rectal cancerrectal cancer - suny downstate medical center · rectal cancerrectal cancer sophia l...
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![Page 1: Rectal CancerRectal Cancer - SUNY Downstate Medical Center · Rectal CancerRectal Cancer Sophia L Fu, MD SUNY Downstate Medical Center, Brooklyn, NY September 10, 2009 . HistoryHistory](https://reader036.vdocuments.net/reader036/viewer/2022062414/5cd35a8388c99315538d536b/html5/thumbnails/1.jpg)
Rectal CancerRectal CancerRectal CancerRectal Cancer
Sophia L Fu, MD
SUNY Downstate Medical Center, Brooklyn, NY
September 10, 2009September 10, 2009
www.downstatesurgery.org
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HistoryHistoryRectal CARectal CA
40 yo female w/rectal cancer treated w/chemo-XRT
at Brookdale 11/08 who p/w rectal-vaginal fistula in
6/09 that underwent diverting ostomy. She then came g y
for an abdomino-perineal resection on 8/4/09.
PMH: depression
PSH/ FHx: Diverting OstomyPSH/ FHx: Diverting Ostomy
SocHx: 1ppd x20yrs, no ETOH, no drug abuse
Meds: Seroquel, Dilaudid, Percocet
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Physical ExaminationPhysical ExaminationRectal CARectal CA
VS 98.2 122/86 90 18
Gen: pleasant, in NAD
HEENT: anicteric no palpable nodesHEENT: anicteric, no palpable nodes
Chest: clear
Cv: nl S1 S2, RRR, no m/r/g
Abd: soft, NT, ND, +BS
Ext: no edemaExt: no edema
Rect: painful w/ulceration
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CT ScanCT ScanRectal CARectal CA
CT ScanCT Scanwww.downstatesurgery.org
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Laboratory workLaboratory work--upupRectal CARectal CA
yy pp
9 6142
4.6
107
22
10
0.774 8.57
9.0
28.0603
9.6
MCH 26.8RDW16.2
TP 6.8Alb 3 9
AST 11ALT 7
12.91 0Alb 3.9
Tbili 0.3ALT 7AP 69 34.9
1.0
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Operative Report Operative Report –– 8/4/20098/4/2009Rectal CARectal CA
p pp pInsertion of Ureteral Stents
Exploratory laparotomy, extended Left Hemicolectomy,
Abdominoperineal ResectionAbdominoperineal Resection
Resection of rectovaginal fistula, TAH/BSO & partial
vulvectomy
Omental flap TRAM flap V Y flapOmental flap, TRAM flap, V-Y flap
Time IVF PRBCS EBL UO4.5 hrs 6.2 L 2 Units 500 mL 1200 mL
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Pathology Pathology –– T4, N0, M0T4, N0, M0Rectal CARectal CA
gygy , ,, ,3/0 perirectal LN neg
Lymphovascular
Colon, rectum, vagina, anus
Ad i d Lymphovascular
invasion neg by CD31 Adenocarcinoma, moderate-
poorly differentiatedstain
Uterus w/cervix6x4cm, invading pararectal fat
Post vaginal wall involved by
Atrophic endometrium
Post vaginal wall involved by
tumor
No tumor
Fallopian tubes/ovaries
Deep resection margin
involved by tumor p
No tumorPerineural invasion
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Hospital CourseHospital CourseRectal CARectal CA
Hospital CourseHospital CoursePOD#4 POD#12
Post-op fever w/u neg
POD#6
Wound Cx – MRSA &
pseudomonasPOD#6
Reg diet POD#14
POD#9
Continued fever spike
Wound debridement
POD#19Continued fever spike
CT Abd/pelvis Awaiting VAC
Perineal wound necrotic
flap – plastics consult
Absconded
Wound care
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Rectal CancerRectal Cancer
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Introduction to Colorectal CAIntroduction to Colorectal CARectal CARectal CA
Introduction to Colorectal CAIntroduction to Colorectal CA
Incidence 41 390 cases Greatest risk factor:Incidence 41,390 cases
Declined 1.8% per yr
Greatest risk factor:
Age
Improved screening & polyp
removal
Median age 71
Polyposis syndromes
Leading cancer death
2nd in men
High risk of colorectal CA
<5% of colorectal CA
3rd in womenPMH or FHx colorectal CA
Inflammatory bowel dz
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Rectal AnatomyRectal AnatomyRectal CARectal CA
