).

10. Magnetic Resonance Imaging (MRI)
Greater accuracy in
defining extent of rectal
cancer
Also helpful in lateral
extension of disease,
critical in predicting
circumferential margin for
surgical excision.

11. Staging
Why ???
Critical information concerning the extent of the disease
Used to
•determine prognosis
•To guide management and
•To assess response to therapy

12. Evolution of Rectal Cancer Staging
Long Evolution
1926 : Lockhart – Mummery
1932 : Dukes
1949 : Kirklin, Dockerty and Waugh proposed modification
of Dukes classification
1954 : Astler and coller : Modified Astler Coller
classification (MAC)
1963 : Turnbell modification
1987 : AJCC and IUCC : TNM staging updated in 2002 and
2009 and 2018

13. 1926, Lockhart – Mummery
•Depth of invasion and
•LN positivity in
specimens removed at
surgery
1932, Dukes
•Rectal cancer begins as
epithelial proliferation
raising from the surface
•carcinoma develops
from a previous adenoma
•Cancer metastasize
through the bowel wall to
lymphatics

14. 1949, Kirklin, Dockerty and Waugh modification of
Dukes staging
Preserved A, B and C frameworks and added
subscript 1 & 2 to B
B1 : lesions that have extended into but not
through the muscularis propria
B2 : tumors that have penetrated the muscularis
propria

15. 1954, Astler and Coller
Modified Astler Coller Classification

16. 1963, Turnbell et al added stage D
St D : tumors metastasized to lung, liver, bone and
adjacent structures
1987 : AJCC & IUCC : TNM staging

20. Stage Grouping

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

22. Treatment
1. Surgery
2. Chemotherapy
3. Radiotherapy

23. Surgery remains the
mainstay of curative
treatment for carcinoma
of the rectum
Surgical management
depends on the stage and
location of a tumor within
the rectum.

24. GOAL
The general principles of a surgical approach
remain the removal of all gross and microscopic
disease with negative proximal, distal, and
circumferential margins
reserve intestinal continuity and the sphincter
mechanism whenever possible while still
maximizing tumor control

25. For Early cancers : limited surgeries like
 Polypectomy
 Transanal excision
 Transanal endoscopic microsurgery (TEM)
For Advanced Cancers :
Low anterior resection (LAR) or
abdominoperineal resection (APR).
Different Surgical Options

26. Transanal Excision
When it can be done ?
selected T1, N0 early-stage cancers.
Small (<3 cm)
well to moderately differentiated tumors
within 8 cm of the anal verge
limited to less than 30% of the rectal
circumference
no evidence of nodal involvement

27. Structures Removed
Full thickness excision of involved rectum
perpendicularly through the bowel wall into
the perirectal fat.
Advantages
Minimal morbidity
Sphincter sparing
Rapid post operative recovery
Limitations
Absence of pathologic staging of nodal
involvement

28. Abdominoperineal Resection (APR)
The gold standard for surgical resection of distal rectal
cancer located within 6cm of the anal verge.
This procedure requires a tranabdominal as well as a
transperineal approach with removal of the entire rectum
and sphincter complex.
A permanent end colostomy is created and the
perineal wound either closed primarily or left to
granulate in after closure of the musculature

29. Limitations
slightly higher morbidity and mortality than LAR
Permanent Colostomy bag : worst quality of life
Higher risk of positive margins with APR as the
mesorectum is very thin in the distal segment of the
rectum

30. Low Anterior Resection
Now being performed not just for cancers of the upper
third of the rectum but also for middle and lower third
cancers
Preserving adequate anorectal function becomes a
bigger problem the more distal the level of anorectal
anastomosis

31. Patient Selection For LAR
Good anal sphincter continence prior to
considering sphincter-preserving options
A 2-cm distal margin of preserved normal
In carefully selected patients a functional coloanal
anastomosis can be achieved with significantly
reduced margins for more distal cancers especially
after neoadjuvant therapy.

33. Total Mesorectal Resection
Mesorectum : the structure that contains the blood
supply and lymphatics for the upper, middle, and
lower rectum.
Most involved lymph nodes for rectal cancers are
found within the mesorectum
T Stage % of Positive LN
T1 5-7 %
T2 20%
T3 65%
T4 78%

34. Bill Heald from
Basingstoke,
England, 1982, first
began to write about
his technique of TME
He recognized that
most local recurrences
seen after rectal cancer
resection were a result
of inadequate
resections performed
using imprecise, blunt
dissection.

