Management of Rectal Cancer

Kassahun G. (GSRII)
Zewditu Memorial Referral Hospital
March, 2020
 Outline
• Anatomy of the rectum
• Pathogenesis of rectal cancer
• Epidemiology
• Symptoms and signs
• Diagnostic work up
• Staging
• Surgical management
• Additional management options
• references
Anatomy
 Risk factors

• Age
• Heredity
• Environmental and Dietary Factors
• Inflammatory Bowel Disease
• Cigarette smoking
• Acromegally
• Pelvic irradiation
 Pathogenesis
Genetic Pathways
 The Loss of Heterozygosity Pathway

.80% percent of colorectal carcinomas

.FAP
 The Microsatellite Instability Pathway

.HNPCC (Lynch syndrome)

 CpG Island Methylation Pathway
Pathogenesis
• Pathologic types:
Adenocarcinoma 90-95%
Mucinous Adenocarcinoma 10%
Signet ring ca
Small cell (oat cell, adenosquamos) ca
Squamos cell ca
Undifferentiated (medullary) ca
 Epidemiology

• Colorectal carcinoma is the most common

malignancy of the gastrointestinal tract.
• The third most lethal cancer in the United States.
• The commonest cancer in males, in Addis Ababa.
• Absolute population risk at age 70 is 3–6%.
• The rectum is the second commonest site in
the colon
 Clinical presentation
• Constitutional symptoms
• Pelvic and/or perianal pain
• Chronic constipation, tennesmus, diarrhea
• Large bowel obstruction
• Bleeding
• Incontinence
• Symptoms related to local extension or distant
spread
 Investigations
• CBC, OFT, S/E, Serum albumin, coagulation pro
• Rigid sigmoidoscopy, colonoscopy with biopsy
• Contrast Enema
• CEA
• Pelvic MRI or CT Scan with contrast
• CT scan of the abdomen, pelvis, and chest
• Endorectal U/S
• PET scaning
• Genetic testing
AJCC staging
 Surgical management

The goals of surgery are:

 To remove the tumor with adequate margins,
 Complete mesorectal package (TME)
 Perform an anastomosis only if there is good blood
supply, absence of tension, and normal anal
sphincters.
If any of these conditions cannot be met, the entire
Rectum shall be removed.
 Preoperative preparation
• Medical obtimization
• Correcting anemia
• Nutritional prehabilitation
• Bowel Cleansing
• Antibiotic prophylaxis
• Thromboembolic Prophylaxis
• Urinary Catheters/Stents.
• Preoperative marking of ostomy Site
• Preemptive Pain Management
 Options of surgery
It has to take into account
• the exact localization of the tumor
• the tumor stage
• the presence of synchronous colonic lesions or an
underlying colonic disease
• the risk for metachronous lesions
• the patient’s age and general condition
• the extent of the local procedure
• the condition of the sphincters
Transanal excision (full thickness or mucosal)

• T1 tumors only, mobile

• With in 8cm of the anal verge
• Well or moderately differentiated
• Size < 2.5 cm
• 1cm margin and full-thickness excision must be
feasible
• <30% circumferential involvement
• No lymphovascular invasion or PNI
• No evidence of LAP on pretreatment imaging
 Ablative techniques
• Electrocautery or endocavitary radiation can be
used.
• The disadvantage of these techniques is that no
pathologic specimen is retrieved to confirm the
tumor stage.
• Fulguration is generally reserved for extremely
high-risk, symptomatic patients with a limited life
span who cannot tolerate more radical surgery.
• Transanal endoscopic microsurgery (TEM
Commonly for polyps
upto 15cm from the anal verge
• Transanal minimally invasive surgery (TAMIS)
 Radical Resection

• Is referred to local therapy for most rectal

carcinomas.
• Involves removal of the involved segment of
the rectum along with its lymphovascular
supply.
• At least a 2-cm distal mural margin is required
for curative resections
 Total mesorectal excision (TME)

• Sharp dissection along anatomic planes to

ensure complete resection of the rectal
mesentery during low and extended low
anterior resections.
• For high anterior resections, a partial
mesorectal excision of at least 5 cm distal to
the tumor appears adequate.
• TME both decreases local recurrence rates
and improves long-term survival rates.
• It is associated with less blood loss and less
risk to the pelvic nerves and presacral plexus
than is blunt dissection.
• The principles of TME should be applied to all
radical resections for rectal cancer
 Stage-Specific Therapy
Stage 0 (Tis, N0, M0)
• Villous adenomas harboring carcinoma in situ
(high-grade dysplasia) are ideally treated with
local excision.
• A 1-cm margin should be obtained.
• Rarely, radical resection will be necessary if
transanal excision is not technically possible
(large circumferential lesions).
Stage I: Localized Rectal Carcinoma (T1-2, N0,
M0)
• Local excision increasingly is offered to
patients with small, low-risk lesions.
• Lesions with unfavorable histologic
characteristics and those located in the distal
third of the rectum, in particular, are prone to
recurrence.
• Adjuvant or neoadjuvant chemoradiation
should be given together with transanal
excision to improve local control.
• Radical resection is recommended in all good-
risk patients who are fit for surgery!
Locally Advanced Rectal Cancer (Stages II and III)

Stage II: Localized Rectal Carcinoma (T3-4, N0, M0)

