Tumor Board

1
Tumor Board

• March 27, 2007

2
Tumor Board

• RB
• 68 y/o AA M who presented to Sinai ER with a 7
  day history of severe rectal pain with bright red
  bloody bowel movements
• c/o narrowing of stool, diminished caliber of
  stools for a few months
• chronic constipation
• PMHx- HTN, anxiety and hemorrhoids

3
Tumor Board

• PSHx- none
• Meds- Lotrel, Ativan
• SHx- Smoking
• FHx- Noncontributory
• Vitals- T 37.1 P-57 Bp 136/65 O2-98 RA
• Gen- elderly gentleman lying comfortably
• HEENT- Sclerae-nonicteric, No lymph nodes in
  cervical or axillary region

4
Tumor Board

• Lungs- CTAB no wheezing, no rales
• Abdomen- soft, nd, nt, bowel sounds-active, no
  shifting dullness, no rebound tenderness
• Rectal- refused due to exquisite tenderness
• Labs
• H/H 11.4/35
• other labs w/n normal limits

5
Tumor Board

• Plan
• Admit IVF, NPO, Bowel prep for Colonoscopy
• Colonoscopy
• Single friable malignant obstructing ulcerated
  whitish mass present at the ano-rectal junction
  which measured about 5 cm
• multiple biopsies taken
• Pathology
• Anorectal mass- tubular adenomatous tissue with
  at least high grade dysplasia, suspicious for
  invasive malignancy

6
Tumor Board

• Surgical Oncology consulted
• CT showed no distant metastases
• Biopsy- Adenocarcinoma
• Groin lymph nodes not involved
• Clinical Impression-Carcinoma of the rectum at
  the lower 1/3 involving the sphinchter
• Rectal Ultrasound- shows invasion into muscle of
  sphincter

7
Tumor Board

• BON
• Post-Op Dx- Lower 1/3 carcinoma of the rectum
• Procedure- APR
• EBL-300cc
• Drain- 1
• Complications- none

8
Tumor Board

• Post Operative
• No complications
• Awaiting Discharge

9
Sphincter Preservation in Rectal CA

• Although optimal treatment of tumors at mid and
  distal rectum continues to be a matter of great
  debate
• goal of sphincter preservation should be
  considered in all patients with an intact
  sphincter is preferred
• Growing evidence and indications
• that sphincter-preserving procedure might be a
  valid alternative to conventional modality in
  tumors of the mid or lower rectum.

10
Tumor Board

• Traditionally, an abdominoperineal resection with
  permanent colostomy would be the sole surgical
  option.
• Recently, a variety of sphincter-preserving
  procedures are being performed in majority of
  distal rectal cancers
• acceptable oncologic and optimal functional
  results.
• Several recent advances may further influence
  future treatment strategies
• and many issues under evaluation

11
Rectal Ca

• Criteria
• Three conditions to be met for any restorative
  procedure
• Excision of tumor must be adequate
• Residual sphincter function must be satisfactory
• Technical difficulty must be manageable

12
Rectal Ca

• Excision of tumor
• Most important recent discovery
• Minimal extent of downward intramural spread of
  the tumor
• In low or average grade tumors spread beyond 2 cm
  from the growing edge of the tumor occurs in only
  1 of patients
• Even for anaplastic tumors, the incidence of
  travel beyond 2 cm is only 5 to 6
• Thus adequate excision my require only 2-3 cm
  margins beyond the edge of the tumor
• Although, the need to remove the proximal rectum
  together with the area of upward lymphatic spread
  and the pararectal tissues up the side wall of
  the pelvis wall remains unchanged

13
Rectal Cancer

• Sphincter control depends on intact
• Sensory
• Preservation of anal canal and pelvic floor
  muscles
• Motor
• Preservation of the puborectalis sling and the
  internal and external anal sphincters

14
Rectal CA

• Technical Feasibility
• Transphinteric Approach
• Short anorectal stump delivered by dividing the
  somatic component of the sphincter complex
• Abdomen then closed
• Anal sphincter incised vertically until gut tube
  exposed
• Tumor is delivered and resection carried out
• Transanal Approach
• Anorectal stump dilated in order to insert
  special retractor
• Tumor is resected through the abdomen
• Cut end of left colon is then drawn into the
  pelvis and sutured to the anorectal stump within
  the lumen

15
Role of TME

• Total Mesorectal Excision
• The mesorectum consists of fatty tissue
  surrounding the rectum and contains the
  lymphatics that drain the rectum
• Isolated deposits of tumor can be found within
  the mesorectum up to 3 cm distal to the main
  tumor
• Total mesorectal excision has reduced local
  recurrence following surgery to less than 10

16
Role of TME

• Theory
• That the embryology of the fetal hind-gut, a
  midline structure,
• predicates that initial cancer spread will remain
  within the mesorectum and thus be encompassed by
  the mesorectal fascia.
• This fascia provides the surgeon with a
  "navigation system" on which the efficient
  performance of TME is based.

17
Role of tme

• TME is the gold standard therapy in many European
  countries for middle and lower third rectal
  cancers
• Specifically, local recurrence following TME is
  about 6.6
• Most of the literature performed are
  restrospective studies
• Recent studies have clarified a benefit to
  adjuvant chemotherapy with TME
• Further literature supports that TME is a
  feasible, reproducible adjunctive surgical
  therapy in the management of Rectal CA

18
Rectal Ultrasound

• Preoperative evaluation of rectal cancer has
  become increasingly important,
• Allowsto identify patients
• with locally advanced disease
• who may benefit from neoadjuvant
  chemoradiotherapy and those suitable for local
  resection.
• Endoscopic rectal ultrasound (ERUS)
• accurately indicates the extent of tumour spread
  through the wall of the rectum in over 90 of
  cases (T stage) and the involvement of perirectal
  lymph nodes in up to 80 (N stage)

19
Rectal Ultrasound

• It is an essential investigation for those being
  considered for local resection
• Currently, examination by ERUS is limited to
  tumors within the distal rectum but the recent
  development of colonoscopic ultrasound may prove
  useful to evaluate more proximal disease

20
Rectal Ultrasound

• Identifying Recurrence
• Endorectal ultrasound identifies one-third of
  asymptomatic local recurrences that were missed
  by digital examination or proctoscopic
  examination

21
Rectal Ultrasound

• Currently evidence supports use of MRI
• The crucial advantage of MRI is not that it
  enables exact T-staging but precise evaluation of
  the topographic relationship of a tumor to the
  mesorectal fascia.
• The fascia is the most important anatomic
  landmark for the feasibility of total mesorectal
  excision, which has evolved into the standard
  operative procedure for the resection of cancer
  located in the middle or lower third of the
  rectum.
• MRI has been shown to illuminate the mesorectum
  well

22
Rectal Ultrasound

• In general,
• Effective method
• Surpassed by some other modalities on certain
  aspects
• Ex. MRI