Rectal Cancer Management Update

Question 1

How is early Rectal Cancer managed ?

Answer 1

T1-T2, N0, M0 will usually be managed with surgery alone. Surgical options include TME, Laparoscopic assisted resection, lower anterior resection, colonic J pouch surgery, abdomino-perineal resection

Question 2

What is TME?

Answer 2

Typically the best option

• Total mesorectal resection.
• Removal of rectum and surrounding fat, leaving nodes and vessels in tact
• Aim for a clear circumferential margin
• Lower risk of recurrence and better functional results

Question 3

what is Laparoscopic assisted resection?

Answer 3

• Keyhole

- Potentially has poorer long term outcomes

Question 4

what is Lower anterior resection?

Answer 4

• Removes central and upper rectal tumours
• Surgeon removed part of the rectum containing the cancer and reconnects what remains
• temporary stoma is likely to be connected
• A sphincter preserving technique

Question 5

Colonic J-Pouch surgery?

Answer 5

• For cancers in the lower rectum
• Rectum is removed and a j-pouch is formed from the colon which acts as a rectum and connect to the anus
• Temp ileostomy is likely

Question 6

Abdomino-perineal resection?

Answer 6

• If cancer is close to the anus
• removal of rectum and anus to ensure the cancer is fully removed
• colostomy required
• Anus can be closed with tissues from other parts of the body
• Open or laparoscopic depending on tumour site.

Question 7

When is pre-op treatment offered?

Answer 7

• Not to T1,T2 or N0,M0 as they are low risk
• Offered to (RT or chemoRT) T1-T2 with N1-2 or T3 and T4
• Surgery will be offered to anyone with a resectable tumour

Question 8

Who is offered papillon?

Answer 8

• Anyone who cannot tolerate surgery
• maybe those who refuse it
• low risk

Question 9

What are papillon prescriptions?

Answer 9

• T1N0 <3cm = 90Gy/3/4 weeks or 110Gy/4/6 weeks
• If T1N1 or T2N1-2 <3cm brachy should be followed with short course RT
• T2, T3a or >3cm RT with concurrent chemo should be delivered first
• If post-op, 60Gy/2# weekly, followed by short course radiotherpy

Question 10

What is offered to high risk stage 2 and 3 ?

Answer 10

• Offered adjuvant chemo post-surgery to reduce recurrence, unless patients have already had long course chemo
• Stage 3 (T1-4, N1-2, M0) who have not had adjuvant treatment or short course RT will be offered
  - Capcitabeine + oxoplatin for 3 months
  - Oxaliplatin + 5FU and folinic acid for 3-6 months

Question 11

Who is offered pre-op radiotherapy?

Answer 11

• Low or moderate risk cancers are offered long or short course radiotherapy or long course chemoRT

Question 12

Pre-op Short course radiotherapy?

Answer 12

• For moderate risk, has a greater benefit for mid/upper rectal cancers and T3b
• Can reduce rates of local relapse and disease free survival (better than post op)
• 25Gy/5#/5 days

Question 13

Pre-op long course radiotherapy?

Answer 13

• When the surgical margin is compromised and borderline int/high risk
• Intention to downstage a tumour
• For low rectal tumours T3 or T4, N1 or N2 within 1mm or breaching resection margin
• Often combined with oral capcitabeine for 35 days
• 42.4-45Gy/20-25#/28-35 days

Question 14

What are post operative treatments?

Answer 14

• Surgery followed by chemo/RT or RT alone
• For late T3 or T4, lateral pelvic side wall nodal involvement
• Dose is 45Gy/25# with a boost to tumour bed 5.4Gy in 3#

Question 15

Chemotherapy options with long course RT?

Answer 15

• Capceitabeine oral tablets, once per day for RT duration
• If capceitabeine is not tolerated, Mitomycin C+5-FU IV on specific days
• Concurrent chemo sensitizes cells to radiation. Cochrane review found T3 and T4 survival was much better with chemoRT compared to RT alone