rectal cancerrectal cancer - suny downstate medical center · rectal cancerrectal cancer sophia l...

Rectal CancerRectal CancerRectal CancerRectal Cancer

Sophia L Fu, MD

SUNY Downstate Medical Center, Brooklyn, NY

September 10, 2009September 10, 2009

www.downstatesurgery.org

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


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


CT ScanCT ScanRectal CARectal CA

CT ScanCT Scanwww.downstatesurgery.org

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


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


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


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


Rectal CancerRectal Cancer


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


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


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


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


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)


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


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


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


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


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.


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.


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.


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.


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


How to determine which How to determine which d ?d ?procedure?procedure?


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


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


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


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


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%


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


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


IMA ligationIMA ligationRectal CARectal CA

IMA ligationIMA ligationwww.downstatesurgery.org

Posterior Dissection in the Posterior Dissection in the avascularavascularRectal CARectal CA

planeplane


Autonomic nerves and lateral Autonomic nerves and lateral Rectal CARectal CA

vascular stalksvascular stalks


Anterior AnatomyAnterior AnatomyRectal CARectal CA

yywww.downstatesurgery.org

Anterior Dissection in Female Anterior Dissection in Female Rectal CARectal CA

PatientPatient


DoubleDouble--stapled, endstapled, end--toto--end end Rectal CARectal CA

anastomosisanastomosis


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


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


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.


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


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


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.


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)


rectal cancerrectal cancer - suny downstate medical center · rectal cancerrectal cancer sophia l...

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