Rectal Cancer

Surgical anatomy
 rectum begins at the
taenia coli of the sigmoid
colon which joins to form
a continous muscle layer
at the level of sacral
promontory
ends at anorectal junction
has 3 lateral curvatures
 on the luminal aspect, these 3
curves are Houstons valves
12-18 cm in length
divided into 3 parts
upper third which is mobile
and has a peritoneal coat
middle third where the
peritoneum covers the
anterior and lateral part
lowest third which lies deep
into the pelvis
lowest third is
separated by the
Denonviliers fascia from
the prostate and vagina
Waldeyers fascia from the
coccyx and lowest two
sacral vertebrae
Lowest third of the
rectum is separated by
Waldeyers fascia from
lowest 2 sacral vertebrae
 Arterial supply
superior rectal artery
middle rectal artery

inferior rectal artery

Venous drainage
superior rectal veins
middle rectal veins

inferior rectal veins

Lymphatic drainage
passes to pararectal nodes and to the inferior mesenteric nodes
some passes into the internal iliac nodes
 Definition of Rectal Carcinoma

Malignant tumor arising from the epithelial layer of

the final part of the large intestine
75 % of carcinoma occurs in the lower part of the
rectal ampulla
mostly, adenocarcinoma
usually they present as an ulcer but polypoid and
infiltrating types are also common
 Age
~ more than 50
Diets
Smoking ~ high in fats and
low in fibres

UC and CD Risk factors Polyps

Genetics
Medical History
~ HNPCC and FAP
Family history
~ 1st degree
relatives
 Pathophysiology

3 pathways are indicated

APC gene adeno-carcinoma pathway
HNPCC pathway
Ulcerative colitis dysplasia
Chronic inflammation can lead to dysplasia and carcinoma
subsequently
TYPES OF CARCINOMA SPREAD
Local spread
occurs circumferentially
muscular coat has been
penetrated then spreads
to mesorectum
if penetration occurs
anteriorly = prostate,
seminal vesicle, urinary
bladder
posteriorly = sacrum
and sacral plexus
laterally = ureters
 Lymphatic spread

Tumors >3cm shows more lymphatic spread

Occurs in an upward direction
Downward spread is exceