ca rectum

1. CARCINOMA RECTUM
DR.BARUN KUMAR
MS GENERAL SURGERY
SSKM & IPGMER

2. INCIDENCE
• Currently third leading cause of death in US in
both gender
• 41000 new cases diagnosed in US each year and
10000 deaths attributed to rectal carcinoma
• Incidence rate in India is quite low about 2 to 8
per 100,000
• Median age- 7th decade but can occur any time in
adulthood

3. Etiology and risk factors
• The lifetime risk of colorectal carcinoma is 6%
in western population
1. Family history in first degree relative
i) FAP
ii) HNPCC
2. Inflammatory bowel disease
i) ulcerative colitis: 25% risk in 25 years
ii) crohn’s disease

4. Etiology and risk factors
3. Dietary fats –
• red meat fats
• 20% of diet as fat
4.Synergistic effect of alcohol and smoking with
increased risk

5. Adenoma to carcinoma sequence
• First described by DUKES in 1926
• The time course is 5-10 years
• Non inherited cases has ras, p53 mutations
• Malignant potential –
villous adenoma
Diameter >2cm

6. .

7. Diagnosis
• HISTORY
Symptoms : bleeding p/r , change in bowel
habit (fixed mass), pain in defecation
(sphincter)
Constitutional symptoms
Family history
Relevant medical conditions

8. Diagnosis
PHYSICAL EXAMINATION
• DRE : size, mobility, fixation, location, distance
from anal verge, relationship with anal
sphincter
• RIGID PROCTOSCOPY : distance from anal
verge, circumferential involvement ,
orientation, relationship with surrounding
structures

9. Diagnosis
PHYSICAL EXAMINATION
• COMPLETE COLONOSCOPY : synchronous
growth in 2-8%
• Pelvic examination in females and prostate
examination in males

10. AJCC 7th edition staging for colorectal ca

11. AJCC 7th edition staging for colorectal ca

12. AJCC 7th edition staging for colorectal ca

13. AJCC 7th edition staging for colorectal ca

14. Preoperative staging
• Abdominal and pelvic CT scan:
sensitivity
• for distant metastasis (75-87%)
• for perirectal nodal involvement (45%)
specifity considered close to 100%
• depth of transmural invasion (70%)
iv contrast for assessment of liver mets and
ureteral involvement

15. Preoperative staging
• Endoluminal ultrasound :
Accuracy of 80-95% for T staging
Instrumental in assessing T1 & T2 lesions
Con: intra-observer difference, understage the
tumor

16. Preoperative staging

17. Preoperative staging
ENDOSCOPIC ULTRASOUND STAGING OF RECTAL TUMORS
uT1 Invasion confined to mucosa and submucosa
uT2 Penetration of muscularis propria but not through to the mesorectal fat
uT3 Invasion into the perirectal fat
uT4 Invasion into the adjacent organ
uN0 No enlargement of lymph nodes
uN1 Perirectal lymph node enlarged

18. Preoperative staging
• ENDORECTAL COIL MRI :
Larger field of view
less operator dependent
Assessment of stenotic tumor
Identification of perirectal nodes (accuracy of
95%)
Identification of sphincter involvement (100%)

19. Preoperative staging
• PET
For assessing the pathological response of
primary tumor to pre-op chemoradiation
Metastasis in brain and bones

20. Preoperative staging
• CEA (carcinoembryonic antigen )
Baseline CEA preoperatively for
staging,
assessment of prognosis (>5ng/ml worse
prognosis)
Presence of persistence disease after
resection

21. GOAL OF SURGERY
• PRIMARY GOAL IS ERADICATION OF PRIMARY
TUMOR ALONG WITH ADJACENT
MESORECTAL TISSUE AND SUPERIOR
HEMORRHOIDAL ARTERY PEDICLE

22. RESECTION MARGIN
• Traditional margin of 5cm
• NSABP demonstrated no difference in survival
or local recurrence in distal margin of 2, 2-2.9,
>3cm
• Therefore, 2cm distal margin Is now
acceptable considering the limitation of distal
intramural spread of 2cm below the
peritoneal reflection

23. RESECTION MARGIN
• Circumferential radial margin is more crucial
• Length of mesorectum removed beyond the
primary tumor is between 3 to 5 cm as tumor
implants have not been shown further than
4cm

24. LOCAL EXCISION
• Provide adequate oncological control with
significantly less morbidity than APR in a
subset of patients.

