2. POINTS TO BE DISCUSSED
Clinical anatomy of colon and rectum
Definition of colorectal ca
Epidemiology of colorectal ca
Risk factor and etiopathogenesis
Screening
Pathology and staging
Clinical presentation
Investigations
Treatment
Follow up
3. Clinical anatomy
Colon and rectum approx length 150 cm
Dovelopement occurs from midgut,hindgut and proctodium
Caecum -7.5 cm diameter and 10 cm in length
Ascending colon apporx 15 cm in length, posterior surface
retroperitonium while anteriolateral surface are
intraperitoneal .white line of told represents fusion of
mesentry with posterior peritoneum.
Transverse colon approx 45 cm in length
Descending colon approx 25 cm in length
Sigmoid colon 15 to 50 cm ( average 38 cm )
Haustration, epiploic appendices,taenia present in colon
while absent in rectum
4. rectum
• 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
5. • Divided into 3 parts
Lower rectum : 3 – 6 cm
from the anal verge
Mid rectum: 6 cm to 8
-10cm
from anal verge
Upper rectum: 8 cm to
12 -15cm from anal verge
• 3 distinct intraluminal
curves ( Valves of
Houston)
6. 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
11. Lymphatic drainage
Upper and middle rectum
Pararectal lymph nodes, located
directly on the muscle 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
12. Definition
Colorectal Cancer is the cancer affecting caecum,
colon and rectum
Anal canal and Appendix are not considered in the
definition, and are treated as a separate entities
13. Epidemiology
Colorectal caner is the third most common malignancy
worldwide ( after lung, prostste in males –lung ,breast in females
Worldwide approx. 1 million new cases p.a. are diagnosed, with
529,000 deaths.
Incidence rate in India is quite low about 2 to 8 per 100,000
More than 90% cases diagnosed after 50 yrs of age.
15. Others
Smoking
Alcohol consumption
Calcium and microneutrients
Asprin and cox-2 inhibitors
Cholecystectomy and bile salts
Personal and family history ( synchronous lesions in
5-10% and metachronous 10-20%
16. Screening for colorectal cancer
Asymtomatic average risk people-start at the age of
50 yrs and end at 75 yrs with- FOBT yearly (6 samples ) if
positive results then full colonoscopic evaluation
Baseline colonoscopy and if no pathology then repeat every
10 yearly
Every 5 yr flexible sigmoidoscopy or barium enema
If precursor lesion are found ,they should be removed and
colonoscopy performed after 1-3 years
In high risk people (peraonal or family history of
polyp/familial cancer /african american ethnicity) screening
should be started early
FAP 10-15yr of age anually
HNPCC at 20 Yrs every 2 yr and anually after 40 yrs or 10-15
yrs before cancer onset in youngest family member
19. Adenoma to Carcinoma Pathway
APC
loss
Normal
Epithelium
Early
Adenoma
Cancer
Hyper-
proliferation
Intermediate
Adenoma
Late
Adenoma
K-ras
mutation
Chrom 18
loss
p53
loss
AdenomaNormal Cancer
20. Non hereditary colon cancer
1-sporadic –no family history ,older age of onset ( 60
to 80 years),isolated colon and rectal lesion
2 familial-lifetime risk of colorectal cancer increases
for members in families in which index case is young
<50 yrs and the relative is first degree.
21. Hereditary colon cancer
FAP (familial adenosis polyposis )-mutation in
APC gene on chromosome 5 (1% of total colorectal
cases)
More then 100 polyps throughout GI tract.
100% chances of malignant transformation.
Age of onset is late 2nd
decade or early 3rd
decade .
