Journal club presentation - Paradigm shift in management of Ca rectum

1. Journal Club: Paradigm Shift
in the Management of CA
Rectum Dr. Priyadarshan Konar
1st year PGT
Department of General Surgery
IMS & SUM Hospital
Bhubaneswar
04.03.2017

4. ABSTRACT:
Surgery For Rectal Cancer In Pre-total Mesorectal Excision(TME) era
Was Associated With High Local Recurrence.
Adoption Of The TME Technique With The Addition Of Neoadjuvant
Therapies Reduced Local Failure Rates & Improved Survival.
Advances In Our Knowledge, Better Understanding Of Tumor Biology
& Refinement In Minimal Access Techniques And Equipment Have
Significantly Changed The Management Of Rectal Cancer.
This Paper Reviews These Changes & Proposes A Paradigm Shift In
How A Rectal Cancer M/g Is Conceptualized And Treated, Such That
The T/t Of Rectal Cancer is Separated into Early Tumors, TME
Tumors & Beyond TME Tumors.

5. INTRODUCTION:
Worldwide, ½ a million patients are diagnosed with colorectal
cancer each year, of which approx. 1/3rd are located in Rectum.
In 1982, Heald reported the technique of TME that removed the
rectal bowel tube along with the surrounding Mesorectal envelope.
TME has been adopted worldwide as the surgical technique of
choice to treat rectal cancer.
TME has reduced the local recurrence rates following surgery from
30 to under 10%.
Surgery at the TME plane appears optimal for most Rectal cancer,
however problem in its use for the tumors in the lower Rectum.

6. Tumor at this level treated by Abdominoperitoneal Excision (APE)
- as Mesorectum narrows, dissection in the TME plane
therefore culminates in dissection between the Levator Ani muscle
and the Lamina Propria of Rectum.
 This risk entering the tumor, which may lead to an involved
Circumferential Resection Margin (CRM) & greatly increases the
risk of local recurrence.
 CRM involvement rates are far higher after APE than after Anterior
Resection.
 As a consequence of the high failure rates after APE, the technique
of Extra Levator AbdominoPerineal Excision (ELAPE) has been
promulgated by Holm.

7. ELAPE involves wide excision of the pelvic floor en bloc with the
rectum mobilized in the TME plane to the top of the pelvic floor.
ELAPE technique reduced local recurrence rate after APE.
 There are other developments which helped improving
outcomes & surgical planning are:
a) Improved radiological staging
b) Use of Neoadjuvant therapy
c) Improvements in minimally invasive techniques
and skills.
This paper reviews the developments in Rectal Cancer
management over recent years & proposes a change In thinking
about how Rectal CA management is conceptualized & treated.

8. DEFINITION OF RECTUM:
Anatomically, the Rectum is 12-15 cm long and starts at the level of
the S3 sacral vertebra and ends at the level of the Anal Canal.
Radiologically, judged on the MRI criteria, the rectum is the portion
of the large bowel below the level of the Sacral Promontory with a
clearly definable Mesorectum posteriorly.
From a surgical perspective , the rectum starts at the point of fusion
of the 2 antemesenteric taenias on the sigmoid colon.

9.  In 1999, The American Society of Colon and Rectal Surgeons,
The Association of Coloproctology of Great Britain And
Ireland and Australian Society met to agree on a definition of
the Rectal Cancer. Rectal Cancer being defined as,
“Any Tumor whose distal margins visible at or
below 15cm from the Anal Verge on Rigid Sigmoidoscopy”

10. PRE OPERATIVE IMAGING:
 Preoperative investigations are important to assess the presence of
synchronous tumors, local invasion, nodal disease and distal
metastases. They are…

11. 1. COMPUTED TOMOGRAPHY(CT)
 All patients with rectal cancer should have a CT scan of the
chest, abdomen and pelvis to assess local & distal spread.
 The role of CT in local staging of the primary tumor is limited by
poor sensitivity and specificity for T stage & N stage when
compared to ERUS and MRI.
 At present time, the main role of CT is in the assessment of
distant metastases.

12. Computed tomography scan of the liver in a patient with a
rectal cancer showing multiple liver metastases

13. 2. MAGNETIC RESONANCE IMAGING (MRI)
 All patients being considered for surgical resection of Rectal
cancer should undergo MRI assessment.
 MRI can predict the T & N stage of Rectal Cancer more
accurately than CT.
 MRI is superior at identifying contiguous organ involvement, a
threatened CRM or the presence of extra-mural vascular
invasion, which may influence the decision to use Neoadjuvant
treatment.

14. Endorectal MRI of a T3 lesion
Arrowhead indicates the site of the endorectal coil. Large arrow
demonstrates finger- like projections of carcinoma invading into the
mesorectal fat. Small arrow points to the anterior rectal wall.

15. 3. ENDORECTAL ULTRASONOGRAPHY (ERUS)
 Particularly helpful in assessment of mid and low rectal
carcinoma.
 Considered to be more accurate than MRI in defining T stage of
early tumors.
 Inferior to MRI in the assessment of lymph node involvement.
 The author believes that both MRI and ERUS should be used
synergistically for optimal decision making for the patient with
Rectal cancer.

16. Transrectal Endoluminal Ultrasonography of a uT2 lesion. The arrow
indicates the intact serosa

17. TNMStaging

18. MANAGEMENT:
 Once the patient with rectal cancer has been staged, the patient
should be discussed in a colorectal cancer multidisciplinary team
(MDT) meeting.
 The majority of Rectal Cancer patients do not have metastases at
presentation are treated by surgery with or without neoadjuvant
therapy.