35. en bloc removal of the mesorectum, including
associated vascular and lymphatic structures
Structures Removed

36. Laparoscopic Resection
Advantages
less blood loss
shorter hospital stays
quicker return of bowel function
Limitations
larger operation times
No difference in completeness of resection, percentage
of patients with positive CRM

37. Adjuvant Therapy
Why ???
Results
Incidence of local failure was strongly dependant on
pathological stage
duke A : 8 %
duke B : 31 %
duke C : 50 %

38. Pattern of local failure for tumors without lymph node
metastasis = 17 % but increased to 54 % in tumors that
were adherent to or invading adjacent organ and
structures
Five year survival for
Duke A : 77 %
Duke B : 44 %
Duke C : 23 %

39. Adjuvant treatment
Only Radiotherapy
Radiotherapy + Chemotherapy

40. Radiotherapy Alone
•Several trials have shown local benefit with RT alone with
acceptable toxicity
•NSABP R01 trial
randomized 555 patients with Duke B and C to 3 arms
1. observation
2. chemo (MOF)
3. RT : 46 to 47 Gy in 26 to 27 #
•Results
•RT arm : reduction in local failure from 25% to 16% but no
difference in overall survival (OS) and Disease free survival
(DFS)
•Chemo arm showed no improvement in local failure but
significant improvement in DFS and OS

41. MRC Trial
469 Post-curative surgery patients with Duke St B & C
Randomized into two arms :
Observation Vs RT @ 40 Gy/20#/4 weeks
Results
Local failure : 34 % 21 %
5 year survival : 41% 39%

42. NSABP and MRC trials
RT improved local control without improvement in overall
survival (OS)
??? Addition of Chemotherapy ??
RT + Chemotherapy ????

43. Gastrointestinal Tumor Study
Group (GITSG ) 7175 trial :
227 post-op patients with Duke stage B and C
Randomized into 4 arms
 Observation
 RT (40-48 Gy in 4/5 weeks)
 Chemo ( 5 FU/Semustine)
 RT + Chemo
Results
•combination treatment significantly reduced recurrence
rate and also prolonged time to recurrence
•Significant improvement in DFS (70% Vs 46%) and OS
(58% Vs 45%) in combination arm as compared to
surgery alone arm.

44. Mayo Clinic Trial
204 post-op patients stage T3, T4 or N1/N2
Randomized into two Arms
1. RT @ 45 to 50 Gy/5 weeks
2. RT + Chemo
Results
F/U of 7 years, overall recurrence reduced by 34% with
RT + Chemo and local recurrence reduced by 46 %
Distant metastasis reduced by 37 % and 29% reduction
in deaths
Toxicities : diarrhoea and dermatitis

45. Now, Proven clinical success of adj
Chemoradiation
Aim : improving the post-op
chemotherapy to further impact
overall survival

46. NCCTG Trial
Infusional 5 FU Vs Bolus 5 FU, further randomized into
bolus 5 FU + Semustine
Results :
F/U 46 months, 4 year OS significantly improved with
continuous infusion of 5 FU (70% Vs 60%)
Continuous infusion of 5 FU with conc. RT also reduced
the risk of distant metastasis (40% to 31%)
Addition of semustine to 5 FU had no beneficial efffect
on patient outcome

47. Neoadjuvant Vs Adjuvant Treatment
Timing of conc. Chemotherapy and RT in management
of rectal cancer -------- Controversial
Rationale for adjuvant treatment :
Accurate depth of tumor and LN status can be assessed
accurately  Stage I tumors can be spared from adj. Rx

48. Rationale for using neoadjuvant
treatment :
Major benefit : increased rate of sphincter
preservation
Reduction in toxicity as after LAR or APR small bowel
falls into pelvis and hence they come into radiation
portals
By neoadjuvant Rx, irradiating bowels are later
removed during surgery and hence no risk of long term
toxicity eg. Perforation
From radiobiological perspective, tumor is well
oxygenated during neoadjuvant setting while blood flow
to tumor bed is compromised post surgery, hence low
sensitivity to RT

49. Trial : Neoadjuvant Vs Adjuvant
Sauer et al, 2004
823 patients, T3, T4 or N+
Two arms
1. Pre-op CRT
2. Post-Op CRT
Neoadj. Arm : 50.4 Gy, 1.8 Gy/# +
continuous infusion of 5 FU over
120 hrs during 1st and 5th week of
RT
6 weeks
surgery
1 month
4 five day cycle of 5 FU
@500mg/m2/day
Adj Arm : same with additional
boost of 540 cGy to tumor bed

