Management of Rectal Cancer

Introduction
• How are rectal cancer different from colon
cancer?
– Sex predilection , colon M=F, rectal M>F
– Anatomy : Blood supply and lymphatic drainage
– Disease recurrence : rectal cancer are more difficult
to cure, recurrence : 15-45 % patients
– Invasion of nearby tissues :
• Colon cancer : in abdomen, much more room around it
• Rectal : tighter spot, pelvis, high chance of spreading to
nearby tissues
– Surgery : surgery for colon at any stage of disease
while surgery alone without chemo/RT
• Surgery for rectum is difficult then of colon
– Colostomy : rectal surgery : permanent colostomy
(d/t removal of anal sphincter, most of the times)
– RT : not for colon, but for rectal cancers (stage 2
and stage 3)
 Rectal cancer
Symptoms and signs
• Gross red blood, mixed with stool
• Change in bowel habbits and unexplained
constipation, diarrhoea
• Locally advanced rectal cancer : urgency,
inadequate emptying and tensesmus
• Urinary symptoms and perineal pain from
posterior extension : grave’s signs
• Sciatic pain : indicative of tumor invasion into
sciatic notch
 Examination
• Digital Rectal Examination :
– Assessed for size, ulceration and fixation to
surrounding structures
– Assess sphincter function
 Investigations
• For diagnosis
– Proctosignoidoscopy and
– Biopsy from the lesion
• For staging
– EUS
– CT of abdomen
– CT of thorax
– MRI
 Investigations for staging
• Local Information
– Tumor location
– Depth of invasion
– LN positivity
– Proximity to neighbouring structures
– Integrity of mesorectal envelope
– Lateral margin
– Local peritoneal involvement by tumor and
– Venous invasion
• Metastatic Work up :
 Endoscopy
• Not only for tumor detection and biopsy but
also for
– Tumor dimension assessment
– Distance from anal sphincter
– Relations to prostate and vagina
• Colonoscopy :
– To r/o synchronous lesions
 Transrectal Ultrasound : EUS
• 90% accurate in tumor staging
• 75% accurate in mesorectal lymph node staging
• Good at demonstrating layers of rectal wall
• Useful in determining the extension of disease
into anal canal
• Disadvantage :
– Use is limited to lesion <14 cm from anus, not
applicable for upper rectum, and for stenosing tumor
 CT scan
• Useful in identifying enlarged pelvic lymph
nodes and metastasis outside the pelvis than
the extent or stage of primary tumor
• Ability to detect pelvic and para aortic lymph
nodes is higher than peri-rectal lymph nodes
• Sensitivity : 50-80 %
• Specificity : 30-80%
• Limitation : in small primary cancer
 MRI
• Greater accuracy in defining extent of rectal
cancer extension and also location and stage
of tumor
• Also helpful in lateral extension of disease,
critical in predicting circumferential margin for
surgical excision
 Staging
• Critical information concerning the extent of
the disease
• Used to
– determine prognosis
– To guide management and
– To assess response to therapy
 Evolution of Rectal Cancer Staging
• Long Evolution
– 1926 : Lockhart – Mummery
– 1932 : Dukes
– 1949 : Kirklin, Dockerty and Waugh proposed
modification of Dukes classification
– 1954 : Astler and coller : Modified Astler Coller
classification (MAC)
– 1963 : Turnbell modification
– 1987 : AJCC and IUCC : TNM staging updated in 2002
and 2009 and 2018
• 1926, Lockhart – Mummery
– Depth of invasion and
– LN positivity in specimens removed at surgery
• 1932, Dukes
– Rectal cancer begins as epithelial proliferation
raising from the surface and carcinoma develops
from a previous adenoma
– Cancer metastasize through the bowel wall to
lymphatics
• 1949, Kirklin, Dockerty and Waugh
modification of Dukes staging
– Preserved A, B and C frameworks and added
subscript 1 & 2 to B
• B1 : lesions that have extended into but not through
the muscularis propria
• B2 : tumors that have penetrated the muscularis
propria
• 1954, Astler and Coller
– Modified Astler Coller Classification
• 1963, Turnbell et al added stage D
– St D : tumors metastasized to lung, liver, bone and
adjacent structures
• 1987 : AJCC & IUCC : TNM staging