Carcinoma Rectum

By
Dr SYED UBAID
why is rectal carcinoma different

• Anatomy

• Relations

• Mesorectum

• Lateral nodal spread .

 Epidemiology
• Colorectal caner is the third most frequently
diagnosed cancer in the US men and women.

• Incidence rate in India is quite low about 2 to 8

per 100,000
• Median age- 7th decade but can occur any time
in
adulthood
• Lifetime risk
 1 in 10 for men
 1 in 14 for women
Incidence in Large Bowel
• Cecum 14
%
• Ascending colon 10
%
• Transverse colon 12
%
• Descending colon 7
%
• Sigmoid colon 25
%
• Rectosigmoid junct
0.9 %
 ANATOM
Y
• 15cm

• Starts - 3rd sacral vertebra

• Ends 2-3cm infront of the x
coccy

• The rectum is “fixed” posteriorly and laterally by Waldeyer’s

fascia
• anteriorly : Denonvilliers’ fascia

Reference: NCCN guidelines on colorectal carcinoma,

Fishers mastery of surgery 6th edition,Maingots abdominal operations 12th edition
 Clinical Anatomy
• Begins at 12-15 cm
from anal verge.
• Diameter
 4 cm (upper
part)
 Dilated (lower
part)

• Posterior part of the

lesser pelvis and in
front of lower three
pieces of sacrum and
the coccyx

• Begins at the
rectosigmoid junction,
at level of third sacral
vertebra
 Clinical
• Ends at Anatomy
.
the anorectal
junction, 2-3 cm in front of
and a little below the coccyx

• Taenia of the sigmoid colon

form a continuous outer
longitudinal layer of smooth
muscle

• Fatty omental appendices are

discontinued
 Rectum is divided into 3

portions
3 distinct
intraluminal
curves ( Valves of
Houston)

Lower rectum : 3 – 6 cm
from the anal verge

Mid rectum: 6 cm to 8
-10cm from anal verge

 Upper rectum: 8 cm to
12 -15cm from anal
verge
 Peritoneal Relations
 Superior 1/3rd of the rectum
 Covered by peritoneum on
the anterior and lateral
surfaces

 Middle 1/3rd of the rectum

 Covered by peritoneum on
the anterior surface

 Inferior 1/3rd of the rectum

 Devoid of peritoneum
 Close proximity to adjacent
structure including boney
pelvis.
 Arterial Supply
• Superior rectal A –
from IMA; supplies
upper and middle
rectum
• Middle rectal A-
from
Internal iliac A.
(supplies lower
rectum)

• Inferior rectal A- from

Internal pudendal A.
 Venous Drainage
 Superior rectal V- upper
& middle third rectum

 Middle rectal V-
lower rectum and
upper anal canal

 Inferior rectal vein-

lower anal canal
Nerve supply
• Sympathetic , L1–L3
• sacral (parasympathetic), s2-s4
• inferior hypogastric nerves

innervate - rectum, bladder, ureter, prostate,

seminal vesicles, membranous urethra,
corpora cavernosa.
• injury- impotence, bladder dysfunction, and
loss of normal defecatory mechanisms.
Reference: Sato K, Sato T. The vascular and neuronal composition of the lateral ligament of the
rectum and the rectosacral fascia. Surg Radiol Anat. 1991;13:17–22.
 Lymphatic drainage

• upper and middle rectum - inferior

mesenteric nodes
• lower rectum - inferior mesenteric system
• posteriorly - middle sacral artery
• anteriorly - retrovesical or
rectovaginal septum
iliac nodes

periaortic nodes.
 Lymphatic drainage
 Upper and middle rectum
 Pararectal lymph nodes,
located directly on the
muscle layer of the rectum
 Inferior mesenteric
lymph nodes, via the nodes
along the superior rectal
vessels
 Lower rectum
 Sacral group of lymph
nodes or Internal iliac
lymph nodes
 NODAL

GROUPS Internal iliac

Perirectal Paraortic
Common iliac
Lymphatic Drainage
 Aetiology
 Etiological agents
 Environmental & dietary factors
 Chemical carcinogenesis.

