Rectal Ca:: Malueth Abraham, MBCHB Vi

RECTAL CA:
Malueth Abraham, MBChB VI

Clinical Anatomy
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
Ends at the anorectal junction, 2-3 cm in frontof and a little below the
coccyx
Clinical anatomy cont’d
Divided into 3 parts
Upper third
Middle third
Lower third
3 distinct intraluminalcurves ( Valves of

Houston)
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.
Note: - Distal rectal tumors have no serosal barrier to invasion of adjacent structures and are more difficult to resect
given the close confines of the deep pelvis.
Arterial supply
Superior rectal A – fr. IMA; supplies upper and middle rectum
Middle rectal A- fr. Internal iliac A. (supplies lower rectum)
Inferior rectal A- fr. 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
Innervations
Sympathetic: L1-L3, Hypogastric nerve
Parasympathetic: S2-S4
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
Below the dentate line:
Inguinal nodes and external iliac chain

Epidemiology
Colorectal caner is the third most frequently diagnosed cancer in the US men and women.
108,070 new cases of colon cancer and 40,740 new cases of rectal cancer in the US in 2008. Combined mortality for
colorectal cancer 49,960 in 2008.
Worldwide approx. 1 million new cases p.a. are diagnosed, with 529,000 deaths.
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.
Cecum 14 %
Ascending colon 10 %
Transverse colon 12 %
Descending colon 7 %
Sigmoid colon 25 %
Rectosigmoid junct 0.9 %
Rectum 23 %
Etiology
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)

Clinical presentation
Symptoms
Asymptomatic
Change in bowel habit ( diarrhoea, constipation, narrow stool, complete evacuation, tenesmus).
Blood PR.
Abdominal discomfort (pain, fullness, cramps, bloating, vomiting).
Weight loss, tiredness.
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.
Pathological features
WHO Classification
Adenocarcinoma in situ
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 classification
Stage A : Limited to mucosa.
Stage B1 : Extending into muscularis propria but not penetrating through it; nodes not involved.
Stage B2 : Penetrating through muscularis propria; nodes not involved
Stage C1 : Extending into muscularis propria but not penetrating through it. Nodes involved
Stage C2 : Penetrating through muscularis propria. Nodes involved
Stage D: Distant metastatic spread

TNM Classification
TX 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

Regional lymph nodes (N)
Prognostic factors
Good prognostic factors
Old age
Gender(F>M)
Asymptomatic pts
Polypoidal lesions
Diploid
Poor prognostic factors

Obstruction
Perforation
Ulcerative lesion
Adjacent structures involvement
Positive margins
LVSI
Signet cell carcinoma
High CEA
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

Colonoscopy or Barium enema
To evaluate remainder of large bowel to rule out synchronous tumor or presence of polyp syndrome.
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 node staging
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 (clinical important for planning
sphincter preserving surgery)
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%
Ability to detect pelvic and para-aortic lymph nodes is higher than peri-rectal lymph nodes.
MRI
Greater accuracy in defining extent of rectal cancer extension and also location & stage of tumor
Also helpful in lateral extension of disease, critical in predicting circumferential margin for surgical excision.
Different approaches (body coils, endorectal MRI & phased array technique).
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.

CEA: High CEA levels associated with poorer survival
Routine investigation
Complete blood count,

KFT,
LFT
Chest X-ray
Surgery
Surgery is the mainstay of treatment of RC
After surgical resection, local failure is common
Local recurrence after conventional surgery:
20%-50% (average of 35%)**
Radiotherapy significantly reduces the number of local recurrences

Types of surgery
Local excision- reserved for superficially invasive (T1) tumors with low likelihood of LN
Metastases
Should be considered a total biopsy, with further treatment based on pathology.
With unfavorable pathology patient should undergo total mesorectal excision with or without sphincter
preservation:
positive margin (or <2 mm), lymphovascular invasion,
poorly differentiated tumors, T2 lesion.
Low Anterior Resection - for tumors in upper/midrectum; allows preservation of anal sphincter
Abdominoperineal resection for tumors of distal rectum with distal edge up to 6 cm from anal
Verge.
associated with permanent colostomy and high incidence of sexual and genitourinary dysfunction
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.
Complications of Surgery:
Bleeding
Infection
Anastomotic Leakage
Blood clots
Anesthetic Risks
Purpose of Radio(chemo)therapy in Rectal
Cancer:
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
Chemotherapy agents
5Fu
Leucovorin
Oxaliplatin
Irinotecan
Bevacizumab
Cetuximab
Combinations
FOLFOX
FOLFIRI
Leucovorin/5FU
Capecitabine
Bevacizumab in
combination with the above regimens.
Radiotherapy
Prone position: radiopaque markers include anal, vaginal, rectal, perineal skin; wire perineal scar if present;
small bowel contrast, ensure bladder full.
Target Volume: Primary Tumor or Tumor bed, with margin presacral, and internal iliac nodes (if T4, external
iliac nodes also).

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RECTAL CA:

Malueth Abraham, MBChB VI

Begins at the rectosigmoid junction, at level of third sacral vertebra

3 distinct intraluminalcurves ( Valves of

Middle 1/3rd of the rectum

Inferior 1/3rd of the rectum

Superior rectal A – fr. IMA; supplies upper and middle rectum

Middle rectal A- fr. Internal iliac A. (supplies lower rectum)

Inferior rectal A- fr. Internal pudendal A.

Superior rectal V- upper & middle third rectum

Middle rectal V- lower rectum and upper anal canal

Inferior rectal vein- lower anal canal

Sympathetic: L1-L3, Hypogastric nerve

Sacral group of lymph nodes or

Below the dentate line:

Inguinal nodes and external iliac chain

Incidence rate in India is quite low about 2 to 8 per 100,000

Rectosigmoid junct 0.9 %

Environmental & dietary factors

Associated risk factors

Hereditary Conditions (FAP, HNPCC)

Stage B2 : Penetrating through muscularis propria; nodes not involved

Stage C2 : Penetrating through muscularis propria. Nodes involved

Stage D: Distant metastatic spread

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

Poor prognostic factors

Biopsy of the primary tumor

Carcinoma of the rectum. Double

80-95% accurate in tumor staging

70-75% accurate in mesorectal lymph node staging

Very good at demonstrating layers of rectal wall

Limited utility in small primary cancer

for the detection of metastatic disease in the liver and elsewhere.

Sensitivity of 97% and specificity of 76% in

evaluating for recurrent colorectal cancer.

Complete blood count,

After surgical resection, local failure is common

Local recurrence after conventional surgery:

20%-50% (average of 35%)**

Radiotherapy significantly reduces the number of local recurrences

Should be considered a total biopsy, with further treatment based on pathology.

To lower local failure rates and improve survival in resectable cancers

To allow surgery in primarily inoperable cancers

To facilitate a sphincter-preserving procedure

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