Tag: Rectal Carcinoma

Rectal Carcinoma

Rectal carcinoma

Q. 1

Which of the following is considered to be the treatment of choice, in a case of rectal carcinoma at 5cm from the anal verge?

 A

Anterior resection

 B

Abdominal perineal resection

 C

Posterior resection

 D

Local resection

Q. 1

Which of the following is considered to be the treatment of choice, in a case of rectal carcinoma at 5cm from the anal verge?

 A

Anterior resection

 B

Abdominal perineal resection

 C

Posterior resection

 D

Local resection

Ans. B

Explanation:

Abdomino perineal resection is indicated in the treatment of a rectal cancer in the lower rectum (0-5cm from the anal verge).

It includes removal of the rectum, anus, sphincter muscles, and a permanent colostomy is reserved most of the time for patient whose sphincter muscles are involved by tumor or for patients with rectal cancer who have poor sphincter function preoperatively.

Ideally, a surgical margin of at least 2cm should be obtained.

Recent evidence suggests that a margin as small as 1cm may be sufficient, thus allowing more sphincter-saving procedures.

It is not performed in the presence of peritoneal seeding or fixation to bony pelvis.

Ref: The MD Anderson Manual of Medical Oncology, 2nd Edition, Chapter 21; Principles and Practice of Geriatric Surgery By Ronnie Ann Rosenthal, 2nd Edition, Page 900.


Q. 2

A patient comes with rectal carcinoma situated 6 cm above dentate line with no nodal metastasis. Treatment of choice will be:

 A

Anterior resection

 B

APR

 C

Radiotherapy

 D

Hartmann’s procedure

Q. 2

A patient comes with rectal carcinoma situated 6 cm above dentate line with no nodal metastasis. Treatment of choice will be:

 A

Anterior resection

 B

APR

 C

Radiotherapy

 D

Hartmann’s procedure

Ans. A

Explanation:

“In this patient the tumor lies 6 cms above the dentate line (the lower limit is taken into consideration).

So the adequate margin is available for a colorectal anastomosis, hence a LAR procedure can be done”

Ref: Sabiston 18/e, Page 1413; Schwartz 9/e, Page 1028; CSDT 13/e, Page 664; Devita’s Oncology 8/e, Page Chapter 3, Section 13.

Q. 3

TRUE about Rectal carcinoma:
 
1. Most common type is adenocarcinoma
2. Surgery is the treatment of choice
3. Surgical treatment indicated inspite of hepatic metastasis
4. APR done in lesion of upper zone
 A

1,2 & 4

 B

1,2 & 3

 C

2,3 & 4

 D

All of the above

Q. 3

TRUE about Rectal carcinoma:
 
1. Most common type is adenocarcinoma
2. Surgery is the treatment of choice
3. Surgical treatment indicated inspite of hepatic metastasis
4. APR done in lesion of upper zone
 A

1,2 & 4

 B

1,2 & 3

 C

2,3 & 4

 D

All of the above

Ans. B

Explanation:

Adenocarcinoma is the commonest type of rectal carcinoma, just like colon carcinoma.

Similar to colon carcinoma treatment of rectal carcinoma involves resection of the primary tumor, its lymphatic bed and any other involved organ.
 
Hepatic metastasis can be resected if the remaining liver is adequate for its functioning, even if hepatic Metastasis cannot be resected, surgery is done because it’s the best way of palliation.
 
APR is done for lesions in the lower third of rectum. For upper and mid rectum a sphincter saving procedure i.e low anterior resection is done.
 
Ref: Bailey & Love 25/e, Page 1231.

Quiz In Between


Q. 4

For a rectal carcinoma at 5cm from the anal verge the best acceptable operation is –

 A

Anterior resection

 B

Abdominal perineal resection

 C

Posterior resection

 D

Local resection

Q. 4

For a rectal carcinoma at 5cm from the anal verge the best acceptable operation is –

 A

Anterior resection

 B

Abdominal perineal resection

 C

Posterior resection

 D

Local resection

Ans. A

Explanation:

Ans. is ‘a’ i.e. Anterior resection 

Dentate line is 2 cm from the anal verge, so this tumor is 3 cm above the dentate line. A sphincter saving LAR can be done.


Q. 5

Best procedure in mid rectal Carcinoma is –

 A

Abdomino perinea resection

 B

Anterior resection

 C

Perineal loop

 D

Transverse Colostomy

Q. 5

Best procedure in mid rectal Carcinoma is –

 A

Abdomino perinea resection

 B

Anterior resection

 C

Perineal loop

 D

Transverse Colostomy

Ans. B

Explanation:

Ans. is ‘b’ i.e., Anterior resection 

Quiz In Between



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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