25. LOCAL EXCISION
Tumors amenable to local excision
• T1N0 or T2N0 lesion
• <4cm in diameter
• <40% in circumference of lumen
• <10 cm from dentate line
•Well to moderately differentiated histology
• No evidence of lymphatic or vascular invasion
• Local control for advanced disease

26. LOCAL EXCISION
TECHNIQUES:
Transsphincteric excision
Transanal excision
Transcoccygeal excision
Transanal endoscopic microsurgery

27. LOCAL EXCISION
TRANSANAL EXCISION
• Tumors 6-8 cm from anal verge
• 1 cm circumferential margin
• Full thickness excision

28. LOCAL EXCISION
TRANSANAL EXCISION

29. LOCAL EXCISION
TRANSCOCCYGEAL EXCISION
• Popularized by KRASKE
• Useful for more proximally placed, posterior
lesions
• 1 cm circumferential margin
• Complication: fecal fistula ( 5 to 20%)

30. LOCAL EXCISION
TRANSCOCCYGEAL EXCISION

31. LOCAL EXCISION
• TRANSANAL ENOSCOPIC MICROSURGERY
• the procedure of choice for early mid to upper
rectal lesion
• Offers better visualization, complete intact
excision

32. LOCAL EXCISION

33. LOW ANTERIOR RESECTION WITH TME
• 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)

34. LOW ANTERIOR RESECTION WITH TME
PROCEDURE :
A. MOBILIZATION OF COLON
B. TRANSECTION
C. RECONSTRUCTION
Double stapling technique
• Diverting loop ileostomy
• Colonic pouch/ transverse coloplasty

35. LOW ANTERIOR RESECTION WITH TME

36. LOW ANTERIOR RESECTION WITH TME
Specific complications
• Impotence (10-28%)
• Retrograde ejaculations
• Urinary incontinence

37. LOW ANTERIOR RESECTION WITH TME
TME ALONE (%) TME+RT (%) TME +LND (%)
LOCAL
RECURRENCE
12.1 5.8 6.9
LATERAL PELVIC
RECURRENCE
2.7 0.8 2.2
PRESACRAL
RECURRENCE
3.2 3.7 0.6

38. ABDOMINOPERINEAL DISSECTION
Suitable for
• Cancers involving the sphincter apparatus
• Incontinent to feces
Very High morbidity (61%)
Mortality 0 to (6.3%)

39. ABDOMINOPERINEAL DISSECTION
Complications:
• Perineal wound complications (25%)
• Urinary incontinence (as high as 50%)
• Sexual dysfunction (as high as 67%)
• Stoma complications
(ischemia, retraction, hernia, stenosis , prolapse)

40. ABDOMINOPERINEAL DISSECTION
En block excision :
• Posterior vaginectomy ( 1cm margin)
• prostatectomy
• Pelvic exenteration
( high morbidity and mortality )
Consider prophylactic bilateral oopherectomy

41. CHEMORADIATION
ADVANTAGES OF NEOADJUVANT CHEMOTHERAPY
• Downstage the tumor (60-80%)
• Achieve complete pathological response (15-30%)
• To allow sphincter preserving procedures
• No radiation to anastomosis, small bowel in pelvis