Rectal AnatomyRectal AnatomyAutonomic Nerve
Preservation
Hypogastric nerve form yp g
ventral nerve roots T12 to
L3 & Sympathetic nerveL3 & Sympathetic nerve
innervation
Parasympathetic
innervation from S2 to S4
ventral nerve roots
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PresentationPresentationRectal CARectal CA
Assess phys’l condition Pelvic pain: sacral
Need for neoadjuvant
chemo
involvement
Obstipation orchemo
Need for local excision
Obstipation or
constipation: bulky
Pre-op sphincter &
sexual fxn
obstructing lesion
sexual fxn
Predisposing conditions
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DiagnosisDiagnosisRectal CARectal CA
Digital Rectal Exam Rigid proctoscopy
Ant vs post
Mobile or fixed
Prox vs distal levels
Relation to sphincterob e o ed
Ulceration
e a o o sp c e
Vagina/prostate
Size
Extent of circumferential
Invasive CA Dx by Bx
Colonoscopyinvolvement
Relation to sphincter
py
3-5% have synchronous
l iRelation to sphincter lesions
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PrePre--operative Evaluationoperative EvaluationRectal CARectal CA
CEA levels CXRCEA levels
>5ng/mL have worse
CXR
Pulmonary mets
prognosis compared
w/stage-matched ptsCT Abd/pelvis
Distant mets (75 87% sens)Elevated pre-op levels that
do not normalize may imply
Distant mets (75-87% sens)
Tumor-related complicationsdo not normalize may imply
distant dzRegional tumor extension
Regional lymphatic metsIdentifies recurrent dz
Regional lymphatic mets
(45-73% sens)
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EndorectalEndorectal Ultrasound (ERUS)Ultrasound (ERUS)Rectal CARectal CA
EndorectalEndorectal Ultrasound (ERUS)Ultrasound (ERUS)Depth of invasion (T stage)
Accuracy 80-95%
CT: 65-75% vs MRI: 75-85%
Nodal Involvement (N)Nodal Involvement (N)
Accuracy 70-75% (>5mm)y ( )
CT:55-65% vs MRI 60-65%
FNA Bx
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AJCC Rectal Cancer StagingAJCC Rectal Cancer StagingRectal CARectal CA
g gg gPrimary tumor (T)
Tx Primary Tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ: intraepithelial/invasion of lamina propria
T1 T i d bT1 Tumor invades submucosa
T2 tumor invades into muscularis propria
T3 Tumor invades thru muscularis propria into subserosa or
pericolic/perirectal tissuespericolic/perirectal tissues
T4 tumor invades other organs/structures &/or visceral peritoneum
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AJCC Rectal Cancer StagingAJCC Rectal Cancer StagingR i l l h d (N) Di t t t t i (M)
Rectal CARectal CA
Regional lymph nodes (N)
Nx cannot be assessed
0 i l d i
Distant metastasis (M)
Mx cannot be assessed
0 di iN0 No regional node metastasis
N1 Regional node metastasis 1-3
N2 Regional node metastasis >4
M0 No distant metastasis
M1 Distant metastasis present
N2 Regional node metastasis >4Stage T N M % of pts
0 Tis N0 M0I T1
T2N0N0
M0M0
34
IIA T3 N0 M0 25IIB T4 N0 M0IIIA T1-2 N1 M0 26IIIB T3-4 N1 M0IIIC Any T N2 M0IV Any T Any N M1 15
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NeoadjuvantNeoadjuvant TherapyTherapyRectal CARectal CA
jj pypyDistal rectal CA
Sphincter salvage
Converts APR to LARConverts APR to LAR
Large, locally invasive or node +
Downstaging
Improved tumor resectabilityImproved tumor resectability
Higher sphincter-salvage rates
Lower toxicity w/neoadjuvant Tx
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Preoperative Radiation TherapyPreoperative Radiation TherapyRectal CARectal CA
p pyp pySwedish Rectal Cancer Trial
Randomized Ctrl’d: 1168 pts <80 yo w/resectable rectal cancer
Short-course XRT (25Gy)/surgery vs surgery alone
Local ctrl: 89% vs 73% (P<.001)
Overall survival: 58% vs 48% (P=0.008)Overall survival: 58% vs 48% (P 0.008)
GI post-op issues: 2-4x > 1x
Folkesson J et al. J Clin Oncol. 2005; 23(24): 5644-50.
