ADVANCES IN SURGERY:

LOCALLY RECURRENT
RECTAL CANCER

GUIDE : PRESENTED BY:

DR. LATIKA SHARMA DR. HARSHIT SRIVASTAVA
PROF. & UNIT HEAD 2ND YEAR PG RESIDENT
UNIT – D UNIT – D
DEPT. OF GEN. SURGERY DEPT. OF GEN. SURGERY
CLINICAL ANATOMY OF THE
RECTUM
RECTAL CANCER
ETIOLOGY:

 Environmental & dietary factors

 Hereditary factors

MOST COMMON TYPE: Adenocarcinoma

Multiple in 5% of cases.
SYMPTOMS OF RECTAL CANCER:

 Most common: Per rectal bleeding

 Tenesmus

 Spurious diarrhea

 Bloody slime
DIAGNOSIS:

 Rigid sigmoidoscopy & biopsy

 Transrectal ultrasonography

 Endorectal coil MRI

 CECT
STAGING

 Duke’s classification

 Modified Duke’s classification

 TNM staging
DUKE’S CLASSIFICATION

 Stage A- confined to the bowel wall

 Stage B- penetrates the bowel wall

 Stage C- lymph node metastasis

 TNM STAGING
Tis T1 T2 T3 T4

Mucosa
Muscularis mucosae

Submucosa

Muscularis propria

Subserosa
Serosa
Extension to an adjacent organ
REGIONAL LYMPH NODES
 Nx- Regional LN can’t be assessed
 N0- No LN metastasis
 N1- 1-3 regional LN metastasis
 N2- ≥4 regional LN metastasis

METASTASIS
 M0- No distant metastasis
 M1- Distant metastasis
MANAGEMENT OF RECTAL
CANCER
 5-YEAR
STAGE MANAGEMENT SURVIVAL
RATE

STAGE 0 LOCAL EXCISION >90%

(Tis, N0, M0)

STAGE I • LOCAL EXCISION

(T1-2, N0, M0) • RADICAL RESECTION 80-85%

STAGE II PREOPERATIVE CRT

(T3-4, N0, M0) + 70-75%
RADICAL RESECTION
 5-YEAR
STAGE MANAGEMENT SURVIVAL
RATE

STAGE III PREOPERATIVE CRT 25-50%

(Tany, N1, M0) +
RADICAL RESECTION

STAGE IV • PALLIATIVE THERAPY

(Tany, Nany, M1) • RESECTION TO CONTROL <10%
PAIN, BLEEDING OR TENESMUS

PREOPERATIVE CRT +
RECURRENT SURGERY + IOERT
+/- CT
SURGICAL GUIDELINES FOR
TREATMENT OF RECTAL
CANCER
 Ideal bowel margin is ≥ 2 cm distally & ≥ 5 cm proximally

 Minimally acceptable distal margin for sphincter preservation is 1

cm.

 Lymphovascular resection should include a wide anatomic resection

of mesorectum, including

1. Mesorectal fascia propria

2. ≥ 4 cm of clearance distal to the tumor & proximal ligation of the primary feeding
vessel.
LOCALLY RECURRENT RECTAL
CANCER
 INCIDENCE

Reduction in the incidence of local

recurrence of rectal cancer from 30 – 40
% to 5 – 10 %.
FACTORS INFLUENCING
RECURRENCE
 Tumor related factors

 Molecular factors

 Technical factors
 TUMOR RELATED FACTORS
 Disease stage

 High grade tumor (poorly differentiated)

 Involvement of circumferential margins

 Venous, lymphatic & perineural invasion

 Tumor adherent to adjacent organs

 MOLECULAR FACTORS

 Aneuploidy

 Mutant p53 gene expression

 Low microsatellite instability

 TECHNICAL FACTORS

 Inadequate resection margins (radial, distal and

mesorectal).

 Implantation of exfoliated cells

 CLINICAL PRESENTATION OF
LRRC

 Majority within 1st 3 years of primary surgery.

 1/3rd of recurrences are asymptomatic.

 50% of patients have synchronous metastatic disease.

