RECTAL CANCER
| RECURRENT RECTAL CANCER —David A. Rothenberger, MD, Professor and Chairman, Department of Surgery, University
of Minnesota Medical School, Minneapolis
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| Recurrences: most occur after curative treatments; develop within 2 yr of initial treatment; recurrence has not been eliminated,
even with neoadjuvant chemoradiation therapy and total mesorectal excision (TME); classified as local or distant;
local recurrences classified as anastomotic, perineal, or extensive pelvic; often cause devastating local symptoms; most
patients with recurrence die; management focuses on palliation, including pain control process, and management of
bowel and ureteral obstructions, tenesmus, and bleeding; end-of-life team helps patient face mortality
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| Evaluation: confirm diagnosis through biopsy; review record; determine patient’s suitability for major resection; exclude
distant metastases and primary tumors; repeat colonoscopy; assess tumor for resectability; difficult to distinguish scar
from tumor; biopsy—if negative, difficult to determine whether major resection warranted; consider circumstances and
patient input; history—surgeon must understand previous surgeries; review operative reports for findings, surgical challenges,
mobility issues, vessel ligation, and anatomy; look at treatment details; review pathology of original tumor; positive
margins indicative of problematic areas (eg, radial margin positive on right side could indicate recurrence site);
patients may not exhibit wasting, even with extensive disease; operative risks; bowel function and incontinence;
patients—may have specific requests (eg, may not want stoma, will not tolerate extensive resection); consider patient’s
mental status; should be able to undergo major resection, face morbidity, long hospitalizations, and repeated complications
in hope of achieving reasonable quality of life; not all patients qualify; exclude distant metastases—combination
of computed tomography (CT) and positron emission tomography (PET); more radical procedures require more extensive
work-up; review information with team—consider sacral invasion, appearance of obturator fossa, other viscera,
position of ureters and pelvic sidewalls; lateral margins most difficult to manage and require careful evaluation; contraindications
to re-resection—high sacral invasion (S2 and above); extensive infiltration of lateral pelvic sidewall; sciatic
pain; bilateral iliac vein obstruction; principles—complete resection of disease imperative; not beneficial to leave gross or
microscopic residual disease; goal is free circumferential margin; cohesive team includes urologist, vascular surgeon, neurosurgeon;
pool knowledge and expertise of team
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| Treatment plan: maximize preoperative chemoradiation; plan for stomas and extended resections; know decision tree;
determine with patient when to stop treatment; prepare team—discuss positions, order of procedures, incisions, and
flaps to be used; prepare patient and family— define limitations; educate them about postoperative course, recovery,
and possible functional losses; important not to oversell surgical results
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| Operative sequence: may need ureteral stents, although often not used with bladder removal and ureteral resection; explore
abdomen; exclude unanticipated extra spread; dissect into presacral space to S2 to S3 level; if unable to distinguish
scar from tumor, get frozen sections; if negative, assess laterally and anteriorly to determine extent of disease and possibility
of cure; withdraw if situation not feasible; surgical decisions—consider approach; low anterior resection uncommon;
abdominoperineal resection (APR) usually necessary; extended en bloc resection with other organs; with lateral
dissection, loop iliac proximally; reserve superior gluteal for flaps; look for circumferential margin; be flexible; perineal
phase often biggest part of operation; prone jackknife position essential; advantages of radiotherapy—reduced field;
clear site; intraoperative radiation therapy or interstitial implantation; brachytherapy uses vicryl mesh inserted into catheters,
followed by afterloading; helpful in patient with difficult sidewall and possible residual disease
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| Lessons learned: of patients with failed local excisions who underwent salvage multimodality surgery, potential 80%
cure rate; unfavorable histology predictor of poor outcome; of patients with locally recurrent cancer after radical surgery,
options palliative treatment, chemotherapy and/or radiation therapy, and surgical intervention; surgical intervention improves
outcome, but surgery curative in <50% of these patients; noncurative surgery does not improve survival
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| CONTROVERSIES IN RECTAL CANCER TREATMENT: VARIABLES AFFECTING OUTCOME —Thomas E. Read,
MD, Associate Professor of Surgery, Temple University School of Medicine, Philadelphia, PA, Chief, Division of Colon
and Rectal Surgery, and Program Director, Colon and Rectal Surgery Residency, Western Pennsylvania Hospital, Pittsburgh
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| Modern surgical techniques: remove entire cancer and lymphatic tissue at risk; rectal cancers grow out, not up and
down rectal wall; Heald et al repopularized concept of removing entire tumor from pelvis; involved mesorectal nodes rarely
