Christian Medical College and Hospital , Ludhiana

1. By
Dr Parneet Singh

2. Epidemiology
 Colorectal caner is the third most frequently diagnosed
cancer in the US men and women.
 108,070 new cases of colon cancer and 40,740 new cases
of rectal cancer in the US in 2008. Combined mortality for
colorectal cancer 49,960 in 2008.
 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
 Median age- 7th decade but can occur any time in
adulthood
 Lifetime risk


1 in 10 for men
1 in 14 for women

3. Incidence in Large Bowel
• Cecum
14 %
• Ascending colon
10 %
• Transverse colon
12 %
• Descending colon
7%
• Sigmoid colon
25 %
• Rectosigmoid junct
0.9 %
• Rectum
23 %

4. Clinical Anatomy
 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

5. Clinical Anatomy
.
 Ends at the anorectal
junction, 2-3 cm in front of
and a little below the coccyx
 Taenia of the sigmoid colon
form a continuous outer
longitudinal layer of smooth
muscle
 Fatty omental appendices are
discontinued

6. Rectum is divided into 3
portions
 3 distinct intraluminal
curves ( Valves of
Houston)
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

7. Peritoneal Relations
 Superior 1/3rd of the rectum
 Covered by peritoneum on
the anterior
surfaces
and
lateral
 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.

8. Arterial Supply
 Superior rectal A – from
IMA; supplies upper
and middle rectum
 Middle rectal A- from
Internal iliac A.
(supplies lower rectum)
 Inferior rectal A- from
Internal pudendal A.

9. Venous Drainage
Superior rectal V- upper
& middle third rectum
Middle rectal V- lower
rectum and upper anal
canal
Inferior rectal vein- lower
anal canal

10. Nerve supply
 Sympathetic: L1-
L3, Hypogastric plexus
 ParaSympathetic: S2-S4

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

NODAL GROUPS
Perirectal
Common iliac
Internal iliac
Paraortic

12. Lymphatic Drainage

13. Aetiology
 Etiological agents
 Environmental & dietary factors
 Chemical carcinogenesis.
 Associated risk factors
 Male sex
 Family history of colorectal cancer
 Personal history of colorectal





cancer, ovary, endometrial, breast
Excessive BMI
Processed meat intake
Excessive alcohol intake
Low folate consumption
Neoplastic polyps.
 Hereditary Conditions (FAP, HNPCC)

15. Symptoms
 Asymptomatic
 Blood PR(60%)
 Change in bowel habit(43%) (diarrhoea, constipation,






narrow stool, incomplete evacuation, tenesmus)
Occult bleeding(23%)
Abdominal discomfort (20%)(pain, fullness, cramps,
bloating, vomiting)
Weight loss, tiredness
Back Pain
Urinary symptoms
Pelvic pain(5%) indicating nerve trunk involvement

16. Acute Presentations
 Intestinal obstruction
 Perforation
 Massive bleeding

17. Signs
 Pallor
 Abdominal mass
 PR mass
 Jaundice
 Nodular liver
 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.

18. Signs
 Signs of primary cancer
 Abdominal tenderness and distension – large bowel obstruction
 Intra-abdominal mass
Digital rectal examination – most are in the lowest 12cm &
reached by examining finger
 Rigid sigmoidoscope
 Signs of metastasis and complications
 Signs of anaemia
 Hepatomegaly (mets)
 Monophonic wheeze
 Bone pain

19. WHO Classification of
Rectal Carcinoma
 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

20. Dukes classification
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

21. Modified astler coller
classification Stage A : Limited to mucosa
 Stage B1 : Extending into muscularis propria
penetrating through it; nodes not involved
but not
 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

22. TX
T0
Tis
T1
T2
TNM Classification
Primary tumor cannot be assessed
No evidence of primary tumor
Carcinoma in situ: intraepithelial or invasion of lamina propria
Tumor invades submucosa
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
Tis
T1
T2 T3
T4
Mucosa
Muscularis mucosae
Submucosa
Muscularis propria
Subserosa
Serosa
Extension to an adjacent organ

