Downloaded 25 times
Uploaded byNabarun Biswas
Ca rectum
This document discusses updates in the management of rectal cancer. It covers the anatomy, risk factors, staging, clinical features, investigations, and various treatment modalities for rectal cancer including surgery, chemotherapy, and radiotherapy. It describes in detail the different surgical procedures like local excision, anterior resection, abdominoperineal resection, and total mesorectal excision. It discusses the importance of clear circumferential resection margins and vascular ligation. Neoadjuvant chemoradiotherapy is emphasized for locally advanced tumors to downstage the cancer before surgery.
In this document
Powered by AI
Introduction to updates in the management of rectal carcinoma by Dr. Nabarun Biswas.
Basic anatomy concerning nodes in relation to inferior mesenteric and sigmoid arteries, along with lymph nodes in the pelvic area.
Basic anatomy concerning nodes in relation to inferior mesenteric and sigmoid arteries, along with lymph nodes in the pelvic area.
Rectal cancer is the 2nd most common cancer in females and 3rd in males, being the 4th leading cause of cancer deaths.
Identifies risk factors such as diet, lifestyle, genetic predispositions, inflammatory bowel diseases, and family history.
Discusses adenomas, chronic inflammatory bowel disease, and hereditary factors as premalignant conditions for rectal cancer.
Explores the genetic mutations and paths leading to colorectal cancer: hereditary (5%) and sporadic cases (95%).
Describes the adenoma-carcinoma progression, prevalent in 75-95% of sporadic colorectal tumors through specific mutations.
Discusses various staging systems including Duke's, Astler-Coller, and TNM, and correlations with clinical examination findings.Identifies early and late symptoms of rectal cancer, including rectal bleeding, diarrhea, pain, and weight loss.Techniques for evaluating rectal cancer including abdominal and rectal exams, rigid proctoscopy, colonoscopy, and imaging methods.
Identification of CT and MRI as key imaging modalities for localizing tumors and assessing metastatic spread.
Laboratory tests for evaluating rectal cancer, including blood count, electrolytes, liver enzymes, and tumor markers.
Outline of management protocols including preoperative assessment, surgical procedures, postoperative care, and surveillance.
Includes various types of surgeries such as local excision and various anterior resections based on tumor staging.
Detailed steps and techniques in performing anterior resections and the importance of surgical approach in outcomes. Differentiates between high, low, and ultra-low anterior resections, outlining specifics on surgical execution and recovery.
Treatment options for advanced rectal cancer include en bloc resections, pelvic exenteration, and management of liver/lung metastases.
Describes palliative measures for rectal cancer including options for symptomatic relief and management of stage IV disease.
Outlines chemotherapy as adjuvant therapy and the role of targeted approaches, detailing drug regimens for specific cases.
Discusses immunotherapy and its role in enhancing immune response against rectal cancer through checkpoint inhibitors.
Overview of treatment guidelines by the NCCN for rectal cancer stratified by staging and risk factors.
Management strategies for recurrence and follow-up care based on prior treatments and current cancer stage.
Concludes with advancements in diagnostic and surgical techniques, affirming that rectal carcinoma is regarded as highly treatable.
List of references used in compiling the information on rectal carcinoma management, covering surgical texts and cancer guidelines.
More Related Content
More from Nabarun Biswas
Ca rectum
- 1. Updates In Management Of CaRectum Dr. Nabarun Biswas Indoor Medical Officer Surgery Dep. MMCH
- 2.
- 6. Nodes in theorigin of inferior mesenteric artery Nodes in the origin of sigmoid branches Sacral nodes Internal iliac nodes Inguinal nodes
- 8. Rectal cancer • 2ndmost common malignancy in female & 3rd most common in male • 4th most common cause of cancer death after lung, stomach & liver
- 9. Risk factor • Redmeat and saturated fatty acids • Obesity • Sedentary lifestyle • Old age • Alcohol and Smoking • FAP - defect in APC gene on chromosome 5q21 • HNPCC - MSH2 & MLH1 gene defect • Family history – 2 or more first degree relatives • Inflammatory bowel disease – Ulcerative Colitis • Adenomatous polyp
- 10. Premalignant conditions 1. Adenoma 2.Chronic IBD 3. Hereditary FAP
- 11.
- 12. Adenoma - Carcinomasequence • Accounts for upto 75-95% of sporadic colo-rectal tumours and typically arise form adenomatous polyp •Mutation in wnt signaling pathway 1.APC mutation activation of proto-oncogene (required for normal cell renewal) over expression 2.Activation of oncogene k-ras increase cell proliferation. 3.Suppression of P 53 (for apoptosis) immortal cell
- 13.