 Associated risk factors

 Male sex
 Family history of colorectal cancer
 Personal history of colorectal cancer, ovary,
endometrial, breast
 Excessive BMI
 Processed meat intake
 Excessive alcohol intake
 Low folate consumption
 Neoplastic polyps.

 Hereditary Conditions (FAP, HNPCC)

 Adenoma to carcinoma sequence
• First described by DUKES in 1926
• The time course is 5-10 years
• Non inherited cases has ras, p53 mutations

•Malignant potential –
villous adenoma
Diameter >2cm
.
 CLINICAL
PRESENTATIO
NS
 Symptoms
 Asymptomatic
 Blood PR(60%)
 Change in bowel habit(43%) (diarrhoea, constipation,
narrow stool, incomplete evacuation, tenesmus)
 Occult bleeding(23%)
 Abdominal discomfort (20%)(pain, fullness, cramps,
bloating, vomiting)
 Weight loss, tiredness
 Back Pain
 Urinary symptoms
 Pelvic pain(5%) indicating nerve trunk involvement
 Acute Presentations
• Intestinal obstruction

• Perforation

• Massive bleeding
 Signs
• Pallor
• Abdominal mass
• PR mass
• Jaundice
• Nodular liver
• Ascites

 Rectal metastasis travel along portal drainage to liver

via superior rectal vein as well as systemic drainage to
lung via middle inferior rectal veins.
 Signs
 Signs of primary cancer
 Abdominal tenderness and distension – large bowel obstruction
 Intra-abdominal mass

Digital rectal examination – most are in the

lowest 12cm & reached by examining finger
 Rigid sigmoidoscope
 Signs of metastasis and
complications
 Signs of anaemia
 Hepatomegaly (mets)
 Monophonic wheeze
 Bone pain
 W H O Classification of
Rectal Carcinoma
• Adenocarcinoma in situ / severe dysplasia
• Adenocarcinoma
• Mucinous (colloid) adenocarcinoma (>50% mucinous)
• Signet ring cell carcinoma (>50% signet ring cells)
• Squamous cell (epidermoid) carcinoma
• Adenosquamous carcinoma
• Small-cell (oat cell) carcinoma
• Medullary carcinoma
• Undifferentiated Carcinoma
 Dukes
classification
Dukes A: Invasion into but not through the
bowel wall

 Dukes B: Invasion through the bowel wall

but not involving lymph nodes

 Dukes C: Involvement of lymph nodes

 Dukes D: Widespread metastases

 Modified astler
coller
 Stage A :classification-
Limited to
mucosa
 Stage B1 : Extending into muscularis
but not
propriapenetrating through it; nodes not involved
 Stage B2 : Penetrating through
propria; nodes not involved
muscularis
 Stage C1 : Extending into muscularis propria
not
butpenetrating through it. Nodes involved
 Stage C2 : Penetrating through
propria. Nodes involved
muscularis
 Stage D: Distant metastatic
spread
TX
TNM Classification
Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ: intraepithelial or invasion of lamina propria
T1 Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades through the muscularis propria into pericolorectal tissues

