Rectal Cancer

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Rectal Cancer

• 1/5/11

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Pre-Op Staging

• Useful info
• Depth of penetration through the rectal wall
• Presence or absence of mets to regional lymph
  nodes
• Presence of distant mets
• Diagnostic tools
• Clinical exam
• CT
• MRI
• ERUS
• PET

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Pre-Op Staging

• Labs
• CEA
• LFTs
• Baseline CXR

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Hints in the History

• Tenesmus often indicative of larger cancer
• Constant anal pain or pain with defecation
  invasion of the anal sphincters or pelvic floor
• Incontinence not a candidate for
  sphincter-sparing procedure

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Tumor characteristics to assess on digital exam

• Location
• Morphology
• Number of quadrants involved
• Degree of fixation
• Mobility
• Extrarectal growths
• Direct continuity
• Separate

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Pearls on Physical Exam

• DRE
• Fixation to anal sphincter
• Relationship to anorectal ring
• Fixation to rectal or pelvic wall
• Rigid sigmoidoscopy
• How much normal rectum lies distal to lower
  border of tumor

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Clinical Staging System
Clinical Stage Mobility Path correlation (level of invasion)
CS1 Freely mobile Submucosa
CS2 Mobile with rectal wall Muscularis propria
CS3 Tethered mobility Perirectal fat
CS4 Fixed/tethered fixation Adjacent tissues
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Treatment

• Current management more varied and complex
• Multimodality therapy
• Refinements in surgical techniques

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Factors determining treatment

• Surgical anatomy
• Depth of invasion
• Lymph node status
• Metastatic disease
• Palliation should be the goal in patients for
  whom curative resection is not possible
• If patient is reasonable operative risk,
  palliative resection may lead to better quality
  of life
• Diversion can improve immediate status if primary
  is not resectable
• Nonoperative therapy should be considered with
  significant metastatic disease

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Total Mesorectal Excision (TME)

• Precise sharp dissection and removal of the
  entire rectal mesentery, including that distal to
  the tumor, as an intact unit
• Autonomic nerve preservation
• Complete hemostasis
• Avoidance of violation of the mesorectal envelope
• Hypothesis that the field of rectal cancer spread
  is limited to this envelope and total removal
  encompasses virtually every tumor satellite

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Surgical Therapy

• Three major curative options
• Local excision
• Sphincter-saving abdominal surgery
• APR
• Each patient should be viewed individually and a
  plan devised based on their stage, gender, age,
  body habitus

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APR

• First described in 1908
• Candidates are patients whose tumors have invaded
  the anal sphincters or are so close to the
  sphincter that a safe distal margin cannot be
  obtained
• Poor continence may benefit from APR

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LAR

• Maintain continuity and preserve sphincter
  function
• /- diverting loop ileostomy

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Local Excision

• PATIENT SELECTION REMAINS KEY!!
• Take into account certain pathologic features
• Depth of invasion
• Lymphatic invasion
• Histologic grade
• Clear negative margins at the time of resection
• Patients considered medically unfit for major
  resection may be good candidates for local exc

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Local excision

• Preserves anal sphincter anatomy and function
• Small T1 and T2 lesions
• T2 lesions probably should not have surgery alone
• Preop or postop adjuvant chemoradiation is of
  benefit
• Currently not recommended for T3 lesion

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Local Excision

• Properties of the tumor
• lt4 cm in diameter
• lt40 of bowel circumference
• Within 10 cm of dentate line
• Freely mobile on DRE
• ERUS findings
• T1 or T2
• Negative nodes

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Techniques

• Transanal excision
• 1-2 cm margin
• Transcoccygeal excision (Kraske approach)
• Middle or distal third of rectum, especially
  along posterior wall
• Removes perirectal nodes
• Transsphincteric excision
• Increased risk of incontinence
• TEM
• Special resectoscope, better for more proximal
  lesions

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Treatment recommendations after initial resection
T stage Low risk High risk
T1 No further treatment Adjuvant chemoradiation
T2 Adjuvant chemoradiation Radical resection
T3 Radical resection Radical resection
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Stage I (T1N0, T2N0)

• Distal T1
• Local excision
• Radical resection, often APR
• Adjuvant therapy usually not recommended
• Distal T2
• Local excision with preop or postop adjuvant
  therapy
• Radical resection without adjuvant therapy, often
  APR

• Mid T1
• TEM
• Radical resection, usually LAR
• Adjuvant therapy not recommended
• Mid T2
• TEM with pre or postop adjuvant therapy
• Radical resection similar to T1
• Adjuvant therapy not recommended for radical
  resection
• Upper T1 and T2
• LAR

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Stage II (T3N0) and Stage III (TanyN)

• Distal
• Preop adjuvant therapy followed by radical
  resection
• If preop imaging does not clearly define stage,
  resection can be done first, followed by postop
  adjuvant therapy

• Mid
• Same as distal except usually LAR can be
  performed
• Upper
• LAR, with either preop or postop adjuvant therapy

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