Rectal Cancer Management Flashcards
What is the typical surgical technique for rectal cancer?
- gold standard
- Used to be blunt dissection
- Now sharp dissection around mesorectal fascia (fat, nodes and vessels), crm
- Clear
When or why are alternative surgical techniques suggested?
- Laparoscopic can be offered
- Open surgery my be offered for locally advanced tumours
- Robotic can be considered with appropriate audited outcomes
What is laparoscopic surgery?
- Keyhole
- ## MDT will discuss
What is Transanal Total Meso Rectal Excision?
- Most people will have TME
- Remove fatty tissue containing lymph nodes, blood vessels meaning tumour is less likely to recur
What is an anterior resection?
- Used for rectal cancers of the upper and middle part of the rectum
- Removes part of the bowel which contains the cancer
and rejoins the open ends - May result in a temporary stoma, may be reversed after a few months.
What is colo-anal and j-pouch surgery?
- Cancer in low rectum
- Surgeon makes a pouch from part of colon before joining to the anus
- Pouch acts as new rectum and stores stool until it is convenient to pass them
- May use temporary stoma
Abdomino - Perineal Resection is used when?
- Extremely low cancer in rectum (close to anus)
- Rectum and anus are removed
- Long wound
- Wound may be closed using muscle and skin from other part of body (flap)
- Permanent stoma bag
What are TAE, TAMIS, TEMS?
- TAE = transanal excision, enter through anus and remove tumour and small amount of tissue
- TAMIS = laparoscopic procedure, sphincter sparing
- TEMS = uses endoscope, sphincter sparing
Who is offered pre-op treatment?
- Not RT for early stage (T1,T2,N0,M0) as patients are low risk
- Will offer RT or chemo-RT if node positive
When is surgery offered?
- T1-T2, cN1-N2, M0 or cT3-T4, any cN, M0
- Make sure patients are aware of risk of recurrence if surgery is deferred
- Anyone with a resectable tumour
What does NICE classify as high or low risk?
- Margin breached or threatened, or encroaching on sphincter
- Low risk is cT1,2 or 3a
What is Papillon and when is it used?
- Used when surgery is not suitable
What if a tumour is not resectable?
- Pre-op RT can be used
- Ideally will shrink tumour
- Gap between
Post-op options for treatment?
- Stage 3 rectal cancer, without pre-op, may be given post-op chemotherapy
Role of XRT in rectal cancer treatment?
- Post-op with or without chemo
- Short course pre-op
- long course pre-op
Using Short Course XRT?
- Moderate risk: - T3b, upper rectum, potential surgical margin threatened
- Reduces risk of relapse
- Improves disease free survival
- Usually 25Gy in 5#
Using Long Course XRT?
- When margin is threatened
- Low rectal cancers
- T3 and T4s
- N1 and N2
- Tumour within 1mm of CRM
- 42.5Gy in 20-25# over 28-35 days
- Maybe a boost if nodal involvement
- If inoperable - 50.4Gy in 28#
Chemo with XRT?
- Capceitabine tablets - once a day during XRT
- Alternatively Mitomycin C and 5FU IV Day 1-4 and day 29-32. 2hrs prior for day 1.
Why concurrent chemo?
- RT efficacy improved with chemo
- 5 FU is the oldest example
What are some side effects of capceitabine?
- chest pain
- feeling sick and being sick
- Sore mouth
- Taste changes
- Diarrhoea
- Abdo pain
- Constipation
- Tiredness
What happens in Papillon?
- 50KeV energy brachy
- Enema used to pretreat and local anaesthetic relaxes sphincter muscles
- A rigid sigmoidoscopy identified tumour size and site.
- Applicator through anus
Who is pappillon for and what are is the prescription?
- Patients who cannot have surgery (low risk)
- T1N0 <3cm = 90Gy/3#/4 weeks
- if T1/N1 or T2N0-1 or >3cm = followed by short course RT or chemoRT
- T2, T3a or >3cm = RT and concurrent chemo first
- Post-op =60Gy/2# followed by RT