SYMPTOMS OF LRRC
 Pelvic, perineal or sciatic pain

 Non-healing perineal wounds

 Anorexia and weight loss

 Rectal bleeding

 Change in bowel habits

 Perineal/Abdominal mass with/without enlarged supraclavicular

node
INVESTIGATIONS
ROUTINE INVESTIGATIONS

 Routine blood investigations

 Chest radiograph

 USG
 SPECIFIC INVESTIGATIONS
 CEA test

 CT Thorax and CT Abdomen & Pelvis

 Gadolinium enhanced MRI

 PET-CT

 Colonoscopy

 Trans-Rectal Ultrasonography (TRUS)

CHEST RADIOGRAPH
CT THORAX
CT ABDOMEN & PELVIS
MRI
 PET-CT

Small bowel
cancer
bladder
rectum
pubic bone
rostate
TRUS
 CLASSIFICATION OF LRRC

 The Leeds Group Classification

 The Memorial Sloan Kettering Group Classification

 The Mayo Clinic Classification

CLINICAL APPROACH TO
DISEASE RECURRENCE
 PRE-OPERATIVE EVALUATION
AND PATIENT SELECTION
 General health

 Exclusion of extrapelvic disease

 Evaluation of the presence and extent of local disease

 Resectability
 EVALUATION OF PRESENCE AND
EXTENT OF LOCAL DISEASE
 1ST to differentiate between recurrent tumor and post operative
changes.

1. Change in the lesion

2. Invasion of adjacent organs

3. Histologic evidence

 CEA level
RESECTABILITY

 Determined by:

1. Fixation (F0, FR, FNR)

2. Anatomic location (anterior, posterior and lateral)

CONTRAINDICATIONS TO RESECTABILITY
OF LOCALLY RECURRENT RECTAL CANCER
 Extrapelvic disease

 Sciatic pain

 Bilateral ureteral obstruction

 Circumferential or extensive pelvic side wall

involvement
 S1 or S2 involvement (bony or neural)

 360 degree encasement of iliac vessels

 Poor general condition & surgical risk

MANAGEMENT STRATEGY
TRIMODALITY THERAPY

1. Preoperative radiotherapy + concomitant

chemotherapy

2. Maximal resection for local control

3. Chemotherapy to address the possibility of

systemic failure
PREOPERATIVE RADIATION
THERAPY AND CHEMOTHERAPY
External beam radiotherapy (EBRT): (5040 cGy) (3-5

daily fractions of 180 cGy)

Chemotherapy: 5-Fluorouracil (5-FU) (225

mg/m²/24 hr) +Leucovorin (20 mg/m²) for 5 days

 INTRAOPERATIVE ELECTRON
BEAM RADIATION THERAPY

 It is added to reduce the dose & toxicity of EBRT

 Dose of IOERT depends on the dose of EBRT given

preoperatively
CT ABDOMEN
MRI
OPERATIVE PROCEDURES
 RECURRENT
RECTAL CANCER

LOCOREGIONAL FOCAL DIFFUSE

RECURRENCE METASTASIS METASTASIS
 FIXITY

NON-FIXED FIXED RESECTABLE

ANTERIOR POSTERIOR

SIMPLE COMPLETION RESECTION OF DISTAL

APR RELATED SACRECTOMY
ANATOMICAL
STRUCTURES
PERINEAL WOUND CLOSURE

 Perineal wound complication rates as high as 41%

have been reported after EBRT & APR.

 Vertical rectus abdominis myocutaneous (VRAM) flap

preferred & has a low complication rate.
PELVIC SIDEWALL
INVOLVEMENT

 Poor prognostic marker

 Layered Approach should be utilized

 1st pelvic sidewall layer: Distal pelvic ureter

 2nd pelvic sidewall layer: Pelvic vasculature

 3rd pelvic sidewall layer: Lumbosacral fascia overlying the sciatic

nerve trunks

 4th pelvic sidewall layer: Pelvic musculature & bony sidewall

TARGETED THERAPIES

 Anti-VEGF mAb: Bevacizumab

 Anti-EGFR mAb: Cetuximab

RESULTS OF TRIMODALITY
TREATMENT FOR LRRC

 17–40% short term morbidity & 0–2% mortality

 5-year survival estimate: 30%

 10-year survival estimate: 16%

RE-RECURRENT DISEASE

 Occurs in two-third of the patients

 High postoperative morbidity