Management of

Carcinoma Rectum
Budhi Nath Adhikari
Clinical Evaluation :
History
Often asymptomatic
Symptoms occur late
Rectal complaints, non specific
Risk factors
Physical Examination
DRE – palpable mass
Liver enlargement, previous operations
Assessment of the patient's anal
sphincter

Investigation
Rigid proctosigmoidoscopcopy
feasibility of local excision and obtain an
adequate tissue biopsy
Endorectal ultrasound
Preoperative staging - depth and nodal
enlargement
Confirmation of nodal metastasis with
ultrasound-guided needle biopsy is less
reliable
Overstaging
less able to distinguish accurately T1 from T2
cancers, stenotic lesions and in patients with
prior radiation

CT scans
Regional tumor extension, lymphatic and
distant metastases, and tumor-related
complications such as perforation or fistula
formation.
Less accurate than endoluminal scan (local
spread, adjacent organ invasion) better
for distant metastasis and recurrent
disease detection
MRI
Larger field of view, less operator- and
technique-dependent, allows study of stenotic
tumors
Discriminate small-volume nodal disease and
subtle transmural invasion , local recurrence
Identifies involved perirectal nodes on the
basis of characteristics other than size
Identifies foci not only within the mesorectum
but also outside the mesorectal fascia
Double-contrast MRI may permit more accurate
T staging

Tumour marker
CEA
Up to 95% of patients with advanced
hepatic metastasis will have a CEA level
above 20 ng/mL.
Normal preoperative CEA levels will
identify patients who will not benefit
from following CEA levels
postoperatively

PET
Assessing the extent of pathologic response of
primary rectal cancer to preoperative
chemoradiation and may predict long-term
outcome.
Detection of recurrence of rectal cancer after
surgical resection and full-dose external-
beam radiation therapy
Relatively inaccurate for nodal metastases
Histopathologic examination of the specimen
obtained via biopsy or local excision
Chest x-ray or chest CT scan to exclude
pulmonary metastases
Subjective and objective assessment of
the patient's anal sphincter function
Prostate-specific antigen
Baseline investigations
TNM Staging
Describe the anatomic extent, planning
treatment, evaluating response to treatment,
comparing the results of various treatment
regimens, and determining prognosis
stage I, the tumor invades upto the muscularis
propria
stage II, the tumor invades completely through
this layer.
stage III, lymph node metastasis
stage IV, metastatic disease
TNM Staging
Poor prognostic
Poorly differentiated cancers
factors
Direct tumor extension into adjacent structures
(T4 lesions)
Lymphatic, vascular, or perineural invasion;
and
Bowel obstruction
Principles of Treatment

Surgical resection is the cornerstone of therapy

Liver metastasis
Superficially invasive, small cancers may be
managed effectively with local excision.
Deeply invasive tumors require major surgery:
LAR or APR
Locally advanced tumors adherent to adjoining
structures such as the sacrum, pelvic
sidewall, prostate, or bladder, require an even
more extensive operation.

Bowel Preparation with clear liquid
diet 1-3 days, laxatives and/or enemas,
peglec, Oral and Systemic Antibiotics

Goals of Surgery
The primary goal of surgical treatment for
rectal cancer is complete eradication of the
primary tumor along with the adjacent
mesorectal tissue , LNs and the superior
hemorrhoidal artery pedicle.
reestablishment of bowel continuity and
continence preferable
Resection Margin
2 cm distal margin, if not poorly differentiated
or distant spread
5 cm proximal margin recommended
Radial Margin of 5 cm - more critical than the
proximal or distal margin for local control and
is an independent predictor of both local
recurrence and survival
Local Excision
Disease-free survival may be less; 12% of T1
and 22% of T2 tumors should not have been
treated with local therapy ; some patients
require a salvage APR for ultimate cure.
Palliation of symptomatic but incurable rectal
cancers

Major risk factors for local recurrence : positive
surgical margins, trans-mural extension, and
poorly differentiated histology
Local failure or LN involvement in T1/T2
Repeat local procedures rarely indicated

