Date post: | 30-May-2018 |
Category: |
Documents |
Upload: | goodforamen |
View: | 224 times |
Download: | 0 times |
of 38
8/9/2019 Management of Carcinoma Rectum
1/38
anagement of anagement of arcinoma Rectumarcinoma Rectum
Budhi Nath Adhikari
8/9/2019 Management of Carcinoma Rectum
2/38
8/9/2019 Management of Carcinoma Rectum
3/38
8/9/2019 Management of Carcinoma Rectum
4/38
Clinical Evaluation :
HistoryOften asymptomaticSymptoms occur late
Rectal complaints, non specificRisk factors
8/9/2019 Management of Carcinoma Rectum
5/38
Physical ExaminationDRE palpable massLiver enlargement, previous operations
Assessment of the patient's analsphincter
8/9/2019 Management of Carcinoma Rectum
6/38
InvestigationRigid proctosigmoidoscopcopyfeasibility of local excision and obtain an
adequate tissue biopsy
8/9/2019 Management of Carcinoma Rectum
7/38
Endorectal ultrasoundPreoperative staging - depth and nodalenlargement
Confirmation of nodal metastasis withultrasound-guided needle biopsy is lessreliable
Overstaging
less able to distinguish accurately T1 from T2cancers, stenotic lesions and in patients withprior radiation
8/9/2019 Management of Carcinoma Rectum
8/38
CT scansRegional tumor extension, lymphatic anddistant metastases, and tumor-relatedcomplications such as perforation or fistulaformation.
Less accurate than endoluminal scan (localspread, adjacent organ invasion) betterfor distant metastasis and recurrentdisease detection
8/9/2019 Management of Carcinoma Rectum
9/38
MRILarger field of view, less operator- and
technique-dependent, allows study of stenotictumors
Discriminate small-volume nodal disease andsubtle transmural invasion , local recurrence
Identifies involved perirectal nodes on thebasis of characteristics other than size
Identifies foci not only within the mesorectumbut also outside the mesorectal fasciaDouble-contrast MRI may permit more accurate T staging
8/9/2019 Management of Carcinoma Rectum
10/38
Tumour markerCEAUp to 95% of patients with advanced
hepatic metastasis will have a CEA levelabove 20 ng/mL.
Normal preoperative CEA levels willidentify patients who will not benefitfrom following CEA levelspostoperatively
8/9/2019 Management of Carcinoma Rectum
11/38
PETAssessing the extent of pathologic response of primary rectal cancer to preoperativechemoradiation and may predict long-termoutcome.
Detection of recurrence of rectal cancer aftersurgical resection and full-dose external-beam radiation therapy
Relatively inaccurate for nodal metastases
8/9/2019 Management of Carcinoma Rectum
12/38
Histopathologic examination of the specimenobtained via biopsy or local excision
Chest x-ray or chest CT scan to excludepulmonary metastases
Subjective and objective assessment of the patient's anal sphincter function
Prostate-specific antigen
Baseline investigations
8/9/2019 Management of Carcinoma Rectum
13/38
TNM StagingDescribe the anatomic extent, planningtreatment, evaluating response to treatment,comparing the results of various treatmentregimens, and determining prognosis
stage I, the tumor invades upto the muscularispropria
stage II, the tumor invades completely throughthis layer.
stage III, lymph node metastasisstage IV, metastatic disease
8/9/2019 Management of Carcinoma Rectum
14/38
ag ng
8/9/2019 Management of Carcinoma Rectum
15/38
Poor prognostic factorsPoorly differentiated cancersDirect tumor extension into adjacent structures
(T4 lesions)
Lymphatic, vascular, or perineural invasion;andBowel obstruction
8/9/2019 Management of Carcinoma Rectum
16/38
Principles of Treatment
Surgical resection is the cornerstone of therapyLiver metastasisSuperficially invasive, small cancers may be
managed effectively with local excision.Deeply invasive tumors require major surgery:
LAR or APR
Locally advanced tumors adherent to adjoiningstructures such as the sacrum, pelvicsidewall, prostate, or bladder, require an evenmore extensive operation.
8/9/2019 Management of Carcinoma Rectum
17/38
8/9/2019 Management of Carcinoma Rectum
18/38
Goals of Surgery The primary goal of surgical treatment forrectal cancer is complete eradication of theprimary tumor along with the adjacentmesorectal tissue , LNs and the superiorhemorrhoidal artery pedicle.