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Preoperative Radiation TherapyPreoperative Radiation TherapyRectal CARectal CA
p pyp pyMed’l Research Council/Nat’l Cancer Institute of Canada
Randomized ctrl’d: 1350 Stage I to III pts
Similar design to Swedish study
Post-op chemo: positive circumferential margins &/or + nodes
Local ctrl: 5% vs 11%Local ctrl: 5% vs 11%
Dz-free survival: 80% vs 75%
O ll i l 81% 79%Overall survival: 81% vs 79%
PRE-OP XRT associated w/better local control
Sebag-Montefiore D et al. Lancet. 2009 Mar 7; 373(9666): 811-20.
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PrePre--operative operative ChemoradiationChemoradiationRectal CARectal CA
ppEuropean Organization for Research & Tx of Cancer
Randomized ctrl’d: 22921 T3 or T4 rectal cancers
4 arms
Pre-op XRT vs pre-op chemoradiation
+/- postop chemotherapy (5-FU & Leucovorin)/ postop chemotherapy (5 FU & Leucovorin)
Overall Survival: 65.2% for all groups
Local recurrence at 5yr: 8.7%, 9.6%, 7.6%
For chemo pre, post, & both (P=.002)
Worse local recurrence in no chemotherapy group: 17.1%Bosset JF et al. New Engl J Med. 2006; 355: 1114-23.
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PrePre--operative operative ChemoradiationChemoradiationRectal CARectal CA
ppGerman Rectal Cancer Group
Randomized ctrl’d: 823 T3 or T4 or node-pos dz pts
P t h di tiPre-op vs post-op chemoradiation
Overall 5yr survival: 75% vs 74% (P=0.80)
Local recurrence: 6% vs 13% (P=0.006)
Acute toxic effects: 27% vs 40% (P=0.001)
Long-term toxic effects: 14% vs 24% (P=0.01)
Sauer R et al. New Engl J Med. 2004; 351: 1731-40.
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NeoadjuvantNeoadjuvant TxTx SummarySummaryRectal CARectal CA
jj yySurgical resection @6-8 wks post-neoadjuvant Tx
Maximal response to Tx
All t tAllow pt to recover
Pre-op staging modalities unable to distinguish btwn
Tx-related fibrosis vs residual tumor
1.8-16% pts w/complete path response to primary
tumor still have lymph node involvement
Therefore, pt should continue w/definitive surgical Tx
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How to determine which How to determine which d ?d ?procedure?procedure?
