Rectal Cancer: Surgical Therapy Najjia N. Mahmoud, MD Division of Colon and Rectal Surgery University of Pennsylvania Philadelphia Rectal Cancer Curable—but…. Outcomes influenced by surgical technique. Outcomes influenced by adjuvant/neoadjuvant therapies. Outcomes influenced by surgeon training and experience. Curing Rectal Cancer Treatment is a TEAM EFFORT. – Gastroenterologist – Surgeon – Medical Oncologist – Radiation oncologist – YOU! Anatomy 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 MRI 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 Criteria uT1 NO or benign polyp well to mod. differentiated 1.2 inches in diameter or less absence of lymphatic or venous invasion Accessible! Only DISTAL cancers qualify! Even then, controversial Local Excision for Rectal Cancer 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. Why? – 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 removed. The sphincters can still be saved! Radical excision and sphincter preservation 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? – PROCTOSCOPY IN OFFICE! 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 Approaches 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 sphincters. – 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 ileostomy. – Why? Temporary Ileostomy Surgical Staplers=sphincter preservation Conclusions 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!