occur >5 cm distal to distal margin of tumor; for proximal rectal cancer, remove 5 cm of mesorectum and “take right turn”
(tumor-specific mesorectal excision); for tumors of mid and distal rectum, entire mesorectum removed; excision of anus or
levator complex unnecessary if this will not improve oncologic outcome; abdominoperineal resection necessary if tumor invades
external sphincter or levators; perineal portion of operation critical, and speaker prefers “flip” method for this portion;
outcome related to technique; construction of neorectum with anastomosis at anus or above anorectal muscular ring
with creation of pouch or coloplasty effective in selected patients; creating reservoir instead of straight anastomosis improves
function with no increase in complications; much surgeon-to-surgeon variability in outcome; patient variability also
significant
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| Other factors: choices—use of neoadjuvant radiotherapy and which regimen; use of chemotherapy; removal of rectum
and mesorectum or local excision; whether to perform reconstruction; improved outcome—related to hospital volume,
surgeon volume, training, specialization, and interest; hospital volume has indirect effect related to quality of staff, team
approach (ie, radiation technicians, medical oncologists, radiologists, operating room nurses, enterostomal therapists);
Surveillance Epidemiology and End Results (SEER) database indicates surgeon volume more important than hospital
volume; analysis of data from Maryland shows surgeon volume more important than hospital volume, but hospital volume
has independent effect; American Board of Surgery data—average general surgeon reapplying for certification after
10 yr performed 1 proctectomy per year
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| Study data: Dutch rectal cancer trial—controlled for type of surgery; surgeon quality control and pathologic quality
control; found that administering neoadjuvant radiotherapy with optimal surgery beneficial; local pelvic failure rate half
that of radiotherapy group; survival benefit not shown, but curves beginning to diverge; possible disease-free survival
benefit; speaker’s group—384 consecutive patients with locally advanced tumors; developed clinical staging system to
predict outcome; followed for 5 yr; similar neoadjuvant therapy and proctectomy; 251 patients operated by colorectal
surgeons, 133 by general surgeons; multivariate analysis showed tumor stage and surgeon’s background only independent
predictors of disease-free survival and local control; 9% disease-free survival at 5 yr from pelvic control; effects of
neoadjuvant radiotherapy and optimal surgical technique additive, not compensatory
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| Nonfixed tumors: radiotherapy may be more effective in pelvic sidewall where may have microscopic tumor and small
lymphatics; radiation therapy— best given before surgery to downsize and downstage tumor and sterilize margins; oxygenated
tumor bed more receptive to radiation; irradiate only one side of anastomsis; approach supported by German
prospective randomized trial that looked at preoperative vs postoperative radiotherapy and demonstrated 50% reduction
in local pelvic failure in preoperative group as well as lower toxicity; speaker’s bias—consider radiotherapy for all patients;
nonfixed tumors treated with short course of radiotherapy; healthy patients with locally advanced tumors or obvious
nodal disease treated with chemoradiotherapy; unhealthy patients with locally advanced tumors or obvious nodal
disease treated with long-course irradiation alone; local excision technically challenging and exposes perirectal tissue to
shed tumor cells; poor oncologic results when used as definitive therapy
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| Study bias and predictors: most studies of local excision do not include product limit analysis using Kaplan-Meier
curves; studies biased toward success of local excision; salvage poor option for failed local excision; performance of surgery
must be improved; unclear whether transanal endoscopic microsurgery (TEMS) provides solution; need better predictors
for pathology of mesorectum; imprecise surrogate marker techniques for assessing mesorectal nodal status; T
stage after radiotherapy may be better predictor of mesorectal conditon; neoadjuvant radiotherapy followed by local excision
may be better treatment option, but leaves rectal scarring; speaker prospectively studying proctectomy with restorative
procedure
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| RECTAL CANCER: THE SURGEON IS A PROGNOSTIC FACTOR —D. Scott Lind, MD, Jarrell Distinguished Professor
and Chief of Surgical Oncology, Medical College of Georgia, Augusta
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| Overview: third most common malignancy; slight decrease in mortality in last 15 yr due to screening, polyp elimination;
improvements in surgical techniques; enhanced outcomes; preservation of continence; improved outcomes related to genitourinary
and sexual function
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| Techniques: circular stapling devices—facilitate lower positioning in pelvis, preservation of sphincter, and anastomosis;
mesorectal excision—developed by Heald and Anker; removes rectum and mesorectum en bloc; find right dissection;
preserve nerves; remove specimen as oncologic dissection; initial local recurrence rate <5%; National Institutes of
Health consensus statement (early 1990s)—adjuvant chemoradiation became standard of care for stage II and III rectal
