Rectal Cancer—Surgical Therapy and Imaging by mm6889


									  Rectal Cancer: Surgical Therapy

       Najjia N. Mahmoud, MD
Division of Colon and Rectal Surgery
      University of Pennsylvania
             Rectal Cancer
Outcomes influenced by surgical technique.
Outcomes influenced by adjuvant/neoadjuvant therapies.
Outcomes influenced by surgeon training and
Curing Rectal Cancer Treatment is a TEAM EFFORT.
 – Gastroenterologist
 – Surgeon
 – Medical Oncologist
 – Radiation oncologist
 – YOU!
Distribution of Cancers
Rectal Cancer Staging
Extent of Problem in 2007—in US!
3rd leading cause of cancer death in US.
105,500 cases of colon cancer (49,000 in
men and 56,500 in women).
 42,000 cases of rectal cancer (23,800 in
men and 18,200 in women).
57,100 deaths attributable to cancer of the
colon and rectum.
Pre-op Locoregional Staging
     of Rectal Cancer
  Early confined lesion
          - Local therapy

  Locally advanced
          - Neoadjuvant therapy

 Treatment depends on Staging!
                     Seminal Vesicles

Obturator Internus

                     Mesorectal Fascia
          Physical Exam
Most important staging exercise.
Digital rectal exam.
Rigid proctoscopic exam:
– Distance from the anal verge
– Locations around the circumference
Surgery for rectal cancer: goals
Cure the disease, both locally and distally.
Spare the sphincters! No permanent
bag—if possible.
Establish and maintain high quality of life
with good function and control.
    Surgery and T/N Stage
T1 and T2: early stage cancers
T3 and T4: late stage cancers

N=lymph nodes….ANY T stage with
positive lymph nodes means more
aggressive therapy…usually multimodal.
    Local Excision
uT1 NO or benign polyp
well to mod. differentiated
1.2 inches in diameter or less
absence of lymphatic or venous
Accessible! Only DISTAL cancers
Even then, controversial
Local Excision for Rectal

          Low morbidity
          No colostomy
          Excellent functional results
          Unknown regional LN status
          Adequate cancer treatment?
Local Excision for Rectal Cancer
In many studies, local excision alone
associated with high local recurrence rates
and low survival rates.
– Anatomy
– Positive margins (tumor left behind)
– Tumor biology (more aggressive?)
Local Excision for Early Rectal Cancers

 How can we mitigate the risks and
 maintain function?
  – Be aware of the risks.
  – Combine local excision with chemotherapy
    and radiation?
  – Frequent postoperative checks (every 3-4
    months for the first 2 years and every 6
    months for the next 3 years.
Local Excision For Rectal Cancers
ACOSOG Z6041: Chemotherapy and
radiation followed by local excision for
distal T2N0 rectal cancers.
 – Hopefully, it will confirm that we can locally
   excise rectal cancers and maintain function
   without compromising cancer control.
Radical excision of rectal cancers
“Radical” means taking the tumor, the
bowel, and the lymph nodes involved.
It often implies an abdominal approach.
There is a greater chance of altered bowel
function when a portion of rectum is
The sphincters can still be saved!
 Radical excision and sphincter
Sphincter preservation is directly related to
distance of the tumor from the anus.
How do we know what we can locally
excise and what requires radical excision?
We try to save all sphincters that are:
– NOT invaded by tumor.
– Work well preoperatively, and are not
  compromised by severe incontinence.
Radical Resection: Two General
Low Anterior Resection (LAR):
– Sphincter preserving.
– Total mesorectal excision.
– Appropriate for tumor NOT invading anal sphincters.
Abdominoperineal resection (APR)
– Permanent colostomy.
– Appropriate for tumors invading or very close to anal
– Appropriate for people who have issues with
  preoperative fecal incontinence.
   Stage and radical surgery
Early stage tumors (T1 and T2 N0) in the mid
and upper rectum are best treated by sphincter-
sparing radical excision.
– Low anterior resection.
Later stage tumors (T3 or T4 and any tumor with
N+) in the mid or upper rectum are best treated
by chemoradiation FIRST, followed by sphincter-
sparing radical excision.
– Low anterior resection with temporary diverting
– Why?
Temporary Ileostomy
Surgical Staplers=sphincter
Type of surgery is dictated by:
– Size of tumor
– Stage of tumor
– Distance from the anal opening
– Adjacent organ involvement
– Other medical problems
Generalizations can be made, but surgical
therapy must be individualized!

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