TUMOR BOARD Rectal Carcinoma

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TUMOR BOARD Rectal Carcinoma

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1. TUMOR BOARD Rectal 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 resection Low anterior resection Abdominosacral resection Coloanal resection Local excision or fulguration Primary radiation therapy LOWER THIRD OF THE RECTUM w/n 8 cm from anal verge Abdominoperineal resection Local excision or fulguration Primary 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 <5cm from anal verge=APR >5cm from anal verge=LAR

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

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 >70 y/o, >1 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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