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TUMOR BOARD Rectal Carcinoma

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78 y/o male with a PMHx of HTN initially presented with ... usually in an adenomatous polyp or gland. As they grow. usually invade. the muscularis mucosa ... – PowerPoint PPT presentation

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Title: TUMOR BOARD Rectal Carcinoma


1
TUMOR BOARDRectal Carcinoma
  • 8/28/07

2
Patient 1
  • FB
  • 78 y/o male with a PMHx of HTN initially
    presented with rectal tenderness on defacation
  • He also had noticed a change in the consistency
    of his bowel movements as well as hematochezia
    for a period of two months prior to these
    symptoms
  • Colonoscopy- malignant annular obstructing 5cm
    mass, starting 6cm from anal verge
  • CT scan- liver metastases

3
Patient 1
  • 1/07-6/07-Received Preop chemo/radiation for
    ratal Ca and liver mets
  • PET Scan
  • No active liver lesion
  • 50 reduction in Rectal Ca
  • Pt continued to have bleeding, anemia and
    tenesmus
  • 7/07- APR with ileostomy
  • Pathology-
  • T3N1M1

4
Patient 2
  • FD
  • 55 y/o with a PMHx of HTN presented with c/o
    weight loss, hematochezia and tenesmus
  • Colonoscopy
  • Mass found at 4 to 8 cm from anal verge
  • Strictures noted as well
  • Ct scan
  • Noted for 3 liver lesions
  • Pelvic lesions

5
Patient 2
  • 9/21/06- Sigmoidoscopy, Rectal Ultrasound, LAR
    and Liver bx
  • Proctosigmoidoscopy
  • Tumor occupied half the circumference of the
    rectume from 4 to 8 cm fro anal verge
  • Rectal Ultrasound
  • Tumor involving rectal muscles
  • LAR
  • Performed due to ability to mobilize rectum and
    obtain clear margins
  • Tru-cut liver biopsy

6
Patient 2
  • 4 courses of Chemotherapy
  • PET scan
  • 1 active Liver lesion
  • 8/24/07
  • Right Hepatic lobe resection
  • Segment 6

7
Patient 3
  • RF
  • 77 y/o F presented with crampy lower abdominal
    pain, decreased appetite, and 60 pound weight
    loss over the last year
  • CT scan of chest, abdomen and pelvis
  • 5 cm mucosal thickening in sigmoid colon
  • EGD and Colonoscopy performed the next day
  • EGD-normal
  • Colonoscopy- 5 cm ulcerating circumferential mass
    in sigmoid colon

8
Patient 3
  • 8/20/07- OR
  • Sigmoid Colectomy
  • Splenic flexure takedown
  • 3 1 lymph nodes negative for tumor
  • No Lymphovascular invasion
  • D/C ed on POD 6
  • Will be followed by Medical Oncology surveillance
    CEA, yearly colonoscopy, yearly CT scans

9
Rectal Ca
  • Colorectal cancers are the most common type of GI
    cancer
  • Second most common cause of cancer death in
    developed countries.
  • 2006, there were an estimated 145,290 new cases
    of colorectal cancer in the United States
    104,950 were in the colon and 40,340 rectal
  • Almost all rectal cancers are primary
    adenocarcinomas
  • Rectal cancers are, after colon cancers, the
    second most common gastrointestinal (GI)
    carcinoma, and have the best prognosis
  • The 5-year survival rate is approximately 50
  • Affects both sexes equally
  • Median age-50-70

10
Rectal Ca
  • Adenocarcinoma of the rectum arises as an
    intramucosal epithelial lesion
  • usually in an adenomatous polyp or gland
  • As they grow
  • usually invade
  • the muscularis mucosa
  • lymphatic structures
  • vascular structures
  • and involve regional lymph nodes
  • adjacent structures,
  • and distant sites, especially the liver , lungs

11
Rectal Ca
  • Risk factors for development of Rectal Ca
  • High-fat, low-fiber diet -Age greater than 50
    yrs
  • 1st degree relative colon ca -IBD
  • Familial polyposis coli
  • Clinical presentation
  • Palpable mass on DRE -Rectal bleeding
  • Change in bowel habits -Weight loss

12
Rectal Ca
  • Prognosis
  • Based on 2 factors
  • degree of penetration of the tumor through the
    bowel wall
  • presence or absence of nodal involvement
  • Basis for all staging systems for Rectal Ca
  • Staging procedures
  • digital rectal examination
  • computed tomographic scan
  • magnetic resonance imaging scan of the abdomen
    and pelvis,
  • Endoscopic ultrasound (EUS)
  • accurate method of evaluating tumor stage (up to
    95 accuracy) and the status of the perirectal
    nodes (up to 74 accuracy)
  • National cancer institute recommends at least 12
    lymph nodes be examined