50. Results
Neoadjuvant Adjuvant
OS at 5 yrs 76% 74%
5 yr local rec. 6% 13%
Rate of sphincter
preserving Sx 39% 20%
Toxicity Lower higher
Although no survival benefit has been seen ability to
improve local control and increase the ability to spare the
sphincter shifted the management side to neoadjuvant

51. SHORT COURSE VS LONG
COURSE RT
Two phase III trials
Polish trial : to determine whether long term
course increase chance of sphincter
preservation
TROG trial : compare local recurrence rates
between two approach
Schedule followed : 25 Gy/5# VS 50.4 Gy using
1.8 to 2 Gy fractions with concomitant bolus 5-
FU and leucovorin given during weeks 1 and 5
Results : No significant difference in local control,
overall survival, sphincter preservation with slight higher
incidence of acute toxicity in long CRT arm

52. RADIOTHERAPY

53. INDICATIONS
T3/T4 lesion
Node positive disease
Inoperable disease
Palliation of symptoms

54. TARGET VOLUME
The presacral space
The primary tumor site, and the perineum (for
post- APR cases)
The mesorectal and lateral lymph nodes and internal
illiac are included in all patients
The external iliac nodes should be covered for T4
lesions.

55. The inguinal lymph nodes may be included
if tumour invades the lower third of the vagina
if there is major tumour extension into the
internal and external anal sphincter

56. RADIATION TECHNIQUES
2D Conventional RT
3D Conformal RT
IMRT

57. Belly board

58. Fields

59. Conventional Field borders
Superior Border : L5-S1 junction
Inferior Border : 3 cm below the primary tumor or at the
inferior aspect of the obturator foramen whichever is most
inferior
Lateral Border : 1.5 cm lateral to widest bony margin of true
pelvic side walls
Anterior Border :
T3 disease : posterior margin of symphysis pubis : to
treat only the internal iliac nodes
T4 disease : anterior margin of symphysis pubis : to
include external iliac nodes
Posterior Borders : 1 to 1.5 cm behind the anterior bony
sacral margin

60. Boost field:
A : Treat the primary
tumor bed plus a 3-cm
margin (not the nodes).

61. Fig B: For a T4N1M0 rectal
cancer 8 cm from the anal
verge. Since the tumor was a
T4, the anterior field is at the
anterior margin of the
symphysis pubis (to include
the external iliac nodes).
Fig A: Treatment fields after a low anterior
resection for a T3N1M0 rectal cancer 8 cm
from the anal verge. The distal border is at
the bottom of the obturator foramen and the
perineum is blocked. Since the tumor was a
T3, the anterior field is at the posterior
margin of the symphysis pubis (to treat only
the internal iliac nodes).
Fig C: Treatment fields following an
abdominoperineal resection for a T4N1M0
rectal cancer 2 cm from the anal verge,
because the tumor was a T4, the anterior
field is at the anterior margin of the
symphysis pubis (to include the external
iliac nodes). Since the distal border is
being extended only to include the scar
and external iliac nodes, the remaining
normal tissues can be blocked

62. Isodose curves for 3 field

63. Isodose curves for 4 field

64. 3D CONFORMAL RT

65. CT based Planning
To ensure adequate coverage of the tumor and
regional nodes
Improved dose homogeneity
Planning CT :
Prone Position using Belly board
Mid abdomen L1 to mid thigh
IV, rectal and bowel contrast given
Fusion of planning CT with MRI/PET may be
done for better target delineation
3D CONFORMAL RT

66. Prone Position
Advantages :
Allows access for DRE and allows verification of lower and
middle rectal lesion location in relation to anal verge, while
maintaining the treatment position
Anal verge can be marked with a radiopaque maarker and rectal
contrast to assist radiographic identification of primary lesion
Belly board
Advantages : significant reduction of small bowel in treatment portal
Perineal Scar after APR
Patients who have undergone APR must have the perineal scar
marked and included in the initial pelvic fielsds
Perineal recurrence : 8-30% of patients in absence of adjuvant RT
but as low as 2% when scar is adequately treated.