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Surgical TherapySurgical TherapyRectal CARectal CA
Local Excision Radical Rectal Surgery
Curative intent
Early-stage
High T1 rectal tumor
Muscularis propria a y s age
Distal rectal CA
uscu a s p op a
invasion (T2N0M0)
M di ll fiLimited to submucosa
T1N0M0
Medically fit pts
Pre-op chemoTransanal
TranssphinctericLocally advanced dz
T3/T4 &/ N1Transsphincteric
Transcoccygeal (Kraske)T3/T4 &/or N1
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Local Local TransanalTransanal ExcisionExcisionRectal CARectal CA
Full-thickness resection
f i t l CA /1
Reserved for those w/low
i k f d l t tof primary rectal CA w/1-
cm margin
risk of nodal metastases
T1: 0% to 12% risk
Highly selected T1 rectal
/ i bidi
T2: 12% to 28%
T3: 36 to 79%CA w/min morbidity T3: 36 to 79%
Addition of neoadjuvant Criteria for Transanal Excision of Rectal Cancers (T1N0M0)
chemoXRT allows T2
resection in selected pts
Should be w/i 8-10 cm of anal vergeLess than 4cm wideInvolve less than 1/3 circumference rectum resection in selected ptsInvolve less than 1/3 circumference rectumNo lymphatic/vascular or perineural invasionWell or moderately differentiated
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TransanalTransanal ExcisionExcisionRectal CARectal CA
Post: lithotomy Excise full thickness to
Ant: prone jackknife perirectal fat in proper
orientation for marginsLesion w/i 6-8cm
dentate line
orientation for margins
dentate line
Circumferential block
w/local anesthetic
w/epi
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TransanalTransanal Endoscopic Endoscopic Mi (TEM)Mi (TEM)
Rectal CARectal CA
Microsurgery (TEM)Microsurgery (TEM)Local excision of rectal TEM scope allowsLocal excision of rectal
cancers in upper &
TEM scope allows
10cm anteriorly
middle rectum 15cm laterally
Specialized long
operating 40-mm
18cm posteriorly
operating 40-mm
endoscope to allow full-
thickness rectal resection
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Radical ResectionRadical ResectionRectal CARectal CA
Circumferential margin assessed by serial
slicing & evaluation of tumor & mesorectum
<2 /hi h l l di t t<2mm assoc w/higher local recurrence, distant
mets, & death
Distal margins <2cm are not associated
w/higher local recurrence
Di t l d >1 f l d 10%Distal spread >1cm of mucosal edge = 10%
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TotalTotal MesorectalMesorectal ExcisionExcisionRectal CARectal CA
Total Total MesorectalMesorectal ExcisionExcisionGold standard for
surgical Tx of middle &
lo er 1/3 rectal cancerslower 1/3 rectal cancers
Excising tumor en bloc
w/blood & lymphatic
lsupply
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TotalTotal MesorectalMesorectal ExcisionExcisionRectal CARectal CA
Total Total MesorectalMesorectal ExcisionExcisionLocoregional recurrence in
rectal cancer from
incomplete clearance ofincomplete clearance of
rectal mesentery
Local recurrence: 6.5%
Preservation of fxn of
autonomic nerves &
decrease post-op GU dysfxn
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IMA ligationIMA ligationRectal CARectal CA
IMA ligationIMA ligationwww.downstatesurgery.org
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Posterior Dissection in the Posterior Dissection in the avascularavascularRectal CARectal CA
planeplane
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Autonomic nerves and lateral Autonomic nerves and lateral Rectal CARectal CA
vascular stalksvascular stalks
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Anterior AnatomyAnterior AnatomyRectal CARectal CA
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Anterior Dissection in Female Anterior Dissection in Female Rectal CARectal CA
PatientPatient
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DoubleDouble--stapled, endstapled, end--toto--end end Rectal CARectal CA
anastomosisanastomosis
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Pelvic Pelvic ExenterationExenteration & & SacrectomySacrectomyRectal CARectal CA
yyIndications limited by relatively high morbidity &
mortality assoc w/procedure.
Onocologic & palliative benefits in locally advancedOnocologic & palliative benefits in locally advanced
or recurrent rectal cancer.