Patient die by fifth decade of life in the absence of
surgical intervention
Gardener syndrome ( adenomatous polyp, osteoma,
desmoid tumer, periampullary ca, medulloblastoma,
CHRPE, thyroid papillary ca, hypertrophicfundic
gastric polyp)
PEUTZ JEGHAR syndrome
25. cuthbert Dukes staging (originally for ca rectum )
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 ( In modified duke )
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
26. 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
29. Pathology (microscopic )
WHO Classification (microscopic )
Adenocarcinoma in situ/Severe dysplasia
Adenocarcinoma
Mucinous (colloid) adenocarcinoma (>50% mucinous)
Signet ring cell carcinoma (>50% signet ring cells)
Squamous cell (epidermoid) carcinoma
Adenosquamous carcinoma
Small-cell (oat cell) carcinoma
Medullary carcinoma
Undifferentiated Carcinoma
30. TYPES OF SPREAD
Lymphatic spread –COLON Ca-epicolic/paracolic/principle LN
IN RECTAL CA- Above the peritoneal reflection occurs almost exclusively in an upward direction;
Below that level, the lymphatic spread is still upwards,
but when the neoplasm lies within the field of the middle rectal artery, primary lateral spread along
the
lymphatics .
Downward spread is exceptional, to the lymph nodes draining the perianal rosette and the epithelium
lining the distal 1–2cm of the anal canal.
A radical operation should ensure that the high-lying lymph nodes are removed by ligating the
inferior mesenteric artery at a high level.
Local spread –colan ca can occur longitudinal/transverse /radial- involvement of
ureter/duodenum/post abdominal wall /small intestine/pelvic organs occurs
IN RECTAL CA Local spread occurs circumferentially .
A period of 6 months is required for involvement of a quarter of the circumference, and 18 months to 2
years for complete encirclement.
After the muscular coat has been penetrated, the growth spreads into the surrounding mesorectum, but
is initially limited by the meso- rectal fascia.
Anteriorly, in male the prostate, seminal vesicles or bladder
female, the vagina or the uterus is invaded.
Lateral, a ureter may become involved.
Posterior penetration may reach the sacrum and the sacral plexus.
Downward spread is >4 cm is rare
31. TYPES OF SPREAD
Hematogenous spread –
Principal sites are liver (34%), lungs (22%) ,ovary ,brain ,kidney , adrenals .
• Peritoneal dissemination –
spread by way of cells dislodging from serosa of the bowel or via
subperitoneal lymphatics
32. Clinical presentation of colorectal cancer
Symptoms –in right sided ca symptoms are often
absent untill tumor has grown to a significant size,
only vague symptoms like unexplained weight
loss,anaemia and weakness from chronic blood
loss,melana,episodes of colicky abdominal pain,
because of liquid/semisolid nature of stool in right
colon tumer grow very large size before causing
obstruction.
Left side tumor ( colon/rectum) presentation –
changes in bowel habbit,rectal bleeding,mucous
discharge,tenesmus,decreasing diameter of stool
,pelvic pain due to nerve or sphinctor
invasion,features of large bowel obstruction,passing
of faeces/flatus other than anal opening/wt loss
34. Signs
Pallor,cachexia,dehydration
Abdominal mass
PR mass
Jaundice
Lymph node enlargement ( like left supraclavicular-
troisier sign)
Nodular enlarged liver
Features of obstruction/peritonitis
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.
35. Diagnostic Workup
History— including family history of colorectal cancer or polyps
Physical examinations
Abdominal examination -Abdominal examination is normal in early cases.
Occasionally, annular tumour at the rectosigmoid junction, signs of obstruction of the large intestine .
Metastases in the liver may be palpable.
When the peritoneum has become studded with sec- ondary deposits, ascites results.
Digital rectal examination (DRE) and complete pelvic examination in women: size, location, ulceration,
mobile vs. Fixed to surrounding structures(prostate/vagina/sphinctor), distance from anal verge
Proctoscopy— including assessment of mobility, minimum diameter of the lumen, and distance from
the anal verge
flexible sigmoidoscopy-60 cm ,possible to assess bowel up to splenic flexure
Colonoscopy – To exclude a synchronous tumour ( 3-5%%), be it an adenoma or a
carcinoma.If a prox- imal adenoma snared and removed via the colonoscope for biopsy
If a synchronous carcinoma is present, the operative strategy will need changing.