 TME only Vs TME with adjuvant chemoradiation
• T4 tumor
• Tumor perforation
• undifferentiated tumor
• vascular and perineural invasion
• Inadequate lymph node sampling
• Preoperative CEA>5ng/ml
Stage III: Lymph Node Metastasis (Tany, N1, M0)
• TME
• Require pre-and post operative chemoradiation.
• According to the MERCURY study neoadjuvant
chemoradiation needed if the radial margin is
threatened or involved by the cancer or if anal sphincter
or other local organ invasion is present.
• In the United States, chemoradiation therapy is still
recommended for all patients with stage III disease and
the majority of patients with stage II disease.
 Techniques of Surgery
High anterior resection
• For resection of the distal sigmoid colon and upper rectum
• appropriate operation for benign lesions and disease at the rectosigmoid
junction such as diverticulitis.
• The upper rectum is mobilized, but the pelvic peritoneum is not
divided and the rectum is not mobilized fully from the concavity
of the sacrum.
• The inferior mesenteric artery is ligated at its base, and the inferior
mesenteric vein, which follows a different course than the artery, is
ligated separately.
• A primary anastomosis (usually end-to-end) between the colon and rectal
stump with a short cuff of peritoneum surrounding its anterior two thirds
generally can be performed.
Low Anterior Resection (LAR)
• Is used to remove lesions in the upper and mid
rectum.
• The rectosigmoid is mobilized, the pelvic peritoneum
is opened, and the inferior mesenteric artery is ligated
and divided either at its origin from the aorta or just
distal to the takeoff of the left colic artery.
• The rectum is mobilized from the sacrum by sharp
dissection under direct view within the endopelvic
fascial plane.
• The dissection may be performed distally to the anorectal
ring, extending posteriorly through the rectosacral fascia to
the coccyx and anteriorly through Denonvilliers’ fascia to the
vagina in women or the seminal vesicles and prostate in men.
• The rectum and accompanying mesorectum are divided at
the appropriate level, depending on the nature of the lesion.
• A distal resection margin of 2cm is required.
• A low rectal anastomosis usually requires mobilization of the
splenic flexure and ligation and division of the inferior
mesenteric vein just inferior to the pancreas.
 Extended Low Anterior Resection

• Is necessary to remove lesions located in the distal rectum,

but several centimeters above the sphincter.
• The rectum is fully mobilized to the level of the levator ani
muscle just as for a low anterior resection, but the anterior
dissection is extended along the rectovaginal septum in
women and distal to the seminal vesicles and prostate in
men.
• After resection at this level, a coloanal anastomosis can be
created using one of a variety of techniques.
• An end-to-end stapled or hand-sewn anastomosis has
traditionally been the procedure of choice.
• A history of sphincter damage or any degree
of incontinence is a relative contraindication
for a coloanal anastomosis.
Abdominoperineal Resection (APR)
• The rectum is mobilized via the abdominal route
and buried below the reconstructed pelvic
peritoneum; it is removed via a perineal route.
Abdominal portion
• A conservative incision is made in the peritoneum
on each side of the rectum.
• Conserving the peritoneum facilitates closure at
the end of the operation.
• Preparing and maturing a colostomy.
Perineal portion
• The dissection is not begun until the
abdominal operator has confirmed that the
rectum is resectable.
• The perineal phase of the operation is begun
by placing a heavy, silk pursestring suture
around the anus.
• An elliptical incision is made to encompass an
adequate margin of tissue.
• A wider margin is obtained for low-lying
lesions than for more proximal ones.
• The skin edges are then grasped with baby
Kocher clamps.
• Dissection continues upwards under the
perineal musce and to the pelvic floor.
Adjuvant vs Neoadjuvant
Stage IV: Distant Metastasis (Tany, N any, M1

• Survival is limited in patients with distant metastasis

from rectal carcinoma.
• Isolated hepatic and/or pulmonary metastases are
rare, but when present may be resected for cure in
selected patients.
• Radical resection may be required to control pain,
bleeding, or tenesmus, but highly morbid procedures
such as pelvic exenteration and sacrectomy should
generally be avoided in this setting.
• Local therapy using cautery, endocavitary
radiation, or laser ablation may be adequate
to control bleeding or prevent obstruction.
• Intraluminal stents and a proximal diverting
colostomy many be required to alleviate
obstruction.
Management
 Follow-up and Surveillance
• Patients who have undergone local resection of rectal tumors
should be followed with frequent endoscopic examinations
(every3–6 months for 3 years, then every 6 months for 2 years).
• CEA is often followed every 3 to 6 months for 2 years.
• CT scans are often performed annually for 5 years, but there are
few data to support this practice.
• More intensive surveillance is appropriate in high-risk patients
such as those with possible Lynch syndrome or T3, N+ cancers.
• Although intensive surveillance improves detection of resectable
recurrences, a survival benefit has never been proven.
Management of recurrent rectal ca
• More difficult to manage because of the proximity of other pelvic
structures.
• If the patient has not received chemotherapy and radiation, then
adjuvant therapy should be administered prior to salvage surgery.
• Radical resection may require extensive resection of pelvic
organs (pelvic exenteration with or without sacrectomy).
• Ideally, the aim of a salvage operation should be to resect all of
the tumor with negative margins.
• However, if the ability to achieve a negative margin is in question,
the addition of intraoperative radiation therapy (usually
brachytherapy) can help improve local control.
 References
• Schwartz principles of surgery, 11th edition
• Gordon principles and practice of surgery for
the Colon,Rectum and Anus, 3rd Edition
• Maingot’s Abdominal operations, 12th edition
• Washington manual of surgery
• NCCN Guidelines 2020
• UpToDate 21.6
Thank You!