23. TNM Classification

24. Stage grouping
Stage
0
I
IIA
IIB
T
Tis
T1
T2
T3
T4
N
N0
N0
N0
N0
N0
M
M0
M0
M0
M0
M0
Dukes
A
A
B
B
MAC
A
B1
B2
B3
IIIA
IIIB
IIIC
IV
T1-2
T3-4
Any T
Any T
N1
N1
N2
Any
N
M0
M0
M0
M1
C
C
C
-
C1
C2/C3
C1/C2/C3
D

25. Stage 0 Rectal Cancer
 Known as ―cancer in
situ,‖ meaning cancer
is located in the
mucosa.

26. Stage I Rectal Cancer
 The cancer has grown
through the mucosa
and invaded the
muscularis (muscular
coat)

27. Stage II Rectal Cancer
 The cancer has grown
beyond the muscularis
of the colon or rectum
but has not spread to
lymph nodes

28. Stage III Rectal Cancer
 Cancer has spread to
the regional lymph
nodes (lymph nodes
near the colon and
rectum)

29. Stage IV Rectal Cancer
 Cancer has spread
outside of colon or
rectum to other areas of
the body

30. 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
LVSI
Signet cell carcinoma
High CEA
Tethered and fixed
cancer

31. Stage and Prognosis
Stage
5-year Survival (%)
0,1
Tis,T1;No;Mo
> 90
I
II
T2;No;Mo
T3-4;No;Mo
80-85
70-75
III
T2;N1-3;Mo
70-75
III
T3;N1-3;Mo
50-65
III
IV
T4;N1-2;Mo
M1
25-45
<3

32. Japanese Scientists train
Dogs to detect Colorectal
Cancer ( Gut, 2011)

33. Diagnostic Workup
 History—including family history of colorectal cancer
or polyps
 Physical examinations including DRE and complete
pelvic examination in women:
size, location, ulceration, mobile vs. tethered vs.
fixed, distance from anal verge and sphincter functions.
 Proctoscopy—including assessment of
mobility, minimum diameter of the lumen, and distance
from the anal verge
 Biopsy of the primary tumor

34. Diagnostic Evaluation
 General
Clinical features.
 Lab. Studies
Complete blood cell count
Blood chemistry profile
CEA
 Evaluation

Determination of Occult Blood
Digital Rectal Examination
Proctosigmoidoscopy
Flexible Fibreoptic Sigmoidoscopy & Colonoscopy.
Barium Enema
• Urologic Evaluation
• Other Imaging studies
• CT, USG, MRI, Chest X-ray, FDG- PET scan, Endorectal U/S.

35. Colonoscopy or barium
enema
To evaluate remainder of large bowel to rule out
synchronous tumor or presence of polyp syndrome.
Figure: Carcinoma of the rectum. Doublecontrast barium enema shows a long
segment of concentric luminal narrowing
(arrows) along the rectum with minimal
irregularity of the mucosal surface.

36. Transrectal Ultrasound
 Used for clinical staging.
 80-95% accurate in tumor




staging
70-75%
accurate
in
mesorectal lymph node
staging
Very good at demonstrating
layers of rectal wall
Use is limited to lesion < 14
cm
from
anus,
not
applicable for upper rectum,
for stenosing tumor
Very useful in determining
extension of disease into
anal canal (imp to plan
sphincter
preserving
surgery)
Figure.Endorectal ultrasound
of a T3 tumor of the
rectum, extension through the
muscularis propria, and into
perirectal fat.