cancer; sequence of administration still under discussion; transanal excision—for removal of select tumors; TEMS
allows higher transanal excision; laparoscopic techniques—laparoscopic-assisted APR; laparoscopic total mesorectal
excision (TME); targeted therapy—trials ongoing; translational molecular biologic techniques being added
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| Rectal anatomy: divided into surgical thirds (upper, middle, lower); valves of Houston rough landmarks; middle valve
of most concern because performing transanal full-thickness excision above valve on anterior wall may result in violation
of peritoneum; last 15 cm of large bowel (distal portion) lacks serosa, so low anastomosis may result in leaks; surgical
constraints of bony pelvis—pelvic sidewalls; adjacent organs; circumferential margin more important than distal; blood
supply important; blood supply of proximal rectum from mesenteric circulation; blood supply of distal rectum from internal
iliac circulation, so distal rectal and anal cancers may drain to groin nodes; fascial anatomy—important for TME;
endopelvic fascia consists of visceral and parietal parts; fascia propria becomes external portion of what is being removed
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| Preoperative evaluation: thorough history and physical; review presenting symptoms; assess for comorbidities; document
genitourinary function before surgery; perform digital rectal examination to determine location of lower edge of
tumor in relation to sphincter mechanism (not as sensitive for early rectal lesions); colonoscopy to confirm diagnosis
and characterize lesion (ie, location, size, circumference, morphology); rigid proctoscopy if unable to feel lesion (flexible
scope inaccurate; visualize entire colorectum, looking for synchronous neoplasm or polyps); CT mainstay for staging
(look for visceral metastases and involvement of contiguous organs); not good for detecting peritoneal implants);
endoscopic ultrasonography (EUS; helpful for early [eg, T1] lesions within reach of transanal excision); speaker suggests
T3 and T4 lesions require preoperative irradiation
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 | Magnetic resonance imaging (MRI): traditional body coil MRI not better than CT, except for distinguishing scar from tumor
in pelvic recurrence; endorectal coil MRI helpful to determine T stage and assess circumferential margin; important
for TME; procedure of choice to assess for involvement of mesorectum; coil expensive, large; difficult to visualize
large near-obstructing lesions
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| PET: limited data for primary rectal cancer; shows response to chemoradiation of locally advanced disease; may be independent
prognosticator of outcome; study of choice in patient resected for cure in whom carcinoembryonic antigen
(CEA) returns to normal then starts to rise, with all other studies negative
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| Treatments: patients rarely need APR; if tumor large and within 2 cm of sphincter, APR may be needed, but tumor involving
internal sphincter may be treated with chemoradiation followed by intersphincteric resection; lithotomy position;
2-team approach; high morbidity; permanent colostomy; 70% to 80% have sexual and urinary dysfunction; wound healing
problematic, particularly in patients receiving preoperative irradiation; perineal wound does not heal well (consider
flap; involve plastic surgeon); anterior resection—performed above peritoneal reflection; remove tumor; follow with
anastomosis; low anterior resection below peritoneal reflection; stapling device used for anastomosis; blunt mesorectal
dissection—leads to working in wrong plane; high incidence of nerve injury and high rate of positive circumferential resection
margins, which leads to local recurrence; low anterior dysfunction syndrome results in frequent bowel movements
and inability to differentiate gas from stool; TME—remove rectum and surrounding soft tissue as intact unit; use
precise sharp dissection in areolar plane between visceral and parietal endopelvic fascia; facilitates nerve preservation;
low local recurrence rate; radiation lowers rate further; preserve blood supply to distal segment to reduce leakage; nerve
anatomy—lumbosacral plexus gives off ventral cords S1 to S3 (parasympathetic; control erection); sympathetic nerves
come off higher and become hypogastric nerve; all form plexus on rectum; J-pouch—diminishes stool frequency during
first year; cannot be constructed in 25% of patients; coloplasty provides similar reservoir capacity; TME standard operation
for rectal resection in Norway (reduced local recurrence rate from 28% to 8% in 10 yr); in trials, laparoscopic TME
had higher rate of positive margins (awaiting long-term follow-up); speaker believes visibility better with laparoscope, and
predicts increasing use; transanal excision—Lone Star retractor spreads anus and allows surgeon to work up to 8 cm in;
use depends on location, T1 lesions, morphology, histology (incidence of occult lymph node involvement precludes excision),
tumor differentiation, patient anatomy, and comorbidities; higher local recurrence rate; further studies required;
TEMS—used for lesions too high for conventional excisions; 4-cm rectoscope inserted into anus; CO2 inflation followed
by tumor removal via instrument channels; no long-term problems with continence
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Suggested Reading
Baxter NN et al: Postoperative irradiation for rectal cancer increases the risk of small bowel obstruction after surgery.