If a full colonoscopy is not possible due to obstruction, a CT colonography( virtual colonoscopy) or
barium enema can be
performed.
In stenosing carcinoma it may not be possible to visualise the proximal colon.
However, in view of the high incidence of synchronous tumours, it is imperative that a colonoscopy is always
performed either before or within a 6 months of surgical resection.
37. Figure: Carcinoma of the rectum. Double-
contrast barium enema shows a long
segment of concentric luminal narrowing
(arrows) along the rectum with minimal
irregularity of the mucosal surface.
Barium enema
40. Routine pre-op work up
Complete blood count
Renal function test/liver function test
ECG
CXR
Stool for occult blood(minimum 6 samples needed to
say negative and at least 10 ml blood /day should be
there in stool for positive results)
Serum CEA level ( for prognostic purpose )
41. EVALUATION OF LOCAL TUMER EXTENT AND
METASTATIC DISSEMINATION
CECT abdomen and pelvic (to see status of lymph
node /fat planes/metastasis /ascitis)
CXR if positive findings then CECT Chest
MRI (for local lymph node in ca rectum/ for stenotic
lesion where even DRE is also not possible )
TRUS( for t stage in ca rectum accuracy 80-95% /LN
detection if size more than 5 mm,not useful when
tumer > 14 cm from anal verge or stenoting tumer)
PET scan( indicated in recurrence/high serum CEA
which is not explained by CECT/MRI )
42. AIMS OF TREATMENT
Local control
Long-term survival
Restoration of bowel continuity and Preservation of anal
sphincter.
Bladder and sexual function and maintenance or
improvement in quality of life.
44. pre-op preparation before surgery
1-The bowel is prepared by mechanical cleansing using a combina- tion of diet,
purgatives and enemas -NICHOLS preparation ( Contravesial acc.to ERAS protocol )
2- Prophylactic systemic antibiotics peroperatively. (cefazolin 1000 mg plus
metronidazole 500 mg given on induction of anaesthesia or within 1 hour of surgery
,dose repeated after 4 hore or if bleeding is more)
3-If a patient comes to surgery with a loaded colon, on-table intraoperative irrigation
can be performed.
4-Counselling for :-stoma care nurse preoperatively and be sited for a temporary or
permanent ileostomy or colostomy.
complications of the pro- cedure, and particularly about the risks of
pelvic autonomic nerve damage causing bladder and sexual
disturbance, especially impo- tence.
5-Blood and electrolyte deficiencies are corrected.
6-An indwelling catheter is inserted into the bladder /RT should be inserted
7-Deep vein thrombosis prophylaxis ( 5000 iu heparin sc )
8-Cross-matching of blood.
9 According to ERAS protocol patient can take clear fluid till 2 hour before surgery.
47. Emergency surgery
1 -Tumor obstruction-if proximal obstruction RA like
RH ,ERH hould be performed.
If tumor on left side,stool load proximal to obstruction is
of concern for healing of distal anastomosis and
synchronous lesion can be missed.
So staged procedure ( like hartman ) or colonoscopic
placement of self expanding stents to convert it to a
elective procedure is done
2-perforation-results in tumer spillage and treated as
staged 4
3-massive colonic bleeding-surgry if repeated
transfusion
48. Management of advance disease
Locally advanced disease-en block resection should
be done
Operable metastasis-chemotherapy and surgical
metastasectomy, in case of resectable metastasis
resection of colonic primary tumer should be done in
oncological fashion ( at present only C/I in case of
metastasis is unable to remove all disease –EKEBERG
criteria )
Inoperable disease-palliative Rx
49. Principles of surgery for ca rectum
1-Radical excision of the rectum, together with the mesorectum and associated
lymph nodes, should be the aim. Even in the presence of widespread
metastases, a rectal excision is best means of palliation. (Even in the presence
of liver metastases).
