Rectal cancer Flashcards
What is a pelvic extenteration?
A radical surgical treatment that removes all organs from a person’s pelvic cavity. The urinary bladder, urethra, rectum, and anus are removed. The procedure leaves the person with a permanent colostomy and urinary diversion.
Management of locally advanced rectal cancer
Neoadjuvant concurrent chemoradiation
THEN surgery
THEN adjuvant chemo
CRM refers to
Circumferential resection margin (CRM) in rectal cancer has been defined as the non-peritonealized surface of a resection specimen created by dissection of the subperitoneal aspect at surgery.
LAR stands for
low anterior resection surgery
LAR procedure
Segment of rectum removed and colon reanastamosed to rectum
Treatment of Stage I rectal cancer
Surgery
Goal of preoperative CRTin rectal cancer
Permit sphincter-preserving surgery (low anterior resection)
*also improves local control
Staging modalities for rectal cancer
Pelvic MRI (mandatory) CT chest IF MRI contraindicated OR inconclusive OR superficial lesion → endorectal ultrasound
Rectal vs colon in terms of metastatic pattern, and implications for management
Rectal has a high risk for distant recurrence (as opposed to colon which is typically local recurrence), you can bypass lymphatic system and go to lungs directly, so you need upfront chemo to minimize risk of micrometastatic disease. Surgery is a mess because of fibrosis after.
TNT protocol
Concurrent 5-Fu based long course chemoradiation → restage to rule out progression a couple weeks before chemo → consolidation mFOLFOX or CAPEOX for 12-16 weeks → restage → surgery (preferred at Umass) (OPRA – higher pCR with this approach)
What is an APR?
removal of the anus, the rectum and part of the sigmoid colon along with the associated (regional) lymph nodes, through incisions made in the abdomen and perineum. The end of the remaining sigmoid colon is brought out permanently as an opening, called a stoma, which is used by the patient in conjunction with a colostomy pouch, on the surface of the abdomen.
When TNT is indicated
T3 disease or higher OR any N
T2NO rectal cancer management
Upfront surgery
Surgery used for upper vs. low rectal tumors
LAR = used for upper rectal tumors, APR for low rectal tumors
What is the clinical significance of the distance of the tumor from the CRM in rectal cancer? What is the anatomic boundary?
IF tumor above mesorectal fascia (MRF) (negative CRM), it can be treated as colon cancer
IF positive CRM (invades or close proximity to MRF), must be treated with CRT (positive CRM = risk factor for local recurrence after surgery, so if involved, initial CRT needed)