T4a Tumor penetrates to the surface of the visceral peritoneum

T4b Tumor directly invades or is adherent to other organs or structures

Tis T1 T 2 T3 T4

Mucosa
Muscularis mucosae

Submucosa

Muscularis propria

Subserosa
Serosa

Extension to an adjacent organ

TNM Classification
 Stage grouping
Stage T N M Dukes MAC
0 Tis N0 M0 - -
I T1 N0 M0 A A
T2 N0 M0 A B1
IIA T3 N0 M0 B B2
IIB T4 N0 M0 B B3
IIIA T1-2 N1 M0 C C1
IIIB T3-4 N1 M0 C C2/C3
IIIC Any T N2 M0 C C1/C2/C3
IV Any T Any M1 - D
N
Stage 0 Rectal Cancer
• Known as “cancer in
situ,” meaning cancer
is located in the
mucosa.
Stage I Rectal Cancer
• The cancer has grown
through the mucosa
and invaded the
muscularis (muscular
coat)
Stage II Rectal Cancer
• The cancer has grown
beyond the muscularis
of the colon or rectum
but has not spread to
lymph nodes
Stage III Rectal Cancer
• Cancer has spread to
the regional lymph
nodes (lymph nodes
near the colon and
rectum)
Stage IV Rectal Cancer
• Cancer has spread
outside of colon
or rectum to other
areas of the body
 Prognostic factors
 Poor prognostic
 Good
facto
prognostic  Obstruction
rs
factors  Perforation
 Old age  Ulcerative lesion
 Gender(F>M)  Adjacent structures
 Asymptomatic involvement
pts  Positive margins
 Polypoidal  LVSI
lesions  Signet cell carcinoma
 Diploid  High C E A
 Tethered and fixed
cancer
 Diagnostic Workup
• History—including family history of colorectal
cancer or polyps
• Physical examinations including DRE and
complete pelvic examination in women: size, location,
ulceration, mobile vs. tethered vs. fixed, distance from
anal verge and sphincter functions.
• Proctoscopy—including assessment of mobility,
minimum diameter of the lumen, and distance from the
anal verge
• Biopsy of the primary tumor
 Diagnostic
• General
ClinicalEvaluation
features.
• Lab. Studies
Complete blood cell count
Blood chemistry profile
CEA

• Evaluation
• Determination of
Occult Blood Digital Rectal
Examination
Proctosigmoidoscopy
Flexible Fibreoptic Sigmoidoscopy &
Colonoscopy. Barium Enema
• Urologic Evaluation
• Other Imaging studies
• CT, USG, MRI, Chest X-ray, FDG- PET scan,
 Colonoscopy or barium
enema
To evaluate remainder of large bowel to rule out
synchronous tumor or presence of polyp syndrome.

Figure: Carcinoma of the rectum.

Double- contrast barium enema
shows a long segment of concentric
luminal narrowing (arrows) along the
rectum with minimal irregularity of
the mucosal surface.
 Transrectal Ultrasound
• Used for clinical staging.
• 80-95% accurate in
tumor staging
• 70-75% accurate in
mesorectal lymph
staging node
• Very good at demonstrating
layers of rectal wall
• Use is limited to lesion < 14
cm from anus, not
applicable for upper
rectum, for stenosing tumor
• Very useful in determining
extension of disease into
anal canal (imp to plan
sphincter preserving Figure.Endorec ultrasoun
surgery) tal a T3 tumor of the
of d
rectum,
extension throug the
muscularis h and
propria,
perirectal into
fat.
 EUS : Accuracy
EUS CT

Depth of infiltration T staging 91% 71%

N staging 87% 76%

 CT Scan
• Part of routine workup of patients

• Useful in identifying enlarged pelvic lymph-nodes and

metastasis outside the pelvis than the extent or stage of
primary tumor

• Limited utility in small primary cancer

• Sensitivity 50-80%

• Specificity 30-80%
 CT Scan

• Ability to detect pelvic and para-aortic

lymph nodes is higher than peri-rectal
lymph nodes(75% to 87% vs. 45%)
Accuracy 60-80%
T stage
Accuracy 60-75%
N stage
Liver met. 70-79%
Figure: Rectal cancer with Figure: Mucinous adenocarcinoma
invasion. uterine
scan shows larg of the
rectum. CT scan shows a large
CT
heterogeneo e heterogeneous mass (M) with areas
us
compression and directa invasion wit of cystic components. Note marked
rectal
into the posterior wall mass h
of the uterus luminal narrowing of the rectum
(U). (M) (arrow).
 Magnetic Resonance
Imaging (MRI)
• Greater accuracy in defining extent of rectal
cancer
extension and also location & stage of tumor

• Helpful in lateral extension of disease, critical in

predicting circumferential margin for surgical
excision.