2- Locally advanced tumour(i.e. invading a neighbouring structure or
threatening to breach the circumferential resection margin), preoperative
chemoradiotherapy may reduce its size and make curative surgery possible.
3-Patients unfit for radical surgery or who have widespread metastases, a local
procedure such as transanal excision, laser destruction or interstitial radiation
should be considered.
4-The aim should be to restore gastrointestinal continuity and continence by
preserving the anal sphincter. A sphincter-saving operation (anterior
resection) is usually possible for tumours whose lower margin is two or more
centimetres above the anal canal.
51. TYPES OF SURGERY
Local excision- reserved for superficially invasive (T1) tumors with low
likelihood of LN metastases
Tumors less than 4 cm in diameter
Tumors within 6 cm of anal verge(below peritoneal reflection)
Encompass less than 40% of circumference of bowel wall,
T1 or T2 tumor
well or moderately well differentiated histology,
No pathological evidence of venous or lymphatic vessel invasion on biopsy
Should be considered a total biopsy, with further treatment based on
pathology
With unfavorable pathology patient should undergo total mesorectal excision
with or without sphincter-preservation:
positive margin (or <2 mm), lymphovascular invasion,
poorly differentiated tumors, T2 lesion
Drawback- do not allow full histopathological staging or
deal with the mesorectal or lymphatic spread of the tumour
52. LOCAL EXCISION TECHNIQUES
Transanal Excision.
TEM
Endoscopic snare polypectomy
Fulguration
Endoscopic laser
Staging of such lesions should be performed using EUS to minimize
likelihood of doing a local excision for T3 tumors.
53. - for tumors in upper/mid rectum; allows preservation of anal
sphincter
If there is concern about integrity of anastomosis,temporary
proximal colostomy can be done,which can be closed after 10
weeks
To improve bowel function(frequency) a J-pouch or coloplasty
can be done
If it is done below peritoneal reflection it is called LOW Anterior
Resection ( minimum 5 cm proximal and distal margin required
but with chemoradiation distal margin of 2 cm enough (ULTRA
low anterior resection ) circumferential margin of 2 mm
required.
Principle of TME should be applied to mid and low rectal cancer
Anterior Resection
61. 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)
Dissection in appropriate anatomic planes is essential because dissection medial to
the endopelvic fascia investing the mesorec-tum may doom the patient to local
recurrence of the disease, and dissection laterally to the avascular anatomic
risks injury to the mixed autonomic nerves, causing impotence in men and bladder
dysfunction in men and women.
67. Abdominoperineal resection for tumors of distal rectum with distal edge up to 6 cm from anal verge
associated with permanent colostomy and high incidence of sexual and genitourinary
dysfunction
Chances of recurrence APR>AR
Previously was done in Trendelenberg lithotomy position.
Recently ,Abdominal procedure is done in Lloyd davies position & then
the patient prone
Types:-a)MILES-abdomen first,perineum later.
b)GABRIEL-perineim first,abdomen later
c)Lloyd –Davies-synchronised(togehther),(combined)
71. En block removal with rectum
Posterior vaginectomy
Prostatectomy
Pelvic exenteration
In post op period patient will not be allowed to sit for
5 days
72. Post op Complication of surgery
Early (within 1 month ) Late (after 1 month)
Common to all major GI
surgeries (pain/bleeding
/infection/wound
sepsis/atelectasis/pneumonia
/DVT/MI
Anastomosis leak
Specific complications(low
ant,resection syndrome or
clustering)
Bladder dysfunction
Perineal wound infection
Early complication of stoma
Impotence
Faecal fistua
Recurrence
Delayed complication of
stoma
73. LOCAL RECURRENCE
Local recurrence is a major problem.
