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Cancer of the Rectum: Indian Scenario 2010-11

Cancer of the Rectum: Indian Scenario 2010-11. Dr Ashok Kumar Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow , India-226014 Dr Madhavan Pillai. Cancer of the Rectum: Indian Scenario 2010-11.

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Cancer of the Rectum: Indian Scenario 2010-11

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  1. Cancer of the Rectum: Indian Scenario 2010-11 Dr Ashok Kumar Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India-226014 Dr MadhavanPillai

  2. Cancer of the Rectum: Indian Scenario 2010-11 Aim and objectives Progress in field of rectal cancer in India Basic research Diagnosis Treatment

  3. Cancer of the Rectum: Indian Scenario 2010-11 Methodology- Publication based Pubmed search - rectal cancer/ carcinoma rectum publications from India year 2010-2011 Total Papers 18 Original articles 13 Review articles 01 Case reports 04 Exclusion : one review articles and four case reports two original but not directly related to cancer rectum

  4. Staging of rectal cancer :Radio-pathological correlation Aims and objectives: To establish correlation between preoperative staging based on MRI and final histology with aim to 1. Prediction of metastatic adenopathy 2. Extramural spread Number of patients in study 40 Results: TNM correlation based on MRI and histology of resected specimen

  5. Staging of rectal cancer :Radio-pathological correlation Conclusions: 1. Accurate measurement of extramural spread is possible with MRI ( 3 Tesla), however it has a tendency to overstage extramural spread. 2. Assessment of metastatic adenopathy has low specificity ( Parangama et al. 2011 )

  6. Adequacy of Reporting on LAR specimen Aim: 1.To audit the pathological reporting on LAR specimen 2. To provide recommendations to improve the standard of reporting Methods: Compare the minimum data set provided by the Royal College of Pathologist Results: Between 2004-2005, 17975 specimens were received for reporting Reports available for assessment 59 (Nambiar et al. 2010)

  7. Adequacy of Reporting on LAR specimen REPORTS GIVEN ON There was adequacy in reporting on LAR specimen Proforma based reporting is necessary for rectal cancer Improved education and review of laboratory practice is required time to time Nambiar et al. 2010

  8. Neoadjuvant treatment- pathological responseand prognostic factors Aim : 1. To determine the rate of pathological complete response (p PR) following neoadjuvant therapy 2. Identifying the factors predicting the c PR Period 1993-2008, number of patients 248 ( CT/RT 227, RT alone 21) Complete pathological response 32 patients ( 12.9% ) Factors Analyzed: Gender, Median age ( < 48 Vs >48), Dose of radiation ( < 50 Gy Vs > 50 Gy) Distance of tumor from anal verge ( 6 cm Vs > 6 cm ) Non circumferential Vs circumferential tumor, CEA, grade of Tumor,Histology, CT+RT vs RT alone ( Jayanand et al. 2011 )

  9. Neoadjuvant treatment- pathological responseand prognostic factors Factors significantly associated with p CR : 1.Cirumferential extent of primary tumor 2.Signet ring histology Further analysis of patients with cPR Vs no cPR on survival ( 116 patients available with minimum 5 yr follow up) p CR ( n=16, 13.7%)No p CR ( n =100) Overall survival 75% 54% ns Reduced local recurrence 6.2 % 12.3% ns Conclusions: 1.Absence of circumferential margin and absence of signet ring histology predict the p CR 2. p CR may offer 5 year advantage ( Jayanand et al. 2011 )

  10. Laparoscopic Vs Open surgery after neoadjuvant treatment: short term outcome Aim : Short term outcomes and oncologic adequacy of laparoscopic Vs open surgery for rectal cancer after n CRT Method: Total patients 144 --- 72 in lap and 72 in open group) Lap and open group were matched for sex, ASA grade and type of surgery ( APR 64 in lap and 64 in open; LAR 8 in each group ) Results: No difference in age, BMI, distance of tumor from anal verge and post treatment pathological stage of the disease (Seshadri et al. 2011)

  11. Laparoscopic Vs Open surgery after neoadjuvant treatment: short term outcome Conclusion: LAP Abdominoperineal (APR) resection was safe and was associated with early return of bowel function, less hospital stay and oncologically adequate after neoadjuvant treatment Seshadri et al. 2011

  12. Radiation induced proctitis:Management Method and doses • Formalin and its topical application • 4% , 50ml for 3 minutes • 3 times , max contact time 10 min • If no response, repeat after one week ( Sharma et al. 2010)