• Different approaches (body coils, endorectal MRI &

phased array technique)
Figure Normal rectal and Figure: Mucinous adenocarcinoma of the
:
anatomy perirectal
on high-resolution T2- rectum. T2-weighted MRI shows high signal
weighted
MRI. Rectal mucosa (M), intensity (arrowheads) of the cancer lesion
(SM), and muscularis propria (PM)
submucosa in right anterolateral side of the rectal wall.
are
well Mesorectal
discriminated. fascia
appears as (arrowheads)
structure a low-signal-
and fuses
thin, the
with remnantintensity
of urogenital
septum making Denonvilliers fascia
(arrows).
 PET with FDG
• Shows promise as the most
sensitive study for the detection of
metastatic disease in the liver and
elsewhere.
• Sensitivity of 97% and specificity of
76% in evaluating for recurrent
colorectal cancer.

Small
canc
bowel
er
bladder
rectum
pubic
 Aims of treatment
• Local control
• Long-term survival
• Restoration of bowel continuity and
Preservation of anal sphincter.
• Bladder and sexual function and maintenance or
improvement in QOL.
• Careful preoperative screening is crucial in
determination of the location of lesion and
its depth of invasion
 Treatment

Surgery Chemotherapy Radiotherapy

 Treatment Overview
• Sx mainstay of treatment.
• After curative resection the 5 year survival drops
from 80% in stage I to about 40% in stage III
disease.
• Local recurrence remains a major site of failure
ranging from 5% in few selected series to about
40% in most reports.
 Principles of surgical
management
• Removal of primary tumor with adequate
margin.
• T/t of draining LN.
• Restoration of function
• “En bloc” resection if necessary
 GOAL OF SURGERY

• PRIMARY GOAL IS ERADICATION OF PRIMARY

TUMOR ALONG WITH ADJACENT
MESORECTAL TISSUE AND SUPERIOR
HEMORRHOIDAL ARTERY PEDICLE
 RESECTION MARGIN
• Traditional margin of 5cm
• NSABP demonstrated no difference in survival
or local recurrence in distal margin of 2, 2-
2.9,
>3cm
• Therefore, 2cm distal margin Is now
acceptable considering the limitation of distal
intramural spread of 2cm below the
peritoneal reflection
 RESECTION MARGIN
• Circumferential radial margin is more crucial

• Length of mesorectum removed beyond the

primary tumor is between 3 to 5 cm as tumor
implants have not been shown further than
4cm
 LOCAL EXCISION

Tumors amenable to local excision

• T1N0 or T2N0 lesion
• <4cm in diameter
• <40% in circumference of lumen
• <10 cm from dentate line
• Well to moderately differentiated histology
• No evidence of lymphatic or vascular invasion
• Local control for advanced disease
 Local
• For superficially invasive (T1) tumors with low
excision
likelihood of L N metastases
• Total biopsy, with further T/t based on
pathology
• Tumors within 8 to 10 cm of anal verge,
• Encompass less than 40% of circumference of bowel
wall,
• well or moderately well differentiated histology,
• No pathological evidence of venous or lymphatic
vessel invasion on biopsy
• With unfavorable pathology patient should
undergo total mesorectal excision with or without
sphincter- preservation:
 Positive margin (or <2 mm), lymphovascular
invasion,
 LOCAL EXCISION
TECHNIQUES:
Transsphincteric excision
Transanal excision
Transcoccygeal excision
Transanal endoscopic microsurgery
 LOCAL EXCISION
TRANSANAL EXCISION

• Tumors 6-8 cm from anal verge

• 1 cm circumferential margin
• Full thickness excision
 LOCAL EXCISION
TRANSANAL EXCISION
 LOCAL EXCISION
TRANSCOCCYGEAL EXCISION