37. EUS : Accuracy
EUS CT
Depth of infiltration T staging
91% 71%
N staging
87% 76%

38. CT Scan
 Part of routine workup of patients
 Useful in identifying enlarged pelvic lymph-nodes and
metastasis outside the pelvis than the extent or stage of
primary tumor
 Limited utility in small primary cancer
 Sensitivity 50-80%
 Specificity 30-80%

39. CT Scan
 Ability to detect pelvic and para-aortic lymph nodes
is higher than peri-rectal lymph nodes(75% to 87%
vs. 45%)
Accuracy
T stage
60-80%
Accuracy
N stage
60-75%
Liver met.
70-79%

40. Figure:
Rectal cancer with uterine
invasion. CT scan shows a large
heterogeneous rectal mass (M) with
compression and direct invasion into the
posterior wall of the uterus (U).
Figure: Mucinous adenocarcinoma of the
rectum. CT scan shows a large
heterogeneous mass (M) with areas of
cystic components. Note marked luminal
narrowing of the rectum (arrow).

41. Magnetic Resonance
Imaging (MRI)
 Greater accuracy in defining extent of rectal cancer
extension and also location & stage of tumor
 Helpful in lateral extension of disease, critical in
predicting circumferential margin for surgical excision.
 Different approaches (body coils, endorectal MRI &
phased array technique)

42. Figure: Normal rectal and perirectal
anatomy on high-resolution T2-weighted
MRI. Rectal mucosa (M), submucosa
(SM), and muscularis propria (PM) are
well discriminated. Mesorectal fascia
appears as a thin, low-signal-intensity
structure (arrowheads) and fuses with the
remnant of urogenital septum making
Denonvilliers fascia (arrows).
Figure: Mucinous adenocarcinoma of the
rectum. T2-weighted MRI shows high
signal intensity (arrowheads) of the cancer
lesion in right anterolateral side of the
rectal wall.

43. PET with FDG
 Shows promise as the most sensitive
study for the detection of metastatic
disease in the liver and elsewhere.
 Sensitivity of 97% and specificity of
76% in evaluating for recurrent
colorectal cancer.
cancer
rectum
prostate
Small bowel
bladder
pubic bone

44. 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 QOL.
 Careful preoperative screening is crucial in
determination of the location of lesion and its
depth of invasion

45. Treatment
Surgery
Chemotherapy
Radiotherapy

46. Treatment Overview
 Sx mainstay of treatment.
 After curative resection the 5 year survival drops
from 80% in stage I to about 40% in stage III
disease.
 Local recurrence remains a major site of failure
ranging from 5% in few selected series to about
40% in most reports.
 LF associated with devastating symptoms that
severely affects the QOL & difficult to salvage

47. Principles of surgical
management
 Removal of primary tumor with adequate margin.
 T/t of draining LN.
 Restoration of function
 ―En bloc‖ resection if necessary

48. PELVIC SUBSITES
Five subsites :predominant areas at risk for local
recurrence:
 Mesorectal subsite (MS),
 Posterior pelvic subsite (PPS)
 Lateral pelvic subsite (LPS)
 Inferior pelvic subsite (IPS)
 Anterior pelvic subsite (APS)

49. PATERN OF NODAL
RECURRENCE
 MS less common as it gets totally removed in
TME
 PPS most common site of nodal recurrence 22
to 49% in various series.
 LPS around 21%
 IPS around 3 to 11%
 APS around 5 to17%

51. Surgical procedures for
Rectal ca
 APR ( abdomino-perineal resection).
 LAR ( Low ant. Resection)
Radical
 Proctectomy & colo-anal anastomosis
 Local excision



Transanal excision
Post. Proctotomy
Non-Radical
Trans-anal endoscopic microsurgery(TEM).
 Ablative procedures
Endoscopic surgery
Fulguration

52. Local excision
 For superficially invasive (T1) tumors with low






likelihood of LN metastases
Total biopsy, with further T/t based on pathology
Tumors within 8 to 10 cm of anal verge,
Encompass less than 40% of circumference of bowel wall,
well or moderately well differentiated histology,
No pathological evidence of venous or lymphatic vessel
invasion on biopsy
With unfavorable pathology patient should undergo
total mesorectal excision with or without sphincterpreservation:
 Positive margin (or <2 mm), lymphovascular invasion,
 Poorly differentiated tumors, T2 lesion

53. Local Excision Techniques
 Transanal Excision.
 Post proctotomy.
 TEM
 Fulguration
 Endoscopic laser
 Staging of such lesions should be performed using EUS
to minimize likelihood of doing a local excision for T3
tumors.