  13. Radiation induced proctitis:Management Results: Total patients 13 Number of session Number of Patients 1 8 2 4 3 1 Significant improvement in the bleeding and in the histological changes Clinical response rate 100% Complete cessation 8 (61.5%) Significant cessation 5 (38.5%) ( Sharma et al. 2010)

  14. Management of anastomotic leak after anterior resection • Leak rate 3-30% • High morbidity and mortality • Early detection • How to suspect clinically • When to operate vs conservative treatment • Role of diverting ileostomy/ colostomy

  15. Management of anastomotic leak after anterior resection (AR ) Aim of study : Identify patients who had leaked Indication for re-exploration Impact of covering colostomies on subsequent outcome period 2002-2006, 266 patients of AR Total leak in 21 patients (7.9%) leak Covering colostomy (151,56%) 9 ( 42.8%) No colostomy (115,44%) 12 ( 57.2%) ( Shukla et al.2011 )

  16. Management of anastomotic leak after anterior resection (AR ) Management of leak Management Surgical intervention Covering colostomy group ( 9 ) 6 No colostomy group ( 12 ) 12 Covering colostomy has advantage , whenever indicated following AR ( Shukla et al.2011 )

  17. Anterior resection (AR) or LAR: factors responsible for anastomotic leak Total patients of recta 108 ,underwent either AR or LAR Total anastomotic strictures 19 (17.6%) Factors analyzed for affecting the formation of strictures Age ( < or >60 yr),sex, location of tumor, preopHb and albumin, stapled anastomosis, incompleteness of doughnut, duration of surgery, loss of blood, positivity of resection margin, mucin secreting tumor, diverting stoma and anastomotic leak THE FACTOR FOUND ASSOCITED WITH ANASTOMOTIC STRICTURES WERE Mucin secreting tumor Low rectal Growth Anastomotic leak (kumar et al. 2011)

  18. Anterior resection (AR) or LAR: factors responsible for anastomotic stricture Total patients of recta 108 ,underwent either AR or LAR Total leak in 16 ( 14.6%) patients Leak Covering stoma (60) 8 ( 13.4%) No stoma (48) 8 ( 16.7 %) Factors analyzed affecting the leaks were- Age ( < or >60 yr),sex, location of tumor, preopHb and albumin, stapled anastomosis, incompleteness of doughnut, duration of surgery, loss of blood, positivity of resection margin, mucin secreting tumor, diverting stoma ADVANCE AGE WAS THE FACTOR FOUND ASSOCITED WITH LEAK (kumaretal. 2011)

  19. Anterior resection (AR) or LAR: Anastomotic leak and stricture- management Total patients of recta 108 ,underwent either AR or LAR Total leak 16 ( 14.6%) patients Re-exploration in 11, Conservative in 05 Total anastomotic strictures 19 (17.6%) Anal dilatation 19 ( 1-4 sessions) Successful and closure of stoma in 15 Unsuccessful and failure to close stoma 04 CARE SHOULD BE TAKEN IN ELDERLY, LOW LYING AND MUCIN SECRETING TMOR TO PREVENT THESE COMPLICATIONS ( kumar et al. 2011)

  20. Technique: trans-anal excision of ano-rectal tumor Clinical material : Period 2004-2008, Total patients 46 patients Benign 21 Malignant 25 Excision for Malignant patients 25 A. CURATIVE ( n=20 ) Adenocarcinoma 17 Melanoma 02 Verucous carcinoma 01 B. PALLIATIVE ( n= 05 ) Adenocarcinoma 01 Melanoma 04 ( Mittal et al. 2010)

  21. Technique: Trans-anal excision of ano-rectal tumor OUTCOMES Follow up period 28 months ( 4-63 months) 3 recurrence in curative group One required repeat excision Two required APR Conclusions : Transanal excision provides good palliation of advance malignancy It can be performed in carefully selective group ( Mittal et al. 2010 )

  22. Colorectal cancer in young patients:Presentation and behaviour Between 2000-2006 , Total patients 32 ( age 10-25 year) - colon and rectal cancer Presentations : Pain 81% Bleeding 78% Altered bowel habit 72% Nodal Status and Metastasis Node positive 38% Metastasis 12% Disease is usually aggressive and prognosis is poor in young patients (Mukherji et al. 2011)

  23. Role of Biomarker in rectal cancer Role of alpha-1 syn-trophin protein ( SNTA 1) studied in histologically proven cancers -Esophagus, stomach, lung - Breast -Colon and rectal cancer SNTA 1 was not found to have either diagnostic or prognostic role as a marker in rectal cancer ( Bhat et al. 2010)