42. CHEMORADIATION
• 1990 NIH consensus concluded the efficacy in
local control in stage II & III
• To lower local failure rates and improve survival
in resectable cancers
• to allow surgery in primarily inoperable cancers
• to facilitate a sphincter-preserving procedure
• to cure patients without surgery: very small
cancer or very high surgical risk

43. CHEMORADIATION
 5Fu
 Leucovorin
 Oxaliplatin
 Irinotecan
 Bevacizumab
 cetuximab
Combinations
 FOLFOX
 FOLFIRI
 Leucovorin/5FU
 Capecitabine
 Bevacizumab in
combination with the
above regimens.
Chemotherapy agents

44. Pre-op RT vs. surgery alone
Swedish Rectal Cancer Trial (NEJM 1997;336:980 ): 1168 patients
randomised to 25 Gy (5x5) PRT or no RT.
Surgery alone Preop. RT
Rate of local recurrence 27% 11% p<0.001
5-year overall survival 48% 58% p=0.004
Dutch Colorectal Cancer Group (Kapiteijn E. NEJM
2001;345:638): 1861 patients randomised TME vs PRT+TME
TME PRT+TME
Recurrence rate 8.2% 2.4%
OS ns ns

45. Pre-op vs. post-op Chemo RT
Randomized trial of the German Rectal Cancer study
Group (Sauer R et al. N Engl J Med 2004;351:1731-40):
Preop CRT Postop CRT
Patients N=415 N=384
5 y. OS 76% 74% p=0.8
5 y. local relapse 6% 13% p=0.006
G3,4 toxic effects 27% 40% p=0.001
• Increase in sphincter-preserving surgery with preop Th.
• No difference in overall survival or disease free survival at 4 years

46. Polish Trial
• Polish Study (Br J Surg. 2006): 316 patients with resectable T3-4 rectal
cancer, no sphincter involvement, tumor palpable on DRE (1999-2002).
Preop short Preop
course RT conventional
RT
5 y. OS 67.2% 66.2%
5 y. local relapse 9.0% 14.2%
DFS 58.4% 55.6%
NO difference in anorectal or sexual dysfunction

47. CURRENT RECOMMENDATION
•Primary
surgery
•No adjuvant
therapy
Stage I

48. CURRENT RECOMMENDATION
• Neoadjuvant Chemoradiation
( 5-FU based chemotherapy
with radiotherapy )
• Rest for 4-8 weeks
• Total mesocolic excision
• Rest for 4 weeks
• Chemotherapy in appropriate
patients for 4-6 months
STAGE
II or III
low/
midlesio
n

49. CURRENT RECOMMENDATION
• Pre or post op
chemoradiation
•TME
Stage II
or III
High
lesion

50. CURRENT RECOMMENDATION
• Palliative surgery
• Adjuvant
chemotherapy
• 5-FU + leucovorin
+/- irinotecan or
oxaliplatin
STAGE
IV

51. SURVEILLANCE
• Screening for rectal recurrence and
metachronous colorectal neoplasm
• 60- 80% recurrence in 24 months, 90% in 48
months
• Each visit DRE+ sigmoidoscopy + CEA
• CT scan : 1 year postresection and then
annually till 3 years

52. SURVEILLANCE
• Postoperative at 2 weeks and then every 3
months for 2 years
• After 2 years every 6 months for 5 years
• If no recurrence, then colonoscopy every 3-5
years
• Close observation for high risk patients

53. REFERENCES
1. Maingots’s abdominal operations 12th ed
2. ACS surgery7 , 2014 ed
3. Sabiston’s textbook of surgery, 18th ed
4. NCCN practical guidelines in oncology
v.2.2009
5. Practice Parameters for the Management of
RectalCancer (Revised)
J. R. T. Monson, M.D. • M. R. Weiser, M.D. • W. D. Buie, M.D. • G. J. Chang, M.D.
J. F. Rafferty, M.D.; Prepared by the Standards Practice Task Force of the American Society of Colon and Rectal
Surgeons

54. Thank you