recent advances in the management of rectal carcinoma

PROFESSOR PANKAJ G. JANI. M.MED., FRCS.DEPT. OF SURGERY, UNIVERSITY OF NAIROBI. KENYATTA

NATIONAL HOSPITALCHAIR. EXAMINATIONS AND CREDENTIALS COMMITTEE

COSECSA

INT. ONCOLOGY CONF. NAIROBI, OCTOBER 2011

THEME

Translating recent advances into local practice/clinical care

RECTAL CANCER

Progress in MULTIMODAL THERAPY of Rectal Cancer is one of the BEST examples of success of Clinical Research in the last 2 decades.

RECTAL CARCINOMA – RECENT ADVANCES -- OVERALL

1.SPHINCTER SAVING PROCEDURES – UP FROM 15% TO 50% -- NO COLOSTOMY (IMPROVED QOL)

2. OVERALL FIVE YR SURVIVAL – UP FROM 30% TO 60%

3. DEPTH OF INVASION – DECREASED BY 40%-60% WITH ADJUVANT Rx

4. LYMPH NODE STATUS AND REC. FREE SURVIVAL - SAME

RECENT ADVANCES 1. MOLECULAR BIOLOGY 2. SURGERY 3. IMAGING – MRI, CT AND PET4. CHEMO/RADIOTHERAPY

MOLECULAR BIOLOGY DNA CHIP TECH. – DNA

SEQUENCE CHECKED -- APC GENE – FAP -- MISMATCH REPAIR GENES –

HNPCCSUCH PTS.(5%) PUT ON A

SURVEILLANCE PROG. --PROPHYLACTIC SURGERY

MOLECULAR BIOLOGY

DNA SEQUENCE OF MICROSATELLITE INSTABILITY

-- GOOD RESPONSE WITH 5 FU CHEMO.

P21 MARKER POSITIVE – RADIOSENSITIVE

MOLECULAR BIOLOGY

P53 PROTEIN MUTANT EXPRESSED -- RADIORESISTANT

KRAS, DCC, AND P53 -- IF +ve – POOR PROGNOSIS

MICROSATELLITE INSTABILITY OR LOW Cox2 EXPRESSION & P21 MARKER – IF +ve – GOOD PROGNOSIS

SURGICAL CHALLANGES

I - STAGING

II - USE OF CH/RT

III - SURGICAL TECHNIQUE

I - STAGING

DECIDES –TRANS ANAL LOCAL EXCISIONAPR

.

NEOADJUVANT CH/RT

TRADITIONAL STAGING

DIGITAL RECTAL EXAMINATION

CT SCANS

NEWER STAGING METHODS

DRE

ERUS – NODES

CT

RECENT ADVANCES

DRE

ERUS

MRI

RECENT ADVANCES

DRE

RECTAL CA. RECENT ADVANCES

RECENT ADVANCES ERUS

ERUS ------ BEST FOR NODAL STATUS

( OPERATOR DEPENDANT)

STAGINGERUS

T STAGE ACCURACY 60 – 90% N STAGE ACCURACY 60 – 90%

MRIT STAGE ACCURACY 60 – 90% N STAGE 40 --- 80% ( NODES > 5mm)

CHALLANGE

PICK UP NODES < 5mm (33%OF ALL

NODES)

PICK UP MICRO METS

USE OF CH/RT

MRIHIGH RESOLUTION THIN SLICE (<1mm)

DEPTH OF EXTRAMURAL SPREAD ACCURATELY IDENTIFIED (AIDS CIRCUMFERENTIAL RESECTION MARGIN)

TRADITIONAL- PROXIMAL- DISTAL

RECENT ADV. – CIRCUMFERENTIAL RESEC. MARGINS IMP.

