INT. ONCOLOGY CONF. NAIROBI, OCTOBER 2011
THEME Translating recent advances into local practice/clinical care
RECTAL CANCER
Progress in MULTIMODAL THERAPY of Rectal Cancer is one of the BEST examples of success of Clinical Research in the last 2 decades.
RECTAL CARCINOMA RECENT ADVANCES -- OVERALL1.SPHINCTER SAVING PROCEDURES UP FROM 15% TO 50% -- NO COLOSTOMY (IMPROVED QOL)2. OVERALL FIVE YR SURVIVAL UP FROM 30% TO 60%3. DEPTH OF INVASION DECREASED BY 40%-60% WITH ADJUVANT Rx4. LYMPH NODE STATUS AND REC. FREE SURVIVAL - SAME
RECENT ADVANCES 1. MOLECULAR BIOLOGY 2. SURGERY 3. IMAGING MRI, CT AND PET4. CHEMO/RADIOTHERAPY
MOLECULAR BIOLOGY DNA CHIP TECH. DNA SEQUENCE CHECKED -- APC GENE FAP -- MISMATCH REPAIR GENES HNPCCSUCH PTS.(5%) PUT ON A SURVEILLANCE PROG. --PROPHYLACTIC SURGERY
MOLECULAR BIOLOGY
DNA SEQUENCE OF MICROSATELLITE INSTABILITY -- GOOD RESPONSE WITH 5 FU CHEMO.
P21 MARKER POSITIVE RADIOSENSITIVE
MOLECULAR BIOLOGY
P53 PROTEIN MUTANT EXPRESSED -- RADIORESISTANT
KRAS, DCC, AND P53 -- IF +ve POOR PROGNOSIS
MICROSATELLITE INSTABILITY OR LOW Cox2 EXPRESSION & P21 MARKER IF +ve GOOD PROGNOSIS
SURGICAL CHALLANGES
I-STAGING
II-USE OF CH/RT
III-SURGICAL TECHNIQUE
I - STAGING
DECIDES TRANS ANAL LOCAL EXCISIONAPR.
NEOADJUVANT CH/RT
TRADITIONAL STAGING
DIGITAL RECTAL EXAMINATION
CT SCANS
NEWER STAGING METHODS
DRE
ERUS NODES
CT
RECENT ADVANCES
DRE
ERUS
MRI
RECENT ADVANCES
DRE
RECTAL CA. RECENT ADVANCES
RECENT ADVANCES ERUS
ERUS ------ BEST FOR NODAL STATUS ( OPERATOR DEPENDANT)
STAGINGERUS T STAGE ACCURACY 60 90% N STAGE ACCURACY 60 90%MRIT STAGE ACCURACY 60 90% N STAGE 40 --- 80% ( NODES > 5mm)
CHALLANGE
PICK UP NODES < 5mm (33%OF ALLNODES)
PICK UP MICRO METS
USE OF CH/RT
MRIINDICATORS OF MALIGNANT NODAL INVOLVEMENT
L. NODES -- IRREGULAR BORDER -- MIXED SIGNAL INTENSITY OF NODE
MRI
DETECTS EXTRAMURAL VENOUS INVASION (EMVI)
POOR PROGNOSIS WITHOUT CH/RT IF EMVI PRESENT
II USE OF CH/RT (NEOADJUVANT/ADJUVANT)PTS WITH POOR HISTOLOGY
PTS WITH EXTRA MURAL SPREAD (MRI)
PTS WITH INVOLVED NODES (ERUS)
PTS WITH EMVI (MRI)
CHEMOTHERAPYINJ KYTRIL 3mg Ksh 2,250/-INJ DEXAMETHAZONE 8mg Ksh 385/-INJ FLUOUROURACIL 5500mg Ksh 12,053/-INJ OXALIPLATIN 200mg Ksh 187,600/-INJ LEUCOVORIN 100mg Ksh 1,809/-INJ AVASTIN 400mg Ksh 213,806/-Kshs 417903/-
RADIOTHERAPYEUROPEAN APPROACH(25G/5CYCLES)SHORT COURSE LOW DOSE IMMEDIATE SURGERYNO CHANGE IN PATH STAGINGLOWER COSTBETTER COMPLIANCEDOSE EQUIVALENT TO 30-33GEXPECT 66% REDUCTION IN LOCAL RECURRENCE
AMERICAN APPROACH(45 54G/28 CYCLES)PROLONGED COURSE HIGH DOSE DELAYED SURGERYBETTER SURGICAL TOLERANCEMORE TUMOR REGRESSIONEXPECT >80% REDUCTION IN LOCAL RECURRENCE
III SURGICAL TECHNIQUE TRADITIONALPROCTECTOMY PERFORMED -- In the DARK -- Using BLUNT Dissection -- Without attention to ANATOMIC DetailRESULTED in -- Bloody operation -- Increased -- Autonomic Nerve injury -- Local Rec.
SURGERY - TRADITIONALANT. RESECTION UPPER RECTAL CALOW ANT.RESCETION- MID RECTAL CAA.P.R. - LOWER RECTAL CA
ANY TUMOR 10cms FROM ANAL VERGE -- APR
ANATOMY OF RECTUM
CHANGED FROM TRADIOTIONAL 22 CMS FROM ANAL VERGE TO 15 CMS
ABOVE THAT IS ALL COLON
RECTAL CARCINOMA RECENT ADVANCES>100 YEARS SINCE MILES DESCRIBED ABDOMINO-PERINEAL-RESECTION
>25 YEARS SINCE HEALD DESCRIBED TOTAL MESORECTAL EXCISION
III SURGICAL TECHNIQUERECENT ADV. TOTAL MESORECTAL EXISION
( EXICISION OF FASCIA ENVELOPING THE FAT PAD AROUND THE RECTUM.)
SAUSAGE APPEARANCE
SURGERY RECENT ADVANCES
LOW-ANT RESECTION UPTO 6cms FROM ANAL VERGE
APR ONLY IF SPHINCTOR FUNCTION COMPROMISED
RECTAL CANCER RECENT ADVANCESCAREFUL ASSESSMENT OF SxSEARLY DIGNOSIS WITH ACCURATE STAGING CH/RT - FOR SELECTED PTS- PROCTOSCOPY - SIGMOIDOSCOPY- DRE - ERUS- MRI
OUR SCENARIOLATE PRESENTATIONADVANCED TUMORSANATOMICAL DISTORTIONLACK OF NEOADJUVENTSSURGERY MORE DIFFICULTRESULTS POORER
COMMON PROBLEMS FACING SURGERY IN AFRICALACK OF GUIDELINES AND STANDARDS
INADEQUATE SUPERVISION
VEINS OF SMALL & LARGE INTESTINES
CAECAL CANCER RESECTION
GOALS OF THERAPY FOR RECTAL CARCINOMA
DECREASE LOCAL RECURRANCE
OPTIMISE Q.O.L. AVOID COLOSTOMY
CA. RECTAM (ESP. LOWER TUMORS) SHOULD BE DIAGNOSED EARLY
SHOULD GIVE GOOD RESULTS WITH EARLY THERAPY
LOCAL EXPERIENCE 31 CASES OF RECTAL CA
25 APR DONE
6 LOW ANT RESECTIONS (2 Local Rec.)
SYMPTOMSRECTAL BLEEDING LOWER RECT.TENESMUS
ALT. OF BOWEL HABITS UPPER.ANY G.I. SxS (dyspepsia)
RECTAL CANCER
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