• Popularized by KRASKE
• Useful for more proximally placed, posterior
lesions
• 1 cm circumferential margin
• Complication: fecal fistula ( 5 to 20%)
 LOCAL EXCISION

TRANSCOCCYGEAL EXCISION
 LOCAL EXCISION
• TRANSANAL ENOSCOPIC MICROSURGERY
• the procedure of choice for early mid to upper
rectal lesion
• Offers better visualization, complete intact
excision
LOCAL EXCISION
 LAR
• For tumors in upper/mid rectum allows
preservation of anal sphincter
• Join colon to low rectum
• Permanent colostomy if tumor too low
w
LOW ANTERIOR RESECTION WITH TME
• local failures are most often due to inadequate
surgical clearance of radial margins.

• conventional resection violates the

circumferenc mesorectal during blunt
e dissection, leavingresidual
mesorectum.
• TME involves precise dissection and removal of the entire
rectal mesentery as an intact unit.

• local recurrence with conventional surgery averages

approx. 25-30% vs. TME 4-7% by several groups (although
several series have higher recurrence)
 mesorectum
• Mesentry surrounding the rectum
• Covered by the visceral layer of the end opelvic fascia
• Contains
perirectal fat
Draining lymph nodes
Superior rectal blood ve ssels

• Holy plane – loose areolar tissue separating the

visceral and parietal layers
• Parietal layer covers the superior hypogastric
plexus
,hypogastric
Reference: plexus
Heald, RJ; et and
al. (1982). "Thepelvic plexus.
mesorectum in rectal cancer surgery-the clue
to pelvic recurrence?". Br J Surg (John Wiley & Sons, New Jersey) 69: 613–616.
Reference :Fishers mastery of surgery 6th edition
LOW ANTERIOR RESECTION WITH TME
PROCEDURE :
A. MOBILIZATION OF COLON
B. TRANSECTION
C. RECONSTRUCTION
Double stapling technique

• Diverting loop ileostomy

• Colonic pouch/ transverse
coloplasty
LOW ANTERIOR RESECTION WITH TME
LOW ANTERIOR RESECTION WITH TME
Specific complications

• Impotence (10-28%)
• Retrograde ejaculations
• Urinary incontinence
LOW ANTERIOR RESECTION WITH TME
TME ALONE (%) TME+RT (%) TME +LND (%)

LOCAL 12.1 5.8 6.9

RECURRENCE

LATERAL PELVIC 2.7 0.8 2.2

RECURRENCE

PRESACRAL 3.2 3.7 0.6

RECURRENCE
ABDOMINOPERINEAL DISSECTION
Suitable for
• Cancers involving the sphincter apparatus
• Incontinent to feces

Very High morbidity (61%)

Mortality 0 to (6.3%)
 Abdomino-perineal
resection
 For tumors of distal rectum(lower 1/3rd) with distal
edge up to 6 cm from anal verge
 Associated with permanent colostomy and high
incidence of sexual and genitourinary dysfunction
 Procedure
• Through combined abdominal and perineal
incisions, the anus, rectum, and sigmoid
colon are removed en bloc.
• Also called Miles Resection
• The proximal end of the bowel is exteriorized
through a separate stab wound as a
colostomy.
• The distal end is pushed into the hollow of
the sacrum and removed via perineum
• Performed to treat cancer of the lower
rectum—and diseases are too low for use of
stapling devices
Heavy purse string suture
around anus to occlude it
Colon and Rectum are
delivered through the
perineal resection
 Total mesorectal excision
• Local failures are most often due to inadequate surgical
clearance of radial margins.

• Conventional resection violates the mesorectal circumference

during blunt dissection, leaving residual mesorectum.

• Excision of fascia enveloping the fat pad around the rectum

• TME involves precise dissection and removal of the entire

rectal mesentery as an intact unit.

• Local recurrence with conventional surgery averages approx.