reestablishment of bowel continuity andcontinence preferable
8/9/2019 Management of Carcinoma Rectum
19/38
Resection Margin2 cm distal margin, if not poorly differentiatedor distant spread
5 cm proximal margin recommendedRadial Margin of 5 cm - more critical than the
proximal or distal margin for local control andis an independent predictor of both localrecurrence and survival
8/9/2019 Management of Carcinoma Rectum
20/38
Local ExcisionDisease-free survival may be less; 12% of T1
and 22% of T2 tumors should not have been
treated with local therapy ; some patientsrequire a salvage APR for ultimate cure.Palliation of symptomatic but incurable rectal
cancers
8/9/2019 Management of Carcinoma Rectum
21/38
Major risk factors for local recurrence : positivesurgical margins, trans-mural extension, andpoorly differentiated histology
Local failure or LN involvement in T1/T2Repeat local procedures rarely indicated
8/9/2019 Management of Carcinoma Rectum
22/38
Local ExcisionTransanal procedure : Tumors 3 cm 5 cmfrom the dentate line but not invading thesphincters .Day Care or OPD. Low morbidityno mortality
Transcoccygeal Excision : Larger & tumors 5 7 cm from the dentate line esp posteriorwall. Immediate mesorectal tissue adjacent tothe tumor is removed along with perirectalnodes. Fecal fistula
8/9/2019 Management of Carcinoma Rectum
23/38
Transanal endoscopic microsurgery (TEM)using Wolf operating microscope. Smalltumors 7-10 cm from the dentate line
Transanal fulgurationLocal/contact radiation therapy (Papillon
approach).
8/9/2019 Management of Carcinoma Rectum
24/38
Amenable to Local Excision
T1N0 or T2N0 lesion
8/9/2019 Management of Carcinoma Rectum
25/38
Radical ResectionAPR with permanent colostomy : Distal Rectallesions involving the sphincter or incontinent pts
Low anterior resection with colorectal
anastomosis : Proximal rectal and midrectallesionsHartmann ProcedurePelvic Exenteration and Sacrectomy : Resection of
the anus, the rectum, the bladder, the ureters,and the pelvic reproductive organs
The primary goal of radical resection is to removethe rectal cancer, the rectosigmoid mesentery,and the mesorectum with clear margins
8/9/2019 Management of Carcinoma Rectum
26/38
APRAPR offers no survival advantage oversphincter-sparing procedures
significant morbidity (Urinary complications,perineal wound infections, sexualdysfunction, change in body image ) of 61%and mortality upto 6.3% with recurrencesupto 20%.
T3N0 moderately or well-differentiatedcancers invading less than 2 mm intoperirectal fat low locoregionalrecurrence
8/9/2019 Management of Carcinoma Rectum
27/38
LAR: no incontinence, no extensive pelvicdisease, limited life expectation and lesionwith resected margin above internal sphincterbut risk of recurrence , anastomotic leak &incontinence
body build, sex, obesity, lesion level, localspread, perforation or abscess, size/fixation,grade, obstruction, bowel preparation &general medical condition.
Ultralow colorectal & coloanal anastomosistogether with a colonic pouch or coloplasty
8/9/2019 Management of Carcinoma Rectum
28/38
Other Treatment OptionsLaparoscopic TMEEndocavitary radiationElectrocoagulationLaser vaporization using neodymium:yttrium-
aluminum-garnet laser
8/9/2019 Management of Carcinoma Rectum
29/38
Palliative ProceduresAfter surgical resection , improvement noted in40% with bleeding, 70% with obstruction, and20% with pain.
Seek comorbidities, and patient desires andgoals
Hidden ColostomyHigh Ligation of Inferior Mesenteric Artery
8/9/2019 Management of Carcinoma Rectum
30/38
Obstructing Cancer of
the Rectumloop ileostomyUsually T3 or N1 lesion: the patient is treated
with neoadjuvant chemoradiation andconsidered for subsequent surgical resection
8/9/2019 Management of Carcinoma Rectum
31/38
Therapy
pelvic sidewall recurrenceperipheral neuropathy and ureteral stenosis
8/9/2019 Management of Carcinoma Rectum
32/38
Neoadjuvant
Chemoradiation T3 or N1 rectal carcinomabulky T2 lesions near the sphincters
Neoadjuvant therapy then is followed by TMEwith APR or TME with an end-to-side, colonic
J-pouch, or coloplasty reconstruction.
no difference in overall survival
8/9/2019 Management of Carcinoma Rectum
33/38
Advantagessignificant decrease in the local recurrence rate(6% versus 13%), as well as toxicity
ability to deliver higher doses of chemotherapydownstage the tumor (60 80% cases)achieve a pathologic complete response (15
30% cases)
Decreased radiation enteritis thereby morecomplete radiation therapy
8/9/2019 Management of Carcinoma Rectum
34/38
Eliminate the micrometastatic disease presentat the time of surgery.
Increased resectability,Improves local control and survival in stage II
and III patientsDecreased distant metastasis
Regimens used: 5FU + Leucovorin
8/9/2019 Management of Carcinoma Rectum
35/38
Chemoradiotherapy
8/9/2019 Management of Carcinoma Rectum
36/38
RecurrenceInadequate removal , Implantation at sutureline , New Lesion
5% to 10% synchronous cancers and 30%adenomatous polypsClinical detectionWorkups
Related to the extent of transmuraldisease and associated involvement of regional lymph nodes
8/9/2019 Management of Carcinoma Rectum
37/38
Between 60% and 84% of recurrences are seenin the first 24 months and 90% within 48months.
Median time to recurrence is 1122 months.Local recurrence rates ranges between 4% and
50%.Radiotherapy or surgeryFollow-up: Clinical, CEA , Colonoscopy ,CT
8/9/2019 Management of Carcinoma Rectum
38/38
THANK YOU