Ann Surg 245:553, 2007; Burghardt J, Buess G: Transanal endoscopic microsurgery (TEM): a new technique and development
during a time period of 20 years. Surg Technol Int 14:131, 2005; Bonnen M et al: Long-term results using
local excision after preoperative chemoradiation among selected T3 rectal cancer patients. Int J Radiat Oncol Biol Phys
60:1098, 2004; Daniels IR et al: Accurate staging, selective preoperative therapy and optimal surgery improves outcome
in rectal cancer: a review of the recent evidence. Colorectal Dis 9:290, 2007; den Dulk M et al: A multivariate
analysis of limiting factors for stoma reversal in patients with rectal cancer entered into the total mesorectal excision (TME)
trial: a retrospective study. Lancet Oncol 8:297, 2007; Edwards DP et al: Long-term results show triple stapling facilitates
safe low colorectal and coloanal anastomosis and is associated with low rates of local recurrence after anterior resection
for rectal cancer. Tech Coloproctol 11:17, 2007; Glynne-Jones R et al: The clinical significance of the
circumferential resection margin following preoperative pelvic chemo-radiotherapy in rectal cancer: why we need a common
language. Colorectal Dis 8:800, 2006; Glynne-Jones R et al: Alternative clinical end points in rectal cancer--are
we getting closer? Ann Oncol 17:1239, 2006; Kim NK et al: Adjuvant radiation therapy in resectable rectal cancer:
should local recurrence rates affect the decision? Am Surg 63:579, 1997; Lee SH et al: The effect of circumferential tumor
location in clinical outcomes of rectal cancer patients treated with total mesorectal excision. Dis Colon Rectum
48:2249, 2005; Merchant NB et al: T3N0 rectal cancer: results following sharp mesorectal excision and no adjuvant
therapy. J Gastrointest Surg 3:642, 1999; Nissan A et al: Abdominoperineal resection for rectal cancer at a specialty
center. Dis Colon Rectum 44:27, 2001; Pasetto LM et al: Primary rectal carcinoma in patients with stage IV resectable
disease at diagnosis. Anticancer Res 27:1079, 2007; Read TE et al: Neoadjuvant external beam radiation and proctectomy
for adenocarcinoma of the rectum. Dis Colon Rectum 44:1778, 2001; Saha S et al: Comparative analysis of nodal
upstaging between colon and rectal cancers by sentinel lymph node mapping: a prospective trial. Dis Colon Rectum
47:1767, 2004; Sanfilippo NJ et al: T4 rectal cancer treated with preoperative chemoradiation to the posterior pelvis
followed by multivisceral resection: patterns of failure and limitations of treatment. Int J Radiat Oncol Biol Phys 51:176,
2001; Smith J et al: Ex vivo sentinel lymph node mapping in colon cancer: improving the accuracy of pathologic staging?
Am J Surg 191:665 2006; Valentini V et al: Preoperative hyperfractionated chemoradiation for locally recurrent
rectal cancer in patients previously irradiated to the pelvis: A ulticentric phase II study. Int J Radiat Oncol Biol Phys
64:1129, 2006; Wibe A et al: Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum:
anterior vs. abdominoperineal resection. Dis Colon Rectum 47:48 2004; You YN et al: Is the Increasing Rate of Local
Excision for Stage I Rectal Cancer in the United States Justified?: A Nationwide Cohort Study From the National
Cancer Database. Ann Surg 245:726 2007.
Educational Objectives
| The goal of this program is to improve the general surgeon’s performance in treating rectal cancer. After hearing and
assimilating this program, the clinician will be better able to:
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| 1. Discuss the recurrence of rectal cancer following initial treatment.
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| 2. Summarize the methodologies used in evaluating patients for surgery.
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| 3. Review the surgical and adjunctive treatment plans.
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| 4. Explain the variables affecting rectal cancer treatment.
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| 5. List and explain the different surgical options.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Rothenberger and Read addressed the 69th Annual Colon and Rectal Surgery, held September 7-9, 2006, in Minneapolis,
MN, and sponsored by the Division of Colon and Rectal Surgery, Department of Surgery, and Continuing Medical
Education, University of Minnesota Medical School, Colon and Rectal Surgery Associates, Ltd, and the Minnesota Colon
and Rectal Foundation. Dr. Lind addressed Medical and Surgical Approaches to GI Disorders, held July 10-14, 2006, in
Kiawah Island, SC, and sponsored by the Medical College of Georgia, School of Medicine and Division of Continuing
Medical Education. The Audio-Digest Foundation thanks the speakers and sponsors for their cooperation in the production
of this program.
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