  24. Distribution of nodes in mesorectum: Cadaveric study Aim : • To study the size and distribution of lymph nodes in the fresh cadever • To compare the efficacy of manual retrieval vs fat clearance method Total patients 30 Group A 15 ( Manual retrieval) Group B 15 ( Fat clearance method) Method: fresh cadevers without rectal cancer TME specimens were divided into 3 zones- 1.Upper 2. Middle and 3. Lower All the three zones were further divided into four sectors Right lateral, left lateral , Posterior and Anterior Presence of Nodes were studied in first 3 sectors , which contains the mesorectum and the nodes ( Thakur et al. 2011)

  25. Distribution of nodes in mesorectum: Cadaveric study Results: Mean number of nodes per patient 6.2 (5-9) Mean size of nodes 2.1 mm (2-8mm) Conclusions: 1. No difference was found in the number and the size of nodes in either group , in all the zones of mesorectum 2.Very small nodes were better detected by Fat clearance method than manual method 3. Men have greater number of nodes than women ( 6.59 vs 5.25) , but it was not statistically significant ( Thakur et al.2011)

  26. Cancer of the Rectum: Indian Scenario 2010-11 CONCLUSIONS: 1. There are not many publications in field of rectal cancer from India during the year 2010-2011. 2. Most of the publications are clinical 3. Though , they are few in number but the work done has wide implications in the diagnosis , staging and the treatment, which is worth in Indian scenario.

  27. Cancer of the Rectum: Indian Scenario 2010-11 References: 1... Completeness of low anterior resection pathology report: a hospital-based audit with recommendations on improving reporting. Nambiar A, Vivek N, Bindu MR , Sudhir, OV, Bai L. Indian J cancer 2010, Apr-June , 47( 2) , 156-9 2. Signet ring cell histology and non-circumferential tumors predict pathological complete response following neoadjuvantchemoradiation in rectal cancers. Jayanand SB, Seshadri RA, Takire R Int J colorectal Dis. 2011 Jan; 26(1): 23-7. 3. Anatomic study of distribution, numbers, and size of lymph nodes in mesorectum in Indians: a autopsy study. Thakur S, Somashekhar U, Chandrakar SK, Sharma D Int J surgPathol 2011, Jun; 19 (3) : 315-20

  28. Cancer of the Rectum: Indian Scenario 2010-11 References: 4. Laparoscopic versus open surgery for rectal cancer after neoadjuvantchemoradiation: a matched case-control study of short-term outcomes. Seshadri RA, Srinivasan, Ayyappan, TapkireRitesh, SwaminathanRajaraman SurgEndosc 2011, Jan; 26(1): 154-61 5. Anterior resection for rectal carcinoma - risk factors for anastomotic leaks and strictures. Kumar A, Daga R, Vijayraghavan P. Prakash A, Singh RK, Behari A, Kapoor VK, Saxena R World J Gastroenterol 2012 March 21; 17 ( 11): 1475-9. 6. Alpha-1-syntrophin protein is differentially expressed in human cancers. Bhat SF, Baba RA, Bashe M, Seed S,Kirmani D, Wani MM, wani NA, Wani KA, Khanday FA Biomarkers. 2011 Feb ; 16(1): 31-6

  29. Cancer of the Rectum: Indian Scenario 2010-11 References: 7. Radiologic and Pathological Correlation of Staging of Rectal Cancer with 3 Tesla Magnetic Resonance Imaging Chatterjee P, Eapen A, Perakath B, Singh A, Can Assoc Radiol J 2011 August; 62 (3): 215-22 8. Managing leaks following anterior resections: a new classification system. Shukla P, Barreto SG, pandey D, Kanitkar GA, Shrikahaney SV Hepatogastroenterology 2011 July- Aug ;58(109): 1095-8 9. Transanal excision of anorectal lesions--a single centre experience Mittal R, Perakath B, Chase S, Jesudason MR, Nayak S TropGastroenterol. 2010 Jan-Mar; 31(1): 65-8

  30. Cancer of the Rectum: Indian Scenario 2010-11 References: 10. A study on presentation and behavior of colo-rectal carcinoma in young Indian patients. Mukherji A, Rathi AK, Sharma K, Kumar V, Singh K, Bahadur AK TropGastroenterol. 2011 Japr- Jun; 32(2): 122-7 11. Intrarectal application of formalin for chronic radiation proctitis : a simple , cheap and effective treatment Sharma B, Kumar R , Singh KK, Chahan B TropGastroenterol. 2010 , 31(1): 37-40 Acknowledgement : Authors sincerely acknowledge the contribution of Dr Ashwin Reddy Sama , for helping to search the literature.

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