Tumor Board Sinai Hospital Baltimore 72208 Alexander Aurora PGYIV

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Tumor BoardSinai Hospital Baltimore7/22/08Ale
xander AuroraPGY-IV
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LH 15595914

• 56F with rectal carcinoma
• Large obstructive mass at 8 cm from anus
• Biopsy proven adenocarcinoma
• Due to her poor cardiac status EF 30 not
  surgical candidate, wall stent was placed 02/08
• Elective low anterior resection with loop
  colostomy 6/26/08
• T3N2Mx

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Introduction

• Incidence 42000 with 8500 deaths
• Surgery is primary therapy
• Curative stage I, II, III of upto 90, 60 and 40
  respectiveley
• Type of surgery depends on tumor stage and
  mostly depth
• Minimally invasive disease cured with local
  transanal excisions
• Sphincter preservation is of great importance and
  can be achieved for most lesions 5 cm or more
  proximal to the dentate line

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Preop Evaluation

• HP specifically, rectal, urinary and sexual
  function, and rectal exam
• CT chest abdo/pelvis to r/o mets
• CEA baseline
• Transrectal US

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Stage

• T1- mucosa, T2-muscularis propria, T3-
  serosa/perirectal fat, T4- adjacent organs
• N1- 1-3, N2- 4 or more nodes
• M1- distant mets
• Stage 1- T1-T2, Stage 2A- T3N0, Stage 2B- T4N0,
  Stage 3A- T1-2N1, Stage 3B- T3-4N1, Stage 3C- any
  TN2, Stage 4- anyTNM1

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Surgery

• T1 lesions can be removed by transanal endoscopic
  microsurgery or transanal excision depenent on
  location
• Remove complete tumor and mesorectal tissue (TME)
  including lymphatics and at least 12 lymph nodes,
  usually by LAR
• Margins need be distal (2cm), proximal (5cm) and
  RADIAL
• Re-establishing continuity
• TME decreases local recurrence (16 vs 7) and
  increases survival
• TME also decreases post-op genitourinay
  dysfunction ( from gt50 to lt 30)

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Advanced therapy

• T3-T4 larger more invasive tumors may receive
  neoadjuvant chemoradiation to facilitate complete
  resection at surgery without sacrificing
  significant structures
• 45Gy in 25 fractions plus a boost to Tu bed of
  5.4Gy in 3 fractions along with 5-FU for 5 days
  followed by surgery in 6-8 weeks most will be
  downstaged and 11 will have complete response

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Key to surgery
Total mesorectal excision
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Recommendations

• Currently for T1-T2 disease surgery alone is
  best, no role for chemorads
• Similarly, evidence suggests that radical
  resection of T3 lesions is advised without
  chemorads due to high local recurrence
• Node positive and Metastatic disease should
  receive chemorads after resection

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Node positive/metastatic dz

• Chemorads followed by LAR
• 5-FU was mainstay of therapy
• Irinotecan and oxaliplatin have been added
• Newer MAb EGF receptor and VEGF receptor blockers
  show promise
• Survival with 5-FU and tecan or platin reach 2
  years

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