Local Excision
Transanal procedure : Tumors 3 cm – 5 cm
from the dentate line but not invading the
sphincters .Day Care or OPD. Low morbidity
no mortality
Transcoccygeal Excision : Larger & tumors 5
– 7 cm from the dentate line esp posterior
wall. Immediate mesorectal tissue adjacent to
the tumor is removed along with perirectal
nodes. Fecal fistula
Transanal endoscopic microsurgery (TEM)
using Wolf operating microscope. Small
tumors 7-10 cm from the dentate line
Transanal fulguration
Local/contact radiation therapy (Papillon
approach).
Characteristics of Tumors
Amenable to Local Excision

T1N0 or T2N0 lesion

<4 cm in diameter
<40% circumference of the lumen
<10 cm from dentate line
Well to moderately differentiated histology
No evidence of lymphatic or vascular invasion on
biopsy
Patients with extensive metastatic disease and
poor prognosis who require local control
Adjuvant treatment for patients with lymphatic
invasion, T1 with poor prognosis features, T2
lesions
Radical Resection
APR with permanent colostomy : Distal Rectal
lesions involving the sphincter or incontinent pts
Low anterior resection with colorectal
anastomosis : Proximal rectal and midrectal
lesions
Hartmann Procedure
Pelvic Exenteration and Sacrectomy :Resection of
the anus, the rectum, the bladder, the ureters,
and the pelvic reproductive organs
The primary goal of radical resection is to remove
the rectal cancer, the rectosigmoid mesentery,
and the mesorectum with clear margins
APR
APR offers no survival advantage over
sphincter-sparing procedures
significant morbidity (Urinary complications,
perineal wound infections, sexual
dysfunction, change in body image ) of 61%
and mortality upto 6.3% with recurrences
upto 20%.
T3N0 moderately or well-differentiated
cancers invading less than 2 mm into
perirectal fat – low locoregional
recurrence

LAR: no incontinence, no extensive pelvic
disease, limited life expectation and lesion
with resected margin above internal sphincter
but risk of recurrence , anastomotic leak &
incontinence
body build, sex, obesity, lesion level, local
spread, perforation or abscess, size/fixation,
grade, obstruction, bowel preparation &
general medical condition.
Ultralow colorectal & coloanal anastomosis
together with a colonic pouch or coloplasty

Other Treatment Options
Laparoscopic TME
Endocavitary radiation
Electrocoagulation
Laser vaporization using neodymium:yttrium-
aluminum-garnet laser
Palliative Procedures
After surgical resection , improvement noted in
40% with bleeding, 70% with obstruction, and
20% with pain.
Seek comorbidities, and patient desires and
goals
Hidden Colostomy
High Ligation of Inferior Mesenteric Artery
Obstructing Cancer of
the Rectum
loop ileostomy
Usually T3 or N1 lesion: the patient is treated
with neoadjuvant chemoradiation and
considered for subsequent surgical resection
Intraoperative Radiation
Therapy

pelvic sidewall recurrence

peripheral neuropathy and ureteral stenosis
Neoadjuvant
Chemoradiation
T3 or N1 rectal carcinoma
bulky T2 lesions near the sphincters

Neoadjuvant therapy then is followed by TME
with APR or TME with an end-to-side, colonic
J-pouch, or coloplasty reconstruction.
no difference in overall survival
Advantages
significant decrease in the local recurrence rate
(6% versus 13%), as well as toxicity
ability to deliver higher doses of chemotherapy
downstage the tumor (60 – 80% cases)
achieve a pathologic complete response (15 –
30% cases)
Decreased radiation enteritis thereby more
complete radiation therapy
Adjuvant Chemoradiation

Eliminate the micrometastatic disease present

at the time of surgery.
Increased resectability,
Improves local control and survival in stage II
and III patients
Decreased distant metastasis
Regimens used: 5FU + Leucovorin
Adjuvant
Chemoradiotherapy
Recurrence
Inadequate removal , Implantation at suture
line , New Lesion
5% to 10% synchronous cancers and 30%
adenomatous polyps
Clinical detection
Workups
Related to the extent of transmural
disease and associated involvement of
regional lymph nodes


Between 60% and 84% of recurrences are seen
in the first 24 months and 90% within 48
months.
Median time to recurrence is 11–22 months.
Local recurrence rates ranges between 4% and
50%.
Radiotherapy or surgery
Follow-up: Clinical, CEA , Colonoscopy ,CT
THANK YOU