25-30% vs. TME 4-7% by several groups (although several
series have higher recurrence)
TOTAL
MESORECTAL
EXCISION
Total Mesorectal
Excision
 ABDOMINOPERINEAL DISSECTION

Complications:
• Perineal wound complications (25%)
• Urinary incontinence (as high as 50%)
• Sexual dysfunction (as high as 67%)
• Stoma complications
(ischemia, retraction, hernia, stenosis , prolapse)
ABDOMINOPERINEAL DISSECTION
En block excision :
• Posterior vaginectomy ( 1cm margin)
• prostatectomy
• Pelvic exenteration
( high morbidity and mortality )

Consider prophylactic bilateral oopherectomy

 Pelvic Exenteration
The surgeon removes the rectum as well as nearby organs such as the
bladder, prostate, or uterus if the cancer has spread to these organs.
A colostomy is needed after this operation. If the bladder is removed,
a urostomy (opening to collect urine) is needed.

High Anterior
Resection
Low Anterior Resection

Ultra-low Anterior
cm
15

Resection

Abdominoperineal Resection
(APR)
 CHEMORADIATION
ADVANTAGES OF NEOADJUVANT CHEMOTHERAPY

• Downstage the tumor (60-80%)

• Achieve complete pathological response (15-30%)
• To allow sphincter preserving procedures
• No radiation to anastomosis, small bowel in pelvis
 CHEMORADIATION
• 1990 NIH consensus concluded the efficacy in
local control in stage II & III

• To lower local failure rates and improve survival

in resectable cancers
• to allow surgery in primarily inoperable cancers
• to facilitate a sphincter-preserving procedure
• to cure patients without surgery: very small
cancer or very high surgical risk
 CHEMORADIATION
Chemotherapy
agents Combinatio
 5Fu

ns  FOLFOX
Leucovorin  FOLFIRI
 Oxaliplatin  Leucovorin/5FU
 Irinotecan  Capecitabine
 Bevacizumab  Bevacizumab in
 cetuximab combination with
the above
regimens.
 Polish Trial
• Polish Study (Br J Surg. 2006): 316 patients with resectable T3-4 rectal
cancer, no sphincter involvement, tumor palpable on DRE (1999-2002).

Preop Preop
short conventio
course nal
RT RT
5 y. OS 67.2% 66.2
%
5 y. local relapse 9.0% 14.2
%
DFS 58.4% 55.6
%
NO difference in anorectal or sexual dysfunction
 Dose limitations

• Small bowel- 45–50 Gy

• Femoral head and neck- 42 Gy

• Bladder -65 Gy

• Rectum- 60 Gy
CURRENT RECOMMENDATION

• Primary

Stage I surgery
• No adjuvant
therapy
CURRENT RECOMMENDATION

• Neoadjuvant
Chemoradiation ( 5-FU based
STAGE chemotherapy with
II or radiotherapy )
III • Rest for 4-8 weeks
• Total mesocolic excision
low/ • Rest for 4 weeks
midlesio • Chemotherapy in appropriate
n patients for 4-6 months
CURRENT RECOMMENDATION

Stage II • Pre or post op

chemoradiatio
or III n
• TME
High
lesion
CURRENT RECOMMENDATION

• Palliative surgery
• Adjuvant
STAG chemotherap
y
E • 5-FU +
leucovorin
IV +/- irinotecan or
oxaliplatin
 SURVEILLANCE
• Screening for rectal recurrence and
metachronous colorectal
neoplasm
• 60- 80% recurrence in 24 months, 90% in 48
months

• Each visit DRE+ sigmoidoscopy + CEA

• CT scan : 1 year postresection and then
annually till 3 years
 SURVEILLANCE
• Postoperative at 2 weeks and then every 3
months for 2 years

• After 2 years every 6 months for 5 years

• If no recurrence, then colonoscopy every 3-5

years
• Close observation for high risk patients
Thank You !!