Eighty per cent of all local recurrences develop within 2 years following surgery,
The most common cause is inadequate removal of all the tumour (due to the
presence of microscopic tumour deposits in the tissues surrounding the rectum.)
Other causes include implantation of viable cells on the suture line and the
development of a new primary tumour.
SIGNS & SYMPTOMS –
Persistent pelvic pain, which radiates down the legs (if the sacral roots are
involved.) Bladder problems may occur.
If recurrence develops after abdominoperineal excision, a swelling or induration
may be present in the perineum,or an abscess or discharging sinus may develop.
Occasionally, bilateral leg oedema caused by pressure or invasion of lymphatics or
veins.
After sphincter-saving resection, may produce a change in bowel habit or the
passage of blood per rectum.
74. Sigmoidoscopic examination may reveal friable tissue at the
anastomosis which, when biopsied, confirms the diagnosis.
However, the recurrence is usually situated extrarectally, and is
detected either as induration on digital examination or by
endoluminal ultrasonography, CT or MRI.
The mainstay of therapy for local recurrence is radiotherapy, which is
invariably palliative. Surgery is occasionally indicated and will usually
involve hysterectomy, bladder resection and even partial sacrectomy.
75. LAPAROSCOPIC SURGERY
ADVANTAGES:-
1-More precise anatomical TME dissection
As is under direct vision with better illumination & magnified vision.
2-Reduced trauma to the oncologic specimen with less inadverent
compromise of specimen quality
3- Early recovery ofbowel function,reduced blood loss,less post-
operativepain & decreased hospital stay
with adequate tumour& lymph node clearance
PATIENT SELECTION:-
Would be challenging in patients with significant comorbidities,high
BMI,locally advanced cancers orwho have undergone preoperative long
course downstaging chemoradiotherapy.
77. CONVERSION TO OPEN SURGERY:-
Due to :-a)Technical difficulties secondary to tumour fixity.
b)Dense adhesion.
c)Inadequate visualisation due to obesity
d)uncertainities regarding oncological completeness
e)hemorrhage.
78. ROBOTIC SURGERY
ADVANTAGE:-a)Tri-dimensional imaging & instruments with seven degree of
freedom without hand tremors.
b)Decreased conversion rates in TME in narrow pelvis.
c)Better identification of hypogastric plexus,dissection of
inferior mesentric vessels & mobilisation of splenic flexure.
DISADVANTAGES:-cost,conversion,standardisation of technique & training.
80. Purpose of Radio(chemo)therapy in Rectal Cancer
• To lower local failure rates and improve survival in
resectable cancers
• to allow surgery in primarly inoperable cancers
• to facilitate a sphincter-preserving procedure
• to cure patients without surgery: very small cancer or
very high surgical risk
81. ADVANTAGES OF PRE OP CT+RT
• Down staging, hence increased resectability
• Decreased risk of dissemination during surgery.
• Radiation more effective with tumour cells highly
vascular.
• Less serious bowel toxicity due to easy exclusion.
• Possibility of increasing sphincter preservation in
borderline cases.
• Small bowel not exposed to radiation (in ca rectum)
82. 5Fu
Leucovorin
Oxaliplatin
Irinotecan
Bevacizumab
cetuximab
Combinations
FOLFOX : leucovorin, 5-FU, and
oxaliplatin
FOLFIRI leucovorin, 5-FU, and irinotecan
Leucovorin/5FU
• CapeOX: capecitabine and oxaliplatin
• Any of the above combinations, plus
either bevacizumab or cetuximab (but
not both)
• 5-FU and leucovorin, with or without
bevacizumab
• Capecitabine, with or without
bevacizumab
• FOLFOXIRI: leucovorin, 5-FU,
oxaliplatin, and irinotecan
• Irinotecan, with or without cetuximab
• Cetuximab alone
• Panitumumab alone
• Regorafenib alone
Chemotherapy agents
83. NEOADJUVANT
CHEMOTHERAPY
REGIMENS :
5- FU : 225 mg/ m2 – daily continous infusion
Capecitabine : 825 mg/ m2 BD on days of radiation
5- FU : 400 mg / m2 IV bolus + leucovorin 20 mg /m2 IV
bolus for 4 days : wk 1 & wk 5.
