Rectal Carcinoma

RECTAL CARCINOMA


RECTAL CARCINOMA

Spread

  • Local spread occurs circumferentially rather than in a longitudinal direction
  • Lymphatic spread mainly occurs in the upward direction via the superior rectal vessels to the para-aortic nodes
  • Principle sites of blood borne metastasis are liver (34%), lungs (22%) and adrenals (11%)

Symptoms

  • Bleeding is the earliest and most common symptom
  • Tenesmus
  • Sense of incomplete evacuation (very important early symptom)
  •  Spurious diarrhea
  • Alteration in bowel habits
  • Growth in the ampulla of the rectum – Early morning bloody diarrhea
  • Annular carcinoma at the recto sigmoid junction – increasing constipation

Investigations

  • 90% of rectal growths can be felt by per-rectal examination
  • Investigation of choice – rigid sigmoidoscopy and biopsy
  • To assess local spread – TRUS (Endoluminal ultrasound)
  • For local staging and assessment of proposed circumferential resection margin – MRI (CT is not accurate in local staging)
  • CT chest and abdomen or PET – to exclude distant metastasis

Treatment-

Surgeries

  • Pre-operative neo-adjuvant radiotherapy in resectable rectal cancer reduces the incidence of local recurrence
  • Adjuvant chemotherapy improves survival in node-positive cases
  • Anterior(low) resection: sphincter saving procedure, mid rectum
  • Proximal 2/3rdof rectum(lesions 6cms above the dentate line/2 or more cms above anal canal)
  • Well differentiated tumour

size tumour

T1/T2,NO tumours

  • Recto sigmoid tumors and upper third rectal tumors :High anterior resection (rectum and mesorectum are taken to a margin 5cm distal to the tumour and colorectal anastomosis is performed)
  • Tumours in the middle and lower thirds of rectum: complete removal of rectum and mesorectum (TME-total mesorectal excision)
  • Abdomino perineal resection(Mike’s procedure)- Lower rectum
  • Hartmann’s procedure – for elderly and unstable patients who cannot withstand long procedure of APR
  • Colonoscopy is always performed either before (for synchronous tumours) or within a few months (for metachronous tumours) of surgical resection for tumour detection

 Exam Important

Symptoms

  • Bleeding is the earliest and most common symptom
  • Tenesmus
  • Sense of incomplete evacuation (very important early symptom)
  •  Spurious diarrhea
  • Alteration in bowel habits
  • Growth in the ampulla of the rectum – Early morning bloody diarrhea
  • Annular carcinoma at the recto sigmoid junction – increasing constipation

Treatment-

Surgeries

  • Pre-operative neo-adjuvant radiotherapy in resectable rectal cancer reduces the incidence of local recurrence
  • Adjuvant chemotherapy improves survival in node-positive cases
  • Anterior(low) resection: sphincter saving procedure, mid rectum
  • Proximal 2/3rdof rectum(lesions 6cms above the dentate line/2 or more cms above anal canal)
  • Well differentiated tumour

size tumour

T1/T2,NO tumours

  • Recto sigmoid tumors and upper third rectal tumors :High anterior resection (rectum and mesorectum are taken to a margin 5cm distal to the tumour and colorectal anastomosis is performed)
  • Tumours in the middle and lower thirds of rectum: complete removal of rectum and mesorectum (TME-total mesorectal excision)
  • Abdomino perineal resection(Mike’s procedure)- Lower rectum
  • Hartmann’s procedure – for elderly and unstable patients who cannot withstand long procedure of APR
  • Colonoscopy is always performed either before (for synchronous tumours) or within a few months (for metachronous tumours) of surgical resection for tumour detection
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