5-yr survival rates for
l ll t t l
Primary advanced rectal
i l flocally recurrent rectal
cancer: 20-30%
ca, is less often
amenable to pelvic
exenteration
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Pelvic Pelvic ExenterationExenteration & & SacrectomySacrectomyRectal CARectal CA
yyInvolve resection of anus, rectum, bladder, ureters, &
pelvic reproductive organs
Fecal & urinary diversion may be neededFecal & urinary diversion may be needed
Contraindications
Carcinomatosis Bilateral ureteral
b iLiver metastases
Pelvic sidewall invasion
obstruction
Aortic node metastasesPelvic sidewall invasion
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Metastatic DiseaseMetastatic DiseaseRectal CARectal CA
Recurrence after local resection Resection of Salvage surgery if local dz only
Radical surgery w/adjuvant chemoisolated
metastatic d inad ca su ge y w/adjuva c e o
50-88% 5-yr dz-free survivalmetastatic dz in
liver or lung Salvage surgery in 49 pts
55% extended pelvic dissection
shows long-term
survival benefit55% extended pelvic dissection
58% recurred or died of dz w/i 33mo
survival benefit
5-yr dz-specific survival 53%Weiser MR et al. Dis Colon Rectum. 2005; 48: 1169.
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Adjuvant TherapyAdjuvant TherapyRectal CARectal CA
j pyj pySurgery remains cornerstone for curative approach
Significant tendency for local failure after potentially
ti ticurative resection
Salvage surgical procedures are technically difficult &
often unsuccessful
Improve locoregional ctrl
Lower risk of systemic dz
5-FU based Tx to all pts who received neoadjuvant Tx
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Role of AdjuvantRole of Adjuvant ChemoXRTChemoXRTRectal CARectal CA
Role of Adjuvant Role of Adjuvant ChemoXRTChemoXRTChemoXRT superior to surgery alone or XRT
postop: Recommended for ≥ T3 or node positive
Reduced risk of local failure, distant failure, & death
Continuous infusion of 5 FU w/radiationContinuous infusion of 5-FU w/radiation
225 mg/m2 per day x5wks: 53% survival (4yrs)
500 mg/m2 days 1-3 & days 36-9: 63% survival (4yrs)
Addition of Leucovorin or Levamisole does not increaseAddition of Leucovorin or Levamisole does not increase
efficacy of 5-FU in rectal CA as it does in colon CA
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Surveillance & FollowSurveillance & Follow--upupRectal CARectal CA
Surveillance & FollowSurveillance & Follow upupHistory & Physical E amination
Q3 mo x2 Years & then Q6 mo for total of 5 yearsExamination
CEA Q3mo x2yrs & then Q6mo for 5 yrs for lesions >T2
Colonoscopy Perform in 1 yr. If abnormal, repeat in 1 yr. If no polyps found, repeat Q2-3yrs. If a pre-op colonoscopy could not be performed bcof obstruction, must be done in 3-6mo. For pts w/rectal cancer who did not receive pelvic radiation alt4ernatives may include adid not receive pelvic radiation, alt4ernatives may include a flexible sigmoidoscopy Q6mo x5yrs.
CT scan May be considered annually for people at high risk of recurrence as defined by poorly differentiated histologic grade & tumors w/perineural or venous invasion. If the patient is postmetastectomyfor synchronous liver disease the recommendation for CT scansfor synchronous liver disease, the recommendation for CT scans may be increased to Q3-6mo.
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Current RecommendationsCurrent RecommendationsRectal CARectal CA
Current RecommendationsCurrent RecommendationsStage III (node +) Stage II (node -)
Adjuvant chemo x6mo
FOLFOX-4
Absolute benefit real but small
Small power: controversialFOLFOX-4,
capectibaine or IV 5-
FU/LV l i
S a powe : co ove s a
FOLFOX-4 or 5-FU if path has
hi h i k f ( diffFU/LV as alternatives
FOLFOX-4 most
high risk features (poor diff,
lymph or vasc invasion, bowel
convincing obstruction, inadequate staging,
perforation, direct extension
into other organs)
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