5-FU has been infused into the portal vein during and immediately after the primary operation
have shown a small benefit. Such intraportal adjuvant therapy is thought to kill malignant cells,
which are released into the circulation during operative manipulation of tumour, and thus prevent
the formation of metastases.
Neo adjuvant chemoradiotherapy has no difference in overall survival
84. CHEMOTHERAPY
REGIMENS :
5-FU : bolus weekly regimen ( leucovorin 20 mg/m2 over 2
hrs : 5- FU 500 mg/ m2 bolus weekly for 6 weeks :
Weekly Roswell Park regimen : 5-FU + leucovorin
( leucovorin 500 mg /m2 given over 2 hrs followed by 5-FU
bolus after 1 hour ) :repeated after 4 weeks for 6 cycles .
FOLFOX -5-FU 2800mg/m2 ,leucovorin
1200mg/m2,oxaliplatin 80-100mg/m2 ( every other week
with infusional 5-FU )
oral Capecitabine 1000 – 1250 mg/ m2 from day 1-14 ( 21 day
cycle) plus parentral oxaliplatin (capeox)
Folfiri-irinotecam 100-200mg/m2
Folfox plus bevacizumab
85. Post op chemotherapy for the patient with stage 2
colon ca is contraversial.
It is suggested that 5- FU based chemotherapy can be
given if at least one poor prognostic factor
( insufficient<12 LN sampling,T 4lesions ,poorly
differentiated histology or bowel perforation.
Patients with stage 3 clearly benefit from adjuvent
chemotherapy (FOLFOX )
Stage 4 chemo with bevacizumab,
cetuximab,panitumumab as monotherapy or with
FOLFOX/FOLFIRI
86. Side effects of chemo therapy
1• Hair loss
2• Mouth sores
3• Loss of appetite
4• Nausea and vomiting
5• Low blood counts -This can lead to:
6• Increased chance of infections ,Easy bruising or bleeding ,Fatigue
some side effects are specific to certain medicines, for example:
Hand-foot syndrome can occur during treatment with capecitabine or 5-FU (when given as an
infusion). This starts out as redness in the hands and feet, which can then progress to pain and
sensitivity in the palms and soles. If it worsens, blistering or skin peeling can occur, sometimes
leading to open, painful sores. treated lowering the dose of the drug or stopping it for a time.
Neuropathy is a common side effect of oxaliplatin. Symptoms include numbness, tingling, and
even pain in the hands and feet. It can also cause patients to have intense sensitivity to hot and
cold in the throat and esophagus .
Diarrhea is a common side effect with many of these drugs, but can be particularly bad with
irinotecan. It needs to be treated right away — at the first loose stool — to prevent severe
dehydration. Treated by taking drugs like loperamide
87. ROLE OF RADIOTHERAPY
Biologic property of rectum and its distance from small bowel
provides an opportunity for radiation therapy alone that is not
feasible for colon cancer,as large bowel can tolerate radiation
dose up to 6000cGY but that radiation will include small bowel
in field that can’t tolerate this radiation.
Neo-adjuvant/Adjuvant RT in resectable Ca Rectum
pre-op
post-op
RT in locally advanced rectal cancer
pre-op for down staging
IORT
Definitive RT
unfit for surgery
Palliative RT – in inoperable tumours or local recurrence
88. Types of radiation therapy
External-beam radiation therapy: most often used .
The radiation is focused on the cancer from a machine outside the body.
Endocavitary radiation therapy: used for some rectal cancers.