13
Staging
  • Duke Classification
  • Stage Description 5-yr Survival Rate,
  • A Limited to the bowel wall 83
  • B Extension to pericolic fat no nodes 70
  • C Regional lymph node metastases 30
  • D Distant metastases (liver, lung, bone) 10
  • -Most important prognostic factor is the depth of
    invasion of primary tumor
  • TNM Staging
  • Modification in colorectal staging, better
    reflects the impact of depth of penetration and
    number of lymph nodes involved
  • TNM Stage Modified Dukes Stage Description
  • T1 N0 M0 A Limited to submucosa
  • T2 N0 M0 B1 Limited to muscularis propria
  • T3 N0 M0 B2 Transmural extension
  • T2 N1 M0 C1 T2,enlarged mesenteric nodes
  • T3 N1 M0 C2 T3,enlarged mesenteric node
  • T4 C2 Invasion of adjacent organs
  • Any T, M1 D Distant metastases present

14
Staging
15
Treatment
  • Depends on Location
  • UPPER THIRD OF THE RECTUM 12-16cm from anal verge
  • Resection and anastomosis
  • MIDDLE THIRD OF THE RECTUM 8-12cm from anal verge
  • Abdominoperineal resectionLow anterior
    resectionAbdominosacral resectionColoanal
    resectionLocal excision or fulgurationPrimary
    radiation therapy
  • LOWER THIRD OF THE RECTUM w/n 8 cm from anal
    verge
  • Abdominoperineal resectionLocal excision or
    fulgurationPrimary radiation therapy

16
LAR versus APR
  • The controversy lies in the surgical treatment of
    the middle to lower 1/3 of rectal carcinomas
  • Challenge of adequate resection while preserving
    anal sphincter
  • Traditional dictum 5cm of normal rectum distal to
    the neoplasm
  • Overall, studies show a distal margin of 3cm is
    adequate
  • There is a consensus that rectal carcinoma
    spreads primarily upward through superior
    hemorrhoidal and inferior mesenteric lymphatics
  • Therefore, the decision to perform LAR vs APR
  • is predicated essentially upon the distance of
    the lower border of the cancer from the anus
  • lt5cm from anal vergeAPR
  • gt5cm from anal vergeLAR

17
LAR versus APR
  • Many surgeons use
  • Rule of thumb
  • stated as follows
  • If the lesion is easily palpable with the
    examining finger APR
  • However, if the lesion, after mobilization of the
    rectum to the levator ani level can be brought to
    the level of the abdominal incision, an adequate
    anterior resection may be performed
  • Overall, a good anal sphincter salvage procedure
  • will not sacrifice anal function unnecessarily,
  • will not be associated with excessive
    complication rates.

18
Total Mesorectal Excision
  • Anal sphincter saving techniques
  • Ex. TME-Total Mesorectal Excision
  • Based on principle of
  • Radial margins are more relevant than
    longitudinal margins for local control of mid to
    low rectal cancers
  • Technique of TME includes sharp dissection
    posteriorly in the presacral avascular plane from
    the superior hemorrhoidal vessels to the levator
    ani, laterally encompassing the entire peritoneal
    reflection, and anteriorly including
    Denonvilliers fascia in the specimen
  • TME study
  • the Basingstoke group initially reported a
    dramatic reduction in local recurrence from the
    norm of 30 to 40 to 3.7 over a 4 year
    follow-up period
  • Subsequent studies consistently showed a decline
    in local recurrence of 15 to 40 using
    conventional techniques to 4 to 11 using TME

19
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20
Treatment of Rectal Carcinoma
  • One major concern after rectal cancer surgery
  • Is the high local recurrence rate.
  • Randomized trials have shown that the best local
    control rate for rectal cancer patients as a
    group is achieved after a short course of
    radiation therapy followed by optimal surgery.
  • Radiation therapy combined with surgical
    resection for colorectal cancer has been
    demonstrated to reduce the incidence of local
    tumor recurrence
  • Used where recurrence is usually seen
  • Cancer that extends through the wall or reaches
    lymph nodes

21
Radiation Therapy
  • Examples
  • Stage IIA (T3, N0) rectal tumors, the incidence
    of local recurrence is about 30 to 35 but can
    be reduced to 5 with adjuvant radiation therapy
  • Stage III (any T, N1-2) rectal cancers, the use
    of adjuvant radiation therapy decreases local
    recurrences from the range of 45 to 65 down to
    10