- 14. Duke’s Staging A BC1 C2 D MUCOSA SUBMUCOSA MUSCULARIS PROPRIA SEROSA LYMPHNODE
- 15. TNM Staging N 0N 1 N 2 T1 T2 T3 T4a T4b MUCOSA SUBMUCOSA MUSCULARIS PROPRIA SEROSA/ Perirectal tissue LYMPHNODE
- 16. AJCC Staging • StageI 100, 200 (T1 or 2 N0 M0) • Stage II 300, 400 (T3 or 4 N0 M0) • Stage III any T, any N, M0 • Stage IV any T, any N, M1
- 17. Correlation between TNM,Duke’s & DRE Status Duke’s TNM DRE Early A S-I (T1,N0,M0) Freely mobile over rectal muscle A S-I (T2,N0,M0) Moves with rectal wall Locally advanced B or C S-II, S-III (T3/T4 or N1/N2) Slightly moves along with pararectal fat Advanced C or D S- IV (M1a/M1b) Fixed
- 18. Clinical features • Earlysymptoms 1. Per rectal bleeding 3. Early morning diarrhoea Alteration of bowel habit Change to loose stool is common Stenosing ca may cause constipation 2. Tenesmus Lower half of rectum Spurious diarrhoea Bloody slime
- 19. Clinical features • Latesymptoms 1. Pain Colicky Severe , intractable 2. Weight loss Associated with metastatic disease
- 20. Examination • Abdominal: – Normalin early stage – Obstructive feature in stenosing recto-sigmoid tumour • Rectal: – Assessment of tumor size, mobility and fixation, anterior or posterior location, relationship to sphincter mechanism and the distance from the anal verge.
- 21. Rigid Proctoscope • Demonstratesthe proximal and distal levels of the mass from anal verge • Extent of circumferential involvement • Orientation within the lumen • Aids in determining the feasibility of local excision
- 22. Colonoscopy Torule out synchronous cancers -which occur 2 - 8% of the time.
- 23.
- 24. Transrectal Endoluminal Ultrasound Permits accuratecharacterization of the primary tumor and the status of the perirectal lymph nodes
- 25. MRI • Investigation ofchoice for T staging
- 26. CT scan • Regionaltumor extension • Lymphatic and distant metastasis • Tumor related complications - perforation or fistula formation
- 27. Laboratory studies • CompleteBlood count • Serum Electrolytes • Liver Enzymes • CEA (Carcinoembryonic antigen)
- 28.
- 29. Management Protocol 1. Preoperativeworkup 2. Operative procedure 3. Post operative management 4. Surveillance program 1. Counseling & consent 2. Tumour board formation 3. Correction of co-morbidities 4. Prophylaxis 5. Bowel preparation
- 30. Principle of Treatment 1.Surgery is the mainstay of curative Rx 2. Aim: radical excision of rectum + mesorectum+ lympho-vascular clearance 3. Widespread metastasis: palliative Rx stenting/RT/palliative resection 4. Liver/Lung metastasis: single/well localized resection with curative intent 5. Locally advanced (T3/4 or N1/2): neoadjuvent CRT surgery
- 31. Principle of Treatment 6.Watch & wait policy: after long course CRT if CCR & CPR is found intense surveillance 7. Early cancer(T1,T2 & N0): organ preserving surgery by Local excision /TEMS (for T1) 8. If radical excision possible : APR or AR (High, Low, Ultra low) 9. Sphincter saving possible if tumour margin ≥2 cm from ano-rectal junction 10. Defunctioning stoma: if tumour below peritoneal reflection
- 32. Treatment modalities • Surgery •Chemotherapy • Radiotherapy • Targeted therapy • Immuno therapy • Alternative treatment
- 33. Surgery • Surgery isthe mainstay of treatment • Radiation and chemotherapy are given before or after surgery • The type of surgery depends on the stage of the cancer
- 34. Types of surgery 1.Local excision / TEMS / TAMIS 2. Anterior resection High AR Low AR Ultra Low AR 3. TME / Modified TME 4. APR 5. Surgery in advanced carcinoma
- 35. Approach • Open • Laparoscopic •Robotic • Trans anal
- 36. Trans anal endoscopicmicro surgery: TEMS • For mid and lower rectal tumor • For rectal adenomas and early rectal cancers • Must below peritoneal reflection
- 37. TEMS • Indication: – Welldifferentiated – Grade 1 or 2 – Not mucinous adenoma – Lymphnode –ve – Diameter < 3cm – Tumor invades only submucosa
- 38. Anterior Resection • Itis a sphincter saving operation • Approach: open / laparoscopic / robotic assistance • Two terms: TME & CRM
- 39. Total Mesorectal Excision:TME • Introduced by RJ Heald in 1979 • For middle and lower third rectal carcinoma • Mesorectum: perirectal fascia containing fat and perirectal lymph nodes, lymphatic • Spread of carcinoma rectum occurs in this area.