MRIINDICATORS OF MALIGNANT NODAL INVOLVEMENT

L. NODES -- IRREGULAR BORDER

-- MIXED SIGNAL INTENSITY OF NODE

MRIDETECTS EXTRAMURAL VENOUS INVASION (EMVI)

POOR PROGNOSIS WITHOUT CH/RT IF EMVI PRESENT

II USE OF CH/RT (NEOADJUVANT/ADJUVANT)

PTS WITH POOR HISTOLOGY

PTS WITH EXTRA MURAL SPREAD (MRI)

PTS WITH INVOLVED NODES (ERUS)

PTS WITH EMVI (MRI)

CHEMOTHERAPYINJ KYTRIL 3mg Ksh 2,250/-INJ DEXAMETHAZONE 8mg Ksh

385/-INJ FLUOUROURACIL 5500mg Ksh

12,053/-INJ OXALIPLATIN 200mg Ksh

187,600/-INJ LEUCOVORIN 100mg Ksh

1,809/-INJ AVASTIN 400mg Ksh 213,806/-

Kshs 417903/-

RADIOTHERAPYEUROPEAN APPROACH(25G/5CYCLES)SHORT COURSE – LOW

DOSE – IMMEDIATE SURGERY

NO CHANGE IN PATH STAGING

LOWER COSTBETTER COMPLIANCEDOSE EQUIVALENT TO

30-33GEXPECT 66%

REDUCTION IN LOCAL RECURRENCE

AMERICAN APPROACH

(45 – 54G/28 CYCLES)PROLONGED COURSE

– HIGH DOSE – DELAYED SURGERY

BETTER SURGICAL TOLERANCE

MORE TUMOR REGRESSION

EXPECT >80% REDUCTION IN LOCAL RECURRENCE

III SURGICAL TECHNIQUE TRADITIONAL

PROCTECTOMY PERFORMED

-- In the DARK -- Using BLUNT Dissection -- Without attention to ANATOMIC

DetailRESULTED in -- Bloody operation -- Increased -- Autonomic Nerve injury -- Local Rec.

SURGERY - TRADITIONALANT. RESECTION – UPPER ⅓ RECTAL CA

LOW ANT.RESCETION - MID ⅓ RECTAL CA

A.P.R. - LOWER ⅓ RECTAL CA

ANY TUMOR 10cms FROM ANAL VERGE -- APR

ANATOMY OF RECTUM

CHANGED FROM TRADIOTIONAL 22 CMS FROM ANAL VERGE TO 15 CMS

ABOVE THAT IS ALL COLON

RECTAL CARCINOMA RECENT ADVANCES

>100 YEARS SINCE MILES DESCRIBED ABDOMINO-PERINEAL-RESECTION

>25 YEARS SINCE HEALD DESCRIBED TOTAL MESORECTAL EXCISION

III SURGICAL TECHNIQUERECENT ADV.

TOTAL MESORECTAL EXISION

( EXICISION OF FASCIA ENVELOPING THE FAT PAD AROUND THE RECTUM.)

SAUSAGE APPEARANCE

SURGERY – RECENT ADVANCES

LOW-ANT RESECTION – UPTO 6cms FROM ANAL VERGE≏

APR – ONLY IF SPHINCTOR FUNCTION COMPROMISED

RECTAL CANCER – RECENT ADVANCES

CAREFUL ASSESSMENT OF SxS

EARLY DIGNOSIS WITH

ACCURATE STAGING

CH/RT - FOR SELECTED PTS

- PROCTOSCOPY - SIGMOIDOSCOPY

- DRE - ERUS

- MRI

OUR SCENARIOLATE PRESENTATIONADVANCED TUMORSANATOMICAL DISTORTIONLACK OF NEOADJUVENTSSURGERY MORE DIFFICULTRESULTS POORER

COMMON PROBLEMS FACING SURGERY IN AFRICA

• LACK OF GUIDELINES AND

STANDARDS

• INADEQUATE SUPERVISION

VEINS OF SMALL & LARGE INTESTINES

CAECAL CANCER RESECTION

GOALS OF THERAPY FOR RECTAL CARCINOMA

DECREASE LOCAL RECURRANCE

OPTIMISE Q.O.L. AVOID COLOSTOMY

CA. RECTAM (ESP. LOWER TUMORS)

SHOULD BE DIAGNOSED EARLY

SHOULD GIVE GOOD RESULTS WITH EARLY THERAPY

LOCAL EXPERIENCE 31 CASES OF RECTAL CA

25 APR DONE

6 LOW ANT RESECTIONS (2 Local Rec.)

SYMPTOMSRECTAL BLEEDING LOWER RECT.TENESMUS

ALT. OF BOWEL HABITS UPPER.ANY G.I. SxS (dyspepsia)

RECTAL CANCER