22
Metastases
  • Liver is the most frequent site of blood-borne
    metastases from primary colorectal cancers
  • surgical resection is associated with a 5-year
    survival rate of 25 to 30
  • Patients eligible for hepatic resection
  • no evidence of extrahepatic tumor,
  • no medical contraindications to surgery
  • a limited number of lesions that are amenable to
    resection with negative surgical margins
  • Pulmonary metastases develop in about 10 of all
    patients with colorectal cancer, usually in
    association with widespread metastatic disease

23
When should Liver mets be resected?
  • Synchronous versus metachronous resection
  • World Journal of Gastroenterology 2007
  • Retrospective study of 103 pts from 1/1996-7/2004
  • Synchronous Resection-25 pts Metachronous-78 pts
    (Liver rxn 1-3 months after colon rxn)
  • Both groups were comparable regarding age/gender,
    type of liver lesion and stage of primary tumor
  • Results- hospital stay significantly shorter in
    synchronous group, no difference in 5yr survival
    no postoperative mortaility in either group

24
Liver mets resection
  • Conclusion
  • Synchronous resection is a safe and effective
    method of of treatment of Colorectal Ca with
    liver mets
  • Limiting factor is a patients overall medical
    status and liver lesion
  • Complex liver lesions should be handled
    separately
  • Potential disadvantages-intraoperative
    contamination of cut liver surface, potential
    poor healing of and anastomotoic leak due to
    impairment of liver function, potential for
    higher recurrence rated due to tumor seeding
  • Do not perform in patients gt70 y/o, gt1 liver
    section to remove, or poorly differentiated
    mucinous adenocarcinoma

25
Is RT essential in presence of liver mets
  • Low-dose preoperative radiation postpones
    recurrences in operable rectal cancer Results of
    a randomized multicenter trial in Western Norway
  • A randomized, multicenter clinical trial was
    conducted in Western Norway to study the
    effectiveness of preoperative radiation therapy
    in operable rectal cancer
  • 309 pts entered trial radiation given 2 to 3
    weeks before radical surgery.
  • 200 underwent curative resection 109 underwent
    radiation with surgical resection
  • After radiation no tumor was seen in 4.5 of the
    patients.
  • There was no increased morbidity or mortality at
    surgery.
  • The 5-year survival for evaluable patients was
    57.5 in the control group and 56.7 in the
    radiotherapy group.

26
Is RT essential in presence of liver mets
  • For patients operated on for cure
  • the 5-year survival was 60.9 and 64.2 in the
    control group and radiotherapy group,
    respectively.
  • Radiation significantly delayed both local and
    distant recurrences in patients in the radiation
    group who had curative resection from 13.3 months
    in controls to 27.1 months. the local recurrence
    rate in the corresponding groups was 21.1 and
    13.7, respectively.
  • Conclusion
  • that higher preoperative radiation doses should
    be used in new trials as a higher dosage may
    transform the observed positive effects into a
    survival benefit
  • Shows benefits in abating local recurrence

27
Is radiation therapy essential after TME
  • International Journal Radiation Oncology
  • Purpose- analyze optimal sequencing of modalities
    for adjuvantly treated Rectal Ca
  • 307 patients with adenocarcinoma of the rectum
    underwent adjuvant radiation therapy
  • 251 cases the radiation therapy was administered
    preoperatively followed by TME 6-7 weeks latter
  • 56 cases, patients were referred postoperatively
    for radiation

28
Postoperative Radiation TX
  • 5-year local control and freedom from disease
    for the preoperative RT patients were 90 /- 2
    versus postoperative RT -73 /- 3, respectively
  • Local recurrence control was significant for
    preoperative RT

29
Postopertive Radiation
  • International Journal Radiation Oncology
  • Seventy-three patients received postoperative
    radiotherapy following local surgery for primary
    rectal carcinoma
  • Overall results show postoperative RT after TME
    to be less effective as lymphovascular
    involvement is more extensive
  • Local recurrence was seen in T1 lesions
  • Overall postoperative RT less effective than
    preoperative RT in conjunction with TME

30
Conclusion
  • Liver metastases can simultaneously removed at
    time of colon resection
  • Radiation therapy has repeatedly shown to be
    effective in controlling local recurrence in the
    face of liver metastases and in conjuction with
    TME
  • Preoperative RT has been shown to be optimal
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