Rectal cancer
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Rectal cancer is the second most common cause of cancer death after lung cancer. It occurs most often in those over 50 years old. Adenocarcinoma makes up 98% of rectal cancers. Diagnostic workup includes physical exam, proctoscopy, colonoscopy, MRI or CT scan to determine tumor stage. Treatment depends on stage but may include surgery such as transanal resection or total mesorectal excision, with the goal of removing the tumor and lymph nodes. Chemotherapy and radiation therapy are also often used. Prognosis depends on stage, with 5-year survival rates over 90% for early stage but less than 3% for metastatic disease.
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Rectal cancer
- 1. Rectal Cancer Dr. Sultan Zahir
- 2. Rectal Cancer Rectal cancer is a disease in which cancer cells form in the tissues of the rectum; colorectal cancer occurs in the colon or rectum. Adenocarcinomas comprise the vast majority (98%) of colon and rectal cancers; more rare rectal cancers include lymphoma (1.3%), carcinoid (0.4%), and sarcoma (0.3%). Second most common cancer death after lung cancer. Lifetime risk 1 in 10 for men 1 in 14 for women Generally affect patients > 50 years (>90% of cases)
- 3. 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
- 4. Clinical Presentation Bleeding is the most common symptom of rectal cancer, occurring in 60% of patients. However, many rectal cancers produce no symptoms and are discovered during digital or proctoscopic screening examinations. Other signs and symptoms of rectal cancer may include the following: Change in bowel habits (43%): Often in the form of diarrhea; the caliber of the stool may change; there may be a feeling of incomplete evacuation and tenesmus Occult bleeding (26%): Detected via a fecal occult blood test (FOBT) Abdominal pain (20%): May be colicky and accompanied by bloating
- 5. Back pain: Usually a late sign caused by a tumor invading or compressing nerve trunks Urinary symptoms: May occur if a tumor invades or compresses the bladder or prostate Malaise (9%) Pelvic pain (5%): Late symptom, usually indicating nerve trunk involvement Emergencies such as peritonitis from perforation (3%) or jaundice, which may occur with liver metastases (< 1%) ( Rectal metastasis travel along portal drainage to liver via superior rectal vein as well as systemic drainage to lung via middle inferior rectal veins.)
- 6. Examination Signs of primary cancer Abdominal tenderness and distension – large bowel obstruction Intra-abdominal mass Digital rectal examination – most are in the lowest 12cm and reached by examining finger Rigid sigmoidoscope Signs of metastasis and complications Signs of anaemia Hepatomegaly (mets) Monophonic wheeze Bone pain
- 7. Clinical Staging TNM Primary Lymph-node Distant Dukes stage tumor metastasis metastasis stage Stage 0 Tis N0 M0 A A Stage I T1 N0 M0 A A1 T2 N0 M0 A B1 Stage II T3 N0 M0 B B2 T4 N0 M0 B B2 Stage III A any T N1 M0 C C1/C2 B any T N2, N3 M0 C C1/C2 Stage IV any T any N M1 D D Astler-Coller modified Dukes stage
- 8. 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 Modified astler coller classification- Stage A : Limited to mucosa. Stage B1 : Extending into muscularis propria but not penetrating through it; nodes not involved. 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
- 9. Tis T1 T2 T3 T4 Extension to an adjacent organ Mucosa Muscularis mucosae Submucosa Muscularis propria Subserosa Serosa TNM Classification
- 10. Stage and Prognosis Stage 5-year Survival (%) 0,1 Tis,T1;No;Mo > 90 I T2;No;Mo 80-85 II T3-4;No;Mo 70-75 III T2;N1-3;Mo 70-75 III T3;N1-3;Mo 50-65 III T4;N1-2;Mo 25-45 IV M1 <3
- 11. 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
- 12. Colonoscopy or barium enema Figure: Carcinoma of the rectum. Double- contrast barium enema shows a long segment of concentric luminal narrowing (arrows) along the rectum with minimal irregularity of the mucosal surface. To evaluate remainder of large bowel to rule out synchronous tumor or presence of polyp syndrome.
- 13. Transrectal ultrasound –EUS use 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 (clinical important for planning sphincter preserving surgery) Figure. Endorectal ultrasound of a T3 tumor of the rectum, extension through the muscularis propria, and into perirectal fat.
- 14. 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% Ability to detect pelvic and para-aortic lymph nodes is higher than peri-rectal lymph nodes.
- 15. 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). 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).
- 16. Magnetic Resonance Imaging (MRI) Greater accuracy in defining extent of rectal cancer extension and also location & stage of tumor Also helpful in lateral extension of disease, critical in predicting circumferential margin for surgical excision. Different approaches (body coils, endorectal MRI & phased array technique) Mercury study: 711 patients from 11 European centers. Extramural tumor depth by MR & histo-pathological evaluation equivalent.
- 17. 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. 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).
- 18. 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 pubic bone bladder Small bowel
- 19. CEA: High CEA levels associated with poorer survival Routine investigation Complete blood count, KFT, LFT Chest X-ray
- 21. Surgical Options Trans-anal resection Anterior resection/CAA Abdomino-perineal
- 22. ■ Local excision • Transanal • Total mesorectal excision ■ Direct contact radiotherapy ■ Electrocautery Local Treatment (Low Rectal Cancer)
- 23. ■ Tumor < 8 cm from anal verge ■ Tumor size < 3 cm ( < 1/3 circumference) ■ Histology; well or moderately differentiated ■ UT1 or UT2 with or without radiotherapy ■ Absence of lymph nodes ■ Nonulcerated tumors ■ Mobile Ideal Criteria for Curative Local Treatment of Rectal Cancers
- 24. ■ Full thickness disc excision ■ 2 cm margin ■ Full thickness stay sutures ■ Use electrocautery ■ Closure of incision may implant or bury microscopic tumor Transanal Excision of Rectal Cancer
- 25. Transanal excision For T1 or T2 tumors Somewhat controversial due to higher local recurrence rates Only routinely used in older patients or those with co-morbidity
- 26. Surgical principles High vascular ligation (Corder, Br J Surg, 1992) Remove lymph node basin (Total Mesorectal Excision) “En bloc” resection if necessary
- 28. Total mesorectal excision Standardized technique 4 to 9% local recurrence rate Heald, Lancet 1986 Lavery, Surgery 1997 Heald, Arch Surg 1998 Dutch Trial suggests benefit with XRT
- 30. Anterior resection Cancer of the rectum Join colon to low rectum Permanent colostomy if tumor too low
- 31. Colorectal Anastomosis Suture by hand Staple with instrument Sometimes protect with temporary ostomy
- 32. Colonic J-pouch Proposed by Parc and Lazorthes 1986 6cm vs 12 cm pouch Increases reservoir Improves short term function, reduces leak rate
- 33. Coloplasty Fazio et al, DCR 2000
- 34. Concerns regarding Laparoscpic Surgery Learning curve Reduced ability to define distant disease Difficulty localizing lesion Adequacy of resection OR time and costs Port implantation of tumor