54. LAR
 For tumors in upper/mid rectum allows
preservation of anal sphincter
 Join colon to low rectum
 Permanent colostomy if tumor too low
w
 Reduced ability to define distant
disease
 Difficulty localizing lesion
 OR time and costs

55. Abdomino-perineal
resection
 For tumors of distal rectum(lower 1/3rd) with distal edge
up to 6 cm from anal verge
 Associated with permanent colostomy and high
incidence of sexual and genitourinary dysfunction

56. Procedure
 Through combined abdominal and perineal
incisions, the anus, rectum, and sigmoid colon
are removed en bloc.
 Also called Miles Resection
 The proximal end of the bowel is exteriorized
through a separate stab wound as a
colostomy.
 The distal end is pushed into the hollow of the
sacrum and removed via perineum
 Performed to treat cancer of the lower
rectum—and diseases are too low for use of
stapling devices

57. Heavy purse string suture
around anus to occlude it

58. Colon and Rectum are
delivered through the
perineal resection

60. 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.
 Excision of fascia enveloping the fat pad around the rectum
 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)

61. TOTAL MESORECTAL
EXCISION

62. Total Mesorectal
Excision

63. Pelvic Exenteration
The surgeon removes the rectum as well as nearby organs such as the
bladder, prostate, or uterus if the cancer has spread to these organs.
A colostomy is needed after this operation. If the bladder is
removed, a urostomy (opening to collect urine) is needed.
High Anterior Resection
15 cm
Low Anterior Resection
Ultra-low Anterior Resection
Abdominoperineal Resection (APR)

64. Complications of Surgery
 Bleeding
 Infection
 Anastomotic Leakage
 Blood clots
 Anesthetic Risks

65. SUMMARY OF BOWEL FUNCTION IN THE 2 GROUPS
Non-Radiation
(59 Patients)
No. of bowel movements/day
Medican (range)
4
Clustering
5
Awoken at night for movement
Incontinence
None
Occasional
Frequent
Wear a pad
Perianal skin irritation
Regularly use Lomotil ± Imodium
Unable to differentiate stool from gas
Liquid consistency (sometimes or always)
Unable to defer defecation >15 min
Need to defecate again within 30 min
Bowel function different to preoperative
2 (1-7)
83%
3%
14%
14%
–
93%
7%
0%
10%
12%
5%
15%
5%
19%
37%
61%
Chemoradiotherapy
(41 Patients)
7 (1-20)
22%
42%
37%
46%
–
44%
39%
17%
41%
41%
58%
39%
29%
78%
88%
93%
p Value
<0.001
–
–
–
<0.001
<0.001
–
–
–
<0.001
<0.001
<0.001
0.009
0.001
<0.001
<0.001
0.001
JH012804

66. Adjuvant therapy
Chemotherapy
Radiation therapy
with or without
chemotherapy

67. Purpose of
Radio(chemo)therapy
 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

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

69. PREOPERATIVE CHEMORADIATION
 NSABP R-03 : improved DFS & OS
 German trial : improved locoregional control.
 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.