67. The GTV includes all gross tumour seen on the
planning CT scan with reference to information
from diagnostic endoscopy, MRI and DRE
Any involved lymph nodes, extrarectal extension, or
extranodal deposits seen on MRI should be included
CTV should include peri-rectal, pre-sacral,
internal iliac regions

68. RTOG GUIDELINES
The caudad extent of this elective target volume
should be a minimum of 2 cm caudad to gross
disease, including coverage of the entire
mesorectum to the pelvic floor
The posterior and lateral margins of CTV should
extend to lateral pelvic sidewall musculature or,
where absent, the bone
Anteriorly, the group recommended extending 1 cm
into the posterior bladder, to account for day to day
variation in bladder position.

69. The recommended superior extent of the peri-
rectal component
the rectosigmoid junction or 2 cm proximal to the
superior extent of macroscopic disease in the
rectum/peri-rectal nodes.
To include illiac vessels it should be kept at L5-S1
junction

70. Margin around blood vessels: The group
recommended a 7 mm margin in soft tissue
around the external iliac vessels
but one should consider a larger 10+ mm
margin anterolaterally if nodes are identified
in this area

71. BOOST VOLUME
The group recommend that any boost clinical
target volumes extend to entire mesorectum and
presacral region at involved levels
including ~2 cm cephalad and caudad in the
mesorectum and ~2 cm on gross tumor within the
anorectum.
PTV margin should be ~0.7 to 1.0 cm, except at
skin

76. Techniques to Decrease Radiation
Toxicity in Small Bowel
High-energy (>6 MV) linear accelerators.
Treatment 5 days per week and all fields each
day.
Pelvic field: multiple-field technique (posterior-
anterior plus laterals or posterior-anterior-anterior-
posterior plus laterals) is recommended.

77. Boost field: opposed laterals.
Computerized dosimetry optimizing between
minimizing the lateral hot spots and small bowel
dose and increasing the homogeneity within the
target volume
In thin patients, a combination of 6 MV for the
posterior fields and higher-energy photons for the
lateral fields may result in more homogeneous
dosimetry.
Shaped blocks and, if needed, wedges on the
lateral fields.

78. Intensity-Modulated Radiation
Therapy
Potential to reduce toxicity
No set standards regarding its use
Different IMRT volume–based dose constraints
have been proposed for bowel and bladder, but
there is no set consensus.
IMRT-based sparing of the iliac crests may also
reduce bone marrow toxicity

79. Currently, IMRT is not recommended for routine
use.
IMRT can be used in re irradiation for recurrence

80. Endocavitary radiation therapy.
Indications
T1 or T2 tumors less than 3 cm
not poorly differentiated
with no evidence of nodal involvement.
Patients are treated with a low energy x- ray machine (50 kV)
that is attached to a rigid endoscopic-type device that can
be placed in the rectum directly over the tumor.
As the opening of the applicator is 3 cm, it isdifficult to
treat tumors larger than this.

81. Patients typically receive four treatments of 2,500 to 3,000 cGy each
with 2 to 3 weeks between treatments to allow for tumor regression.
Although the total dose is extremely high, the minimal penetration
of the radiation beam protects the underlying normal tissue.
Local control results with this approach have been very
good in properly selected patients
but specialized equipment is required (which is not generally
available)
less pathological information is obtained than after a local excision.
This approach is rarely used at the present time

82. Dose
Preoperative radiotherapy
Short course: 25 Gy in 5 daily fractions of 5 Gy given in 1
week.
Long course
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks.
Phase 2
5.4 in 3 daily fractions of 1.8 Gy
Postoperative radiotherapy
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks.
Phase 2
5.4–9 Gy in 3–5 daily fractions of 1.8 Gy.

83. Adverse effects
Acute complications
diarrhea and increased bowel frequency (small
bowel)
acute proctitis (large bowel)
thrombocytopenia, leukopenia, and dysuria are
common during treatment.
These conditions are usually transient and
resolve within a few weeks following the
completion of radiation.

84. In the small bowel, loss of the mucosal cells results
in malabsorption of various substances, including fat,
carbohydrate, protein, and bile salts.
The bowel mucosa usually recovers completely in1 to
3 months following radiation.
Management usually involves the use of
antispasmodic and anticholinergic medications.

85. Delayed complications
occur less frequently, but are more serious.
The initial symptoms commonly occur 6 to 18 months
following completion of radiation.
persistent diarrhea and increased bowel frequency
proctitis, small bowel obstruction (SBO) not requiring
surgery,
perineal and scrotal tenderness

86. delayed perineal wound healing
urinary incontinence
bladder atrophy and bleeding.