A small device is placed through the anus and into the rectum to deliver high-intensity
radiation over a few minutes. This is repeated about 3 more times at about 2-week
intervals for the full dose. it is less likely to cause side effects.as the radiation reaches
the rectum without passing through the skin and other tissues of the abdomen . Itis
used only for small tumors
Brachytherapy (internal radiation therapy): uses small pellets of radioactive
material, put into a catheter that was placed next to or directly into the cancer. The
radiation travels only a short distance, limiting the effects on surrounding healthy
tissues.
Radioembolization: Radiation can also be given during an embolization procedure.
89. Radiotherapy for ca rectum
Prone position: radiopaque markers include anal, vaginal, rectal,
perineal skin; wperineal scar if present; small bowel contrast, ensure
bladder full.
Purpose is to displace bowel superior and anteriorly & bladder
anteriorly
Blocks are used to spare the posterior muscle and soft tissues behind
the sacrum and small bowel.
Target Volume: Primary Tumor or Tumor bed, with margin
presacral, and internal iliac nodes (if T4, external iliac nodes also).
Energy
6 MV Co60
90. Dose
Preoperative radiotherapy (stage 2 or higher within 10 cm
from anal verge )
Short course: 25 Gy in 5 daily fractions of 5 Gy given in 1
week.
Long course
180 cGy each day for 5 days in a week for 6 weeks (total
30 doses ) surgery done after 6-10 weeks
Postoperative radiotherapy
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks.
Phase 2 (optional)
5.4–9 Gy in 3–5 daily fractions of 1.8 Gy.
91. Palliative radiotherapy
Phase 1
45 Gy in 25 daily fractions of 1.8 Gy given in 5 weeks.
Phase 2 (optional)
5.4–14.4 Gy in 3–8 daily fractions of 1.8 Gy
or a hypofractionated regimen can be used
30–36 Gy in 5–6 fractions of 6 Gy once weekly given in 5–6
weeks.
Dose limitations (at standard fractionation )
Small bowel 45–50 Gy
Femoral head and neck 42 Gy
Bladder 65 Gy
Rectum 60 Gy
92. Side effects of radiation therapy
1• Skin irritation -range from redness to blistering and peeling
2• Nausea
3• Rectal irritation, which can cause diarrhea, painful bowel movements, or blood in the
stool
4• Bowel incontinence
5• Bladder irritation, which can cause problems like frequency, burning pain while
urinating, or hematuria
6• Fatigue/tiredness
7• Sexual problems (impotence in men and vaginal irritation in women)
Most side effects should lessen after treatments are completed, but problems such as
rectal and bladder irritation may not go away completely.
93. Medical history and physical exam
A physical exam every 3 to 6 months for the first 2 years after treatment, then every 6
months for 5 yrs so for the next few years.
Colonoscopy
A colonoscopy within a year after surgery. If the results are normal, most patients
need another about every 5 years unless no family history.and annually if polyp
detected or removed
Imaging tests
Imaging tests will depend on the stage of disease and other factors. CT scans may be
done regularly, such as once a year, for those at higher risk of recurrence, especially in
the first 3 years after treatment. People who had tumors in the liver or lungs removed
might be tested even more frequently.
Blood tests for tumor markers
Carcinoembryonic antigen (CEA) and CA 19-9 . If the tumor marker level goes up again,
it can be a sign that the cancer has come back, and colonoscopy or imaging tests may
be done to try to locate the site of recurrence. Tumor markers tend to be most useful in
the first 2 years after treatment, when recurrences are most likely to occur.
If the cancer does recur at some point, further treatment will depend on where the
cancer is located. can be seen elevated inulcerative colitis, non-cancerous tumors of the
intestines, or some types of liver disease or chronic lung disease. Smoking can also
raise CEA levels
94. 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
Signet cell carcinoma
High CEA
Tethered and fixed cancer
Vascular & perineural invasion
Primary mucoid carcinoma
Tumour in lower 1/3 rectum
Poor histological grade tumours
Node positive tumours
Editor's Notes
Polyp removal leads to CRC prevention
Polyp is surrogate marker