70. POSTOPERATIVE CHEMORT :
 EORTC 22921 trial : improved DFS & OS.
 MOSAIC trial : Addition of oxaliplatin + 5- FU + leucovorin
.
REGIMENS :
 5-FU : bolus weekly regimen ( leucovorin 20 mg/m2 over 2
hrs : 5- FU 500 mg/ m2 bolus
 if no neoadjuvant chemoRT :
 Weekly Roswell Park regimen : 5-FU + leucovorin
( leucovorin 500 mg /m2 given over 2 hrs followed by 5-FU
bolus ) : weekly over 6 wks then 2 wks rest .
 mFOLFOX 6
 Capecitabine 1000 – 1250 mg/ m2 from day 1-14 ( 21 day
cycle )

71. Role of Radiotherapy
 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 – Pain, bleeding etc.

72. 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.

73. TARGET VOLUME
 Site of local involvement
 spread to other organ - sacrum, vagina or
prostate
 Whole of the sacrum
 Posterior margin should be beyond the sacrum
 Anterior border 2-3 cm anterior to the promontry
of sacrum to include common iliac LN

74. Positioning
 Prone position with belly
board
 Purpose is to displace
bowel superior and
anteriorly & bladder
anteriorly
 Bladder distension
 Blocks are used to spare
the posterior muscle and
soft tissues behind the
sacrum and small bowel.

75. Treatment energy
 PA portal with 6MV to decrease bladder dose
 Lateral portal requires 10/15 MV to increase depth
dose and decrease dose to hip joints
 30 degree wedges improves distribution
 Portals
 4 fields (AP, PA, two lateral fields)
 3 fields (PA, two lateral fields)
 2 fields(AP,PA-rarely used)

76. PA Borders – Pre Op
Case In most cases upper border

lies at L5-S1 junction to
cover Sacral promontary.
 Inferior margin should be 34 cm below inferior tumour
extent on sigmoidoscopy.
 For upper rectal Ca, inferior
border upto dentate line(
cover all mesorectum)
 Lateral border -1.5 cm
beyond the bony pelvic wall

77. Lateral portal
 Upper Border- L5-S1
 Lower Border 3-5 Cm below
inferior Tx extension
 Posterior border should be
atleast 1 cm behind sacral
convexity
 Anterior border at pubic
symphysis*(T3-T4)

78. Issues in Postoperative RT
of Rectum
 Increased risk of bowel toxicity
Adhesions
Bowel sags in pelvic cavity
Large portals
1.
2.
Anastomotic site in ANTERIOR RESECTION
Perineal scar in APR

79. PA Borders – Post Op
Case
 In case of APR, inferior border
should cover perineal scar
 8-30% scar recurrence if scar
not included in field
 While only 2% reoccur if scar
included in portal

80. Lateral Borders – Post Op
Case
 In case of APR, inferior border
should cover perineal scar

81. Dose Distribution: 3
Fields / 30w

82. Dose Distribution: 3 Fields
/ 45w

83. DVH

84. 3 Field / Open

85. Bilateral Portals

86. Portals- Two Fields : APPA
 Parallel opposing not commonly used
 High dose to bladder and bowel
 Used in palliative cases & when bladder or
anterior wall involved

87. 2 Fields AP / PA

88. DVH

90. Pre-Op radiotherapy
 Short course
25 Gy in 5 daily fractions of 5 Gy given in 1
week.
 Long course
 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(2 lat. Fields)

91. Post-Op Radiotherapy
 Phase 1
 45 Gy in 25 daily fractions of 1.8 Gy given in 5 week
 Phase 2 (optional)
 5.4–9 Gy in 3–5 daily fractions of 1.8 Gy(2 lat. fields)

92. 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(2 lat fields)
 A hypofractionated regimen can be used
 30–36 Gy in 5–6 fractions of 6 Gy once weekly given in 5–
6 weeks.