- 40.
- 41. Modified TME • Distalspread of adenocarcinoma either in the rectal wall or mesorectum greater than 2-3 cm is rare. • So the dissection continues to pelvic floor up to ano-rectal junction (low AR) or 5 cm (3cm) below the tomour margin (High AR) Modified TME • Top to down manner
- 42.
- 43. Ta TME • Lowanterior resection can be a challenging operation, especially in obese male patients and in particular after radiotherapy. • Transanal total mesorectal excision (TaTME) might offer technical advantages over laparoscopic or open approaches particularly for tumors in the distal third of the rectum. • Defines the radial and distal margins more clearly. • Bottom up manner • TAMIS: modification of TaTME where SILS instruments are used
- 44.
- 45.
- 46.
- 47. Circumferential Resection Margin: CRM •It is the radial distance between cancer tissue and the non peritonalized margin of the resected specimen • CRM +ve when distance is ≤1 mm • CRM –ve when distance is >1 mm • CRM is an important prognostic factor for recurrence • CRM can be predicted preoperatively by thin slice high resolution MRI • In predicted CRM positivity neoadjuvant CRT is indicated
- 48.
- 49. Anterior resection • 3types of 3 anterior resection 1. High 10cm from anal verge 2. Low 8 cm from anal verge 3. Ultra low 6cm from anal verge • TME /modified TME is incorporated with AR • Gastrointestinal continuity is maintained by stapled anastomosis or hands sewn
- 50. Steps/ Technique inAR • Lloyd-Davies position • Good assistance • Long midline incision • Wide retraction • Small bowel packed out of the way • Full laparotomy
- 51. Steps/ Technique inAR • Assess for synchronous lesion or spread • Sigmoid and descending colon mobilization lateral to medial (in laparoscopic method medial to lateral after ligation of vessels) • Protect left ureter and gonadal vessel • Splenic flexure mobilization
- 52.
- 53. Steps/ Technique inAR….cont. • next step is vascular ligation • High ligation and low ligation of IMA • High for proper lymphatic clearance & low for improve vascularity • 2 step ligation of IMV for tension free anastomosis • Mesocolon divided & lymphovascular pedicle prepaired
- 54. Importance of vascularligation in LN +ve
- 55. Steps/ Technique inAR….cont. • Next step is rectum & mesorectal excision • sharp dissection under direct vision • Preservation of hypogastric nerve in 10 and 2 o’clock position • Retraction and counter retraction given
- 56. Steps/ Technique inAR….cont. • Posterior dissection started 1st through holy plane between presacral fascia and waldayer’s fascia • middle rectal vessel is ligated (20%) • After completing posterior dissection anterior dissection started in denonvillier’s fascia between seminal vesicle and rectum
- 57. Steps/ Technique inAR….cont. • Next step is rectal dissection & anastomosis • Rectum cross clamped • Rectal wash given • Dissection & specimen removed • Gut continuity maintained by circular stapler or hand sewn.
- 58. APR • Tumour ofthe lower 3rd having no adequate free margin • Sphincter involved • 2 surgeon in 2 route • Morbidity - 61% • Mortality - 0 - 6.3% • Urinary complications - 50% • Perineal wound infections - 16%
- 59. APR technique • Abdominalroute 1st done by open / laparoscopic & same way as AR except that the dissection stops before pelvic floor is reached • Perineal excision started with circum anal incision • Depend into ischio-rectal fossa & out towards levator muscles of pelvic side wall • Extended posteriorly by incising waldeyer’s fascia and anteriorly between rectum and prostate or vagina • Specimen delivered through perineal route
- 60. Projected lines ofpelvic floor resection in vertical plane Anal closure Perineal incision
- 61. Incision line anteriorto coccyx through anococcygeal ligament through which scissors are used to gain entrance to the pelvis Planes of pelvic dissection and posterior plane of entry into pelvis through the pelvic floor
- 62. Projected lines of pelvicfloor transection Lateral transection of Levator ani muscle Completion of anterior dissection and removal of rectum through perineal wound Anterior resection of rectourethralis, puborectalis, and pubococcygeus Pelvic floor closed with two drains in place
- 63. Advanced Ca OfThe Rectum
- 64. En block resection •in male cystectomy or prostatectomy and in female posterior vaginectomy or hysterectomy can be undertaken in combination with AR • to achieve oncological clearance
