TUMOR BOARD Rectal Carcinoma

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TUMOR BOARDRectal Carcinoma

• 8/28/07

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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

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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

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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

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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

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Patient 2

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

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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

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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

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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

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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

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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

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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

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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

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Staging
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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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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