19. THE ROLE OF PREOPERATIVE NEOADJUVANT
THERAPY
 It is accepted that preoperative is more efficacious than
postoperative (adjuvant) treatment at achieving local control.
 2 widely accepted approaches to preoperative treatment are
a. Short Course Preoperative Radiotherapy (SCPRT)
b. Long Course Chemotherapy (CRT)
 3 large European trials reported improved local control and
possibly improved survival for Rectal Cancer patients treated with
SCPRT against those treated with surgery alone.

20.  CRT is generally considered for more advanced and lower third
rectal cancer to try and downstage a tumor.
 The Technique was evaluated in the German Rectal Cancer Trial.
 The Trial reported improved local control and sphincter
preservation with preoperative chemoradiotherapy.
 Data from European trials support the use of SCPRT in all
operable Rectal Cancer, though the indications for radiotherapy
in Rectal Cancer management is not standardized yet.
 In more advanced tumors both SCPRT & CRT have been
advocated.
 In more locally advanced tumors, in which the benefits of tumor
downsizing outweigh the potential functional risk of
Radiotherapy, Long course treatment appears much better.

21. THE ROLE OF COMPLETE RESPONSE TO CRT
 At present, subsequent surgical resection remains the standard of
care even if a complete response is suspected.
 Rational for this is concern that there may be undetected
microscopic disease or that the disease will recur.
 There is difference in opinion as different Trials have different
opinion.
 According to Harb-Gama and colleagues who have reported and
advocated for observation rather than resection in patients who
have complete response.

22. SURGERY FOR RECTAL CANCER
The primary goal of surgical treatment for rectal cancer is complete
eradication of the primary tumor along with the adjacent
mesorectal tissue and the superior hemorrhoidal artery pedicle.

23. LOW ANTERIOR RESECTION WITH TOTAL MESORECTAL
EXCISION:
The concept of total mesorectal excision (TME) proposed by Heald et al
has been shown to improve both disease-free and overall survival.
TME in conjunction with an LAR or APR involves precise dissection
and removal of the entire rectal mesentery, including that distal to the
tumor, as an intact unit.
 TME involves sharp dissection under direct vision in the avascular,
areolar plane
 This procedure emphasizes autonomic nerve preservation (ANP) and
complete hemostasis and avoids violation of the mesorectal envelope.
 Because rectal cancer spread appears to be limited to the mesorectal
envelope, its total removal should encompass virtually every tumor
satellite.

24. Technique of Total Mesorectal Excision:
Prior to the procedure, all patients receive a full mechanical and
antibiotic bowel preparation.
The patient’s abdomen is marked preoperatively
An epidural catheter is placed for postoperative pain control.
On the operation table the patient is placed in a modified
lithotomy position.

25. A low midline incision is made between the umbilicus and
the pubis, keeping in mind potential stoma sites.
Cephalad extension may be necessary to mobilize the
splenic flexure.
The rectum is palpated to assess the primary mass.
Too much traction on the colon or omentum can cause
splenic injury.
The transverse colon is freed from the omentum by sharp
dissection along the avascular plane.
The colon usually is divided at the sigmoid-descending colon
junction using a linear stapler or may be divided between
two bowel clamps.

26. A. Incision line around the left
colon.
B. Left colon reflected medially,
exposing the ureter and gonadal
vessels.
Mobilization of the left colon:

27. C. Superior hemorrhoidal artery is divided close to the aorta to result in a high
arterial ligation. The arcade of Riolan is preserved, and the left colon and
mesentery are divided at the junction of the descending and sigmoid colon.

28. D. Proximal ligation of the inferior mesenteric vein adds extra
mobility.

29. The anterior and lateral dissections are then started after the
posterior dissection has been partially completed.
The mesorectum is separated from the pelvic side- wall using
the cautery to divide the thin areolar tissue.
 The dissection is carried down anterolaterally to the lateral
ligaments with special care to protect the hypogastric plexus.
For middle to low rectal cancers, TME involves removing the
entire mesorectum with its enveloping fascia as an intact unit.
For tumors in the upper rectum (>10 cm from the anal verge),
TME is extended to 5–6 cm below the level of the tumor

30. A. Peritoneal incision of the pelvis.
B. Rectum reflected anteriorly and posterior avascular plane entered
between the presacral fascia of Waldeyer and the fascia propria of
the rectum.
Mobilization of Rectum:

31. C. Division of lateral stalks.
D. Projected line of dissection in pelvis through Waldeyer’s and
Denonvilliers’ fascia.

32.  Usually most nodes or mesorectal implants are within 3
cm of the distal edge of the tumor.
 Multiple studies have shown that a 2-cm margin is
adequate on the mucosa.
 Once the bowel has been cleared of mesorectal fat, a 30-,
45-, or 60-mm TA linear stapler is used to staple the
rectum.
 This is the first staple line in the “double-stapling
technique.”

33. A. Transection of the distal rectum
with a linear stapler.
B. Stapling instrument introduced
through rectum.
C. Descending colon purse- string
suture is tied around shaft of anvil.
After the trocar of the circular
stapler penetrates behind the
staple line, the trocar is removed
before reconnecting the anvil to
the shaft.

34. D. The circular stapler is
reconnected, reapproximated,
and fired.
E. The anastomosis is complete.
F. The proximal and distal staple
lines are examined for intact
inner “donuts.”

35. CONCLUSION:
In last 30 years, significant improvements have been made in rectal
cancer treatment with improved outcomes.
More progress around the use of standardized surgery in the TME
plane, and more recently wide perineal excision for patients
undergoing APE.
Finally, ‘Sub TME’ tumors optimally treated by local excision +/-
Chemotherapy, ‘TME’ tumors best treated by standardized
TME/ELAPE surgery and ‘beyond TME’ tumors optimally treated by
multivisceral extended surgery – A Paradigm Shift In Rectal Cancer
Treatment.