93. Dose limitations
 Small bowel- 45–50 Gy
 Femoral head and neck- 42 Gy
 Bladder -65 Gy
 Rectum- 60 Gy

95. CONTOURING
GUIDELINES

96. TARGET VOLUMES
 CTVA: Defined to be the regions that would always be
treated for rectal cancer
 Internal iliac
 Pre-sacral
 Peri-rectal
 CTVB:

External iliac nodal region
 CTVC:

Inguinal nodal region

97. GUIDELINES
 Lower Pelvis:
The caudal extent minimum of 2 cm caudal to
gross disease, including coverage of the entire mesorectum
to the pelvic floor
Extension of CTVA does not need to go more than a few
millimeters beyond the levator muscles unless there is
radiographic evidence of extension into the ischiorectal
fossa
For very advanced anal or rectal cancers, extending
through the mesorectum or the levators, add ~1-2 cm
margin up to bone wherever the cancer extends beyond the
usual compartments
An MRI and/or PET/CT scan is strongly recommended in
such cases.

98. Mid pelvis
The posterior and lateral margins of CTVA should
extend to lateral pelvic sidewall musculature or, where
absent, the bone.
Anteriorly extend CTVA to ~1 cm into the posterior
bladder, to account for day-to-day variation in
bladder position.
Include the posterior portion of the internal
obturator vessels (which lie between the external and
internal iliacs in the mid pelvis) with CTVA.

99. Upper pelvis:
 Superior extent - the rectosigmoid junction or 2 cm
proximal to the superior extent of macroscopic disease
in the rectum/peri-rectal nodes.
 This defines how much of the distal large bowel
within CTVA.
 Properly cover the internal iliac and pre-sacral
regions.
 The most cephalad aspect of CTVA - the common
iliac vessels bifurcate into external/internal iliacs
(landmark: sacral promontory).

100. Indications for elective
irradiation (CTVB+CTVC)
Elective coverage of the inguinal and external iliac regions
should be routine for anal carcinoma.
For rectal carcinomas extending into gynecologic or
genitourinary structures, the external iliac region should be
added (i.e. elective nodal coverage = CTVA + CTVB for
these cases).
Include the external iliacs for rectal cancers that extend
into the anal canal.
Electively irradiate the inguinal nodal region for rectal
adenocarcinomas that extend to the anal verge or peri-anal

101. OAR
The femoral head and neck should be avoidance
structures.
The small and large bowel are important structures to
consider when planning treatment.
The entire abdominal contents need to be contoured up to
~ 1 cm above the PTV.
Absolute volume of bowel (in cc) is more important than
relative volume (in %).

102. IORT radiation therapy (IORT) delivers a
 Intra-operative
concentrated dose of radiation therapy to a tumor
bed during surgery
 Dose range from 1250-2000cGy.
 Patient must be a surgical candidate in order to be
eligible for IORT
 Reserved for pts. with early-stage disease.

103.  Maximum effect, while minimizing recurrence
 Delivered immediately after tumor is removed,
helping to destroy the microscopic tumor cells
that may be left behind
 The tumor site is typically at high risk for
recurrence & traditional RT requires a recovery
period after surgery, which leaves microscopic
disease in the body for longer
 Spares healthy tissues and organs
 Shortened treatment times
 IORT T/t itself takes about 4 to 5 min.

104.  A "boost" for traditional radiation pts.
 Patients who must receive additional radiation
therapy following surgery can receive a boost of
radiation during IORT
After they have recovered from the surgical
procedure, they can continue with their RT with
fewer complications.

106. Endocavitary Radiation
 Propagated initially by Papillon and Sischy
 High doses low energy radiation delivered using
50 KVp unit
 Initially utilised applicator cones of 2.4 – 2.9 cm
dia
 Later intra-luminal catheters were used after
development of after-loading techniques.
 Dose at 1 cm depth = 1/3 rd of surface dose
 Since, very small volume very high doses can be
tolerated
 Multiple treatment done till CR achieved

