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Presented By:
Dr.GHANSHYAM KUMAWAT
Under Guidance Of
Dr.U.S.PARIHAR (Prof & unit head)
Dr.AMIT SINGH (Asst. Prof.)
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
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
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
• 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)
 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
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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
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
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.
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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%
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
Cecum 12 %
Appendix 0.5%
Ascending colon 5 %
Hepatic flexure 2%
Transverse colon 5.5 %
Splenic flexure 3%
Descending colon 4 %
Rectosigmoid junct 21 %
Rectum 38 %
PATHOLOGY-
It follows the adenoma –
carcinoma sequence
Pathogenesis adenoma –carcinoma model
(fearon - vogelstein model )
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
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.
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
HNPCC( total 3% cases)
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PATHOLOGY AND STAGING
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
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
Stage Grouping
Pathology (macroscopic )
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
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
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
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
Acute Presentations
Intestinal obstruction.
Perforation.
Massive bleeding.
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.
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.
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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
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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 )
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 )
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.
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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.
surgery for colon cancer
cont.
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
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
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.
SURGICAL PROCEDURES FOR
RECTAL CARCINOMA
APR ( abdomino-perineal resection).
AR ( ant. Resection) Radical
Local excision
 Transanal excision
 Endoscopic snare polypectomy Non-Radical
 Trans-anal endoscopic
microsurgery(TEM).
Ablative procedures
Endoscopic surgery
Fulguration
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
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.
- 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
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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.
TME
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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)
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En block removal with rectum
Posterior vaginectomy
Prostatectomy
Pelvic exenteration
In post op period patient will not be allowed to sit for
5 days
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
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.
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.
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.
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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.
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.
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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
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)
 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
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
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
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
 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
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
 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.
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
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.
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
 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.
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
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
Carcinomarectum 111113085726-phpapp01 (1).ppt1

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Carcinomarectum 111113085726-phpapp01 (1).ppt1

  • 1. Presented By: Dr.GHANSHYAM KUMAWAT Under Guidance Of Dr.U.S.PARIHAR (Prof & unit head) Dr.AMIT SINGH (Asst. Prof.)
  • 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
  • 17. Cecum 12 % Appendix 0.5% Ascending colon 5 % Hepatic flexure 2% Transverse colon 5.5 % Splenic flexure 3% Descending colon 4 % Rectosigmoid junct 21 % Rectum 38 % PATHOLOGY- It follows the adenoma – carcinoma sequence
  • 18. Pathogenesis adenoma –carcinoma model (fearon - vogelstein model )
  • 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
  • 22. HNPCC( total 3% cases)
  • 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.
  • 46. cont.
  • 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.
  • 50. SURGICAL PROCEDURES FOR RECTAL CARCINOMA APR ( abdomino-perineal resection). AR ( ant. Resection) Radical Local excision  Transanal excision  Endoscopic snare polypectomy Non-Radical  Trans-anal endoscopic microsurgery(TEM). Ablative procedures Endoscopic surgery Fulguration
  • 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.
  • 62. TME
  • 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

  1. Polyp removal leads to CRC prevention Polyp is surrogate marker