Colorectal Carcinoma

Haryono Yarman

Anatomical Definition of Rectum

0-15 cm (as measured by rectoscope);

Lower rectum (0-5 cm)
Mid rectum (6-10 or 12 cm)
Upper rectum (> 10 or 12 cm)

Staging methods (1)
Evaluation starts with clinical examination !
Quality of technical examinations is important
CAT scan, EUS & MRI have each a specific role
and contribute to the precise diagnosis of rectal
cancer and contribute to the optimal
management of a patient with rectal cancer.
CAT, EUS & MRI are essential staging methods
in most patients
Emerging role for MRI

Staging methods(2)
T staging : EUS and MRI have the highest
accuracy. CAT has a low accuracy for T
staging
N staging : the accuracy is not perfect.
EUS seem to have the highest accuracy
(MRI: iron compounds). CAT is performing
worst. Combination of MRI and EUS
Circumferential margins : MRI has the
highest accuracy

Staging methods : specific situation
Metastases : CAT scan essential
Early tumours : EUS
T3-T4 tumours : MRI
PET scan : Not in primary staging; should
be considered before major surgery
Local recurrence : PET
EUS (biopsy)

Surgery
Total Mesorectal Excision = TME
TME is gold standard
TME decreases local failure rate
Local prosedures can be considered in
highly selected T1 tumours
Experienced surgeon

Surgery: sphincter preservation
Influences quality of life of patients
Should only be done if:
Outcome is not worse
Safe margin can be obtained that does not
jeopardize sphincter function
New techniques : in this framework
Whether preoperative chemoradiotherapy

Quality Control of Surgery
Surgeon should be part of a multidisciplinary
team
Dedicated surgeon with adequate training
surgeon and multidisciplinary team should have
a large number of cases
Registration : local recurrence rate, survival
postoperative morbidity and mortality
Role of pathologist : completeness of TME
fascia, circumferential margins

Prognostic Factors for Outcome
Surgeon
TNM stage (+ vascular, perineural,
lymphatic invasion)
RO resection (>1 mm)
Tumour involvement of circumferential
and distal margin
Response to neoadjuvant treatment ?

Indications for neoadjuvant
treatment : clinical stage
It is not really known which patients need
neoadjuvant treatment
High rectal cancer may need a different
approach than mid-and low rectal cancer
Mid-and low rectal cancer:
T3 T4
Threatened circumferential margin
N + tumor
Very low located tumours

Radiotherapy
Radiotherapy
There is no standard
Try to sterilize lymph nodes outside TME
field TME volume + iliac lymph nodes
Prone position + / - belly board

Preoperative chemotherapy in
combination with radiotherapy

No consensus in resectable rectal cancer
in combination with long regiment
Ongoing trials in resectable rectal cancer
In locally advanced non-resectable rectal
cancer : best option chemoradiotherapy

Conclusion-1
Rectal cancer needs a multidisciplinary
approach
Progress has been made in the treatment
of rectal cancer : low local recurrence rate
The challenge remains however to
develop strategies to decrease distant
metastases
Conclusion-2

Consensus cannot be reached on all
aspects of treatment because
Emerging data influence clinical practice
Many clinical trials are ongoing
Experts make decisions on clinical experience
Conclusion-3

Those involved in treatment should be
encouraged to participate in well designed
trials, in order to increase the evidence-
based knowledge and to make further
progress



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