107. Treatment Recommendations
Stage
Rectal cancer
~5-year LF/OS
I
• TME with APR or LAR.
• If pT1-2N0, no adj. treatment.
• Local excision for favorable tumors (<3 cm
size, <30% circumference, within 8 cm of anal
verge, well-moderately differentiated; margin
>3 mm, no LVSI/PNI).
 favorable T1 lesions- observation.
 T2 lesions - adjuvant 5-FU/RT
<5% LF
90% OS
II and III
(locally
resectabl
e)
• Pre-op 5-FU/RT LAR/APR adjuvant 5FU-based therapy × 3 cycles (preferred)
• If surgery initially  then adjuvant 5-FU × 2
cycles  concurrent chemoRT  5-FU ×2
cycles
T3N0 and T1-2N1:
5–10% LF
80% OS
T4N0 and T3N1:
10–15% LF
60% OS
T4N1 and T3/4N2:
15–20% LF
40% OS

108. Stage
III
(T4/ Locally
unresectable
)
Rectal cancer
If obstructed, diverting colostomy or stent
placed  definitive treatment. 5-FU/RT 
resection if possible. Consider
IORT for microscopic disease (after 50 Gy
EBRT, give IORT 12.5–15 Gy) or
brachytherapy for macroscopic disease 
adjuvant 5-FU-based therapy*
IV
Individualized options, including combination
5-FU-based chemo alone, or chemo ± resection
± RT
Recurrent
Individualized options.
If no prior RT, then chemoRT  surgery ±
IORT or brachytherapy.
If prior RT, then chemo surgery ± IORT or
brachytherapy as appropriate.
~5-year LF/OS

109. Clinical Trials

110. 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 2.4%
8.2%
OS
ns
ns

111. 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):
 cT3 or cT4 or node-positive rectal cancer
 50.4 Gy (1.8 Gy per day)
 5-FU: 1000 mg/m2 per day (d1-5) during 1. and 5. week
Preop CRT
Patients
5 y. OS
5 y. local relapse
G3,4 toxic effects
Postop CRT
N=415
76%
6%
27%
N=384
74% p=0.8
13% p=0.006
40% p=0.001
• Increase in sphincter-preserving surgery with preop Th.

112. • MRC CR07/NCIC-CTG C016 (Sebag-Montefiore et al.
2009): 1350 pt. with resectable rectal cancer randomized.
▫ 25 Gy/5# + Surgery (TME)
▫ Surgery (TME) + (45 Gy & 5 FU)
CRT
5 y. OS
5 y. local relapse
DFS
Preop RT
80.8%
4.4%
79.5%
Postop
78.7%
10.6%
74.5%

113. Polish Trial
• Polish Study (Br J Surg. 2006): 316 pts with resectable T3-
4 rectal cancer, no sphincter involvement, tumor palpable
on DRE (1999-2002).
– RT  short-course RT with 5 Gy/d x 5 days + Surgery
(TME)
– CRT  50.4 Gy (1.8 Gy /# over 5.5 weeks) + bolus 5-FU
325 mg/m²/d + LV x 5 days 1st and 5th wks of RT +
Surgery (TME)
Preop SCRT Preop LCRT
5 y. OS
5 y. local relapse
DFS
67.2%
9.0%
58.4%
66.2%
14.2%
55.6%

114. Post-op chemo, RT, and/or ChemoRT
 GITSG 7175 (Thomas and Lindblad, 1988): 227 patients with stage B2-C
rectal CA randomized postoperatively to:
 no adjuvant therapy vs.
 chemo alone vs.
 RT alone vs.
 concurrent chemoRT.
Result: Chemo-RT arm improved 5-year OS (54%) and LR(10%) over
observational arm OS (27%) & LR (25%).
 Mayo NCCTG 79-47-51 (NEJM 1991): 204 patients with T3/4 or
LN+(B2-C) randomized to
 post-op RT (45–50.4 Gy) vs.
 chemoRT (bolus 5-FU concurrent).
Result: Chemo-RT improved LF (25 14%), DFS, and OS (48 58%)
vs. RT alone.

115. Thank You !!