- 65. Line of dissection,including posterior wall of vagina for low anterior rectal cancer Posterior Vaginectomy Lines of transection, including posterior wall of vagina
- 66. Pelvic Exenteration •Morbidity -20 - 40 % •Mortality - 0 - 20% • Aim is to remove pelvic organs involved in the malignant process • Two types partial complete • indication locally advanced recurrence
- 67. liver and lungresection • Single or multiple well localised metastasis • long-term survival can be achieved (40%) • Performed synchronously at the time of AR
- 68. Palliative resection • Indication- stage IVb • Bleeding, Localized perforation and Obstruction • Options • Permanent diversion followed by chemotherapy (+/- radiotherapy demanding on local symptoms) • Palliative resection with a permanent colostomy followed by chemotherapy • Palliative resection with restoration of GI continuity followed by chemotherapy
- 69. • Obstructing cancer •Loop ileostomy for diversion —> neoadjuvant chemoradiation — > surgical resection • • Metastatic cancer • If life expectancy - > 6 months - palliative rectal excision • Rectal stents / laser destruction /Embolisation Recurrent cancer • Usually from residual cancer from pelvic wall
- 70. Radiotherapy • Neoadjuvant ,adjuvantor palliative setting • Neoadjuvant is short course and long course chemoradiation • Long course RT 45-50 Gy for 6 weeks + 1st & last week chemo 6 weeks interval surgery (down staging) • Short course RT 25 Gy for 5 day + 1st & 2nd day chemo surgery within 7-10 days (sterilize tumour) or, 12 weeks later (down staging) • Adjuvant is EBRT or IORT/ contact RT
- 71.
- 72.
- 73. Chemotherapy • As Neoadjuvantwith RT or adjuvant to reduce the risk of disseminated disease • 5 FU remain the 1st line therapy • Oxaliplatin & Irinotcan is 2nd line
- 74. Targeted Therapy • Targetspecific type of cancer cells • Different targeted therapy work in different way • one type stops the growth of new blood vessel into rectal tumour • second type stops the cancer cells from receiving signal to grow • less likely to harm normal cells than chemotherapy • not everyone will benefited from targeted therapy
- 76. Immunotherapy • increases theactivity of immune system • Improves body’s ability to find and destroy cancer cell • drugs are called checkpoint inhibitor
- 77. NCCN Guideline forthe treatment of Rectal Cancer according to stage
- 78. Stage I (T1,T2, N0,M0 or Polyp) High risk are Fragmented specimen Poorly differentiated High grade (3) Mucinous adenoma +ve margine Lympho- vasular invasion Size >3 cm
- 79. Treatment After TransanalLocal Excision And Staging Update
- 80. Treatment After TransanalLocal Excision And Staging Update
- 81. Treatment After AbdominalResection and Staging Update (T3,N0,M0)
- 82. Treatment After AbdominalResection and Staging Update (T4 or N1, Mo)
- 83. Stage II &III Less invasive: 1.T1 or T2 but LN +ve 2.T3 but CRM -ve
- 84. Stage II &III…..cont
- 85. Stage II &III…..cont • More invasive: – T3 + CRM +ve – T4 – Cancer can not be removed with surgery Option 1 Long course CRT then After 6 wk imaging, If CRM –ve then Surgery If surgery not possible, then Systemic therapy Option 2 12-16 wks of chemotherapy (FOLFOX/CAPEOX/5FU-LV) Then CRT Next imaging If possible surgery No further treatment If surgery not possible Then systemic therapy
- 86.
- 87.
- 88. Treatment for localrecurrence
- 89. Treatment for metastaticcancer: Stage IV
- 90. Treatment for metastaticcancer: Stage IV
- 91.
- 92. Stage I (T1or 2, N0, M0)
- 93. Stage II :(T3or4, N0, M0) & Stage III: (any T, any N, M0)
- 94. Stage VI: (anyT, any N, M1) Metastatic Ca Systemic chemotherapy
- 95. Stage VI: (anyT, any N, M1) Metastatic Ca
- 96.
- 97. Conclusion At present withthe advancement in diagnostic procedure and improvement of surgical technique Rectal Carcinoma is regarded as extremely curable malignant disease.
- 98. References • Bailey’s AndLove short practice of surgery 27th edi • Cuschieri’s Essential Surgical practice 5th edi • Current surgical Diagnosis & Treatment 14th edi • American Cancer Society guideline • National comprehensive Cancer Network (NCCN) guideline
Editor's Notes
- #13 It is a stepwise pattern of genetic mutation mutation in wnt signaling pathway APC mutation activation of proto-oncogene (required for normal cell renewal) over expression Activation of oncogene k-ras increase cell proliferation. Suppression of P 53 (for apoptosis) immortal cell
- #84 Less invasive: T1 or T2 but LN +ve T3 but CRM -ve