RECTAL CA

CASE PRESENTATION
JOSIE WALTER
ETIOLOGY AND EPIDEMIOLOGY

• 3rd most common cancer

• 15% in rectum
• 3rd leading cause of death
• Median age 60
• High Fat/Low Fiber Diets
• Genetic- Familial adenomatous polyposis
• maternal grandmother
• IBS
ANATOMY AND PHYSIOLOGY
• Situated pelvic cavity
• Starts at S3
• Last inch is termed the anus
• Lies posterior to bladder and vagina/endometrium
• Layered muscular organ at the caudal end of the
gastrointestinal tract
• Has 3 sphincters that is unique to this portion of the GI tract

LYMPHATICS
Superior- Perirectal, sacral, sigmoidal, superior and inferior mesenteric

Inferior- Perirectal, internal and external iliac, and hypogastric

Anal Verge/ Anus- Inguinal

MEDICAL HISTORY

Previous rectal adenocarcinoma

Diagnosed in 2014- T3N3M0
Treated with surgery, chemotherapy, and radiation
6/2014- Ileostomy
5/2015- Hysterectomy and proctectomy
11/2015- Exploratory laparotomy, colostomy, small bowel resection
12/2015- Started FOLFIRI + Avastin
4/2016- Follow up sigmoidocopy found recurrence
 PATIENTS SYMPTOMS

• Presented with change in bowel movements

• Changes started 3 months prior
• Diarrhea
• Blood in stool
• Polyps
• Fevers
 PATIENT WORK UP
• Sigmoidoscopies and DRE

• Removal of polyps to find cytology

• Ultrasound to determine histology

• Pelvic CT scans after to view recurrence

• Contrast was used

 APPROPRIATE STAGE AND GRADE
• TNM staging Duke’s Staging
• Tumor (T)
A- Tumor invaded submucosa or muscular layer
• 1 – growth to submucosa T1 and T2
• 2 – growth to muscular layer
B- Invasion beyond the muscular layer or direct
• 3 – growth to serosa
extension to other organs
• 4 – growth to or beyond the rectal wall T3 and T4
• Lymph Nodes (N)
C- Metastatic or lymph involvement
• 1 – 1-3 positive lymph nodes
• 2 – 4-7+ positive lymph nodes
• Metastasis
• 0- none
• 1- Present in distant organ
 ADJUVANT THERAPIES

• Chemotherapy
• Capecitabine (Xeloda)
• FOLFIRI Avastin
• 5 FU
 TREATMENT PLAN
• Prescription:
• Total 5040 cGy
• 3000 cGy with a 2040 cGy boost
• BID at 120 cGy per treatment in 42 treatments
• 10 MV
 TREATMENT PARAMETERS
• Positioning: Supine

• Immobilization devices: Lower vacloc bag with arms on chest holding ring ,“F” HR

• Field design and arrangement

• Contoured around – bladder, rectum, and femoral heads

• 2 full ARCs – more evenly distributed dose

• OAR and tolerances

DOSE VOLUME HISTOGRAM
PATIENT CALCULATIONS AND TARGET VOLUMES
PATIENT CALCULATION BOOST
 POTENTIAL SIDE EFFECTS

• Diarrhea • Hematuria
• Erythema • Vaginal Stenosis
• Fatigue • Anal Bleeding
• Abdominal cramping • Adhesions (Late)
• Bloating • Incontinence (Late)
• Dysuria • Proctitis (Late)
DISEASE PROGNOSIS AND SURVIVAL
 POSSIBLE METASTATIC SITES

• Lymph node

• Portal Drainage to Liver

• Lung

• Direct extension
• Vaginal cuff/endometrium/vaginal canal
• Bladder
LIST OF REFERENCES (AMA)

Edge SB, Byrd DR, Compton CC. AJCC Cancer Staging Manual . American Cancer Society . 2009.

Hackworth, Ruth. ”Colorectal CA". 2017. Presentation.

Washington, Charles M, and Dennis T Leaver. Principles And Practice Of Radiation Therapy. 4th ed. St.
Louis, MO: Mosby, 2015. Print.

What Are the Survival Rates for Colorectal Cancer, by Stage? American Cancer Society.
https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/survival-rates.html.
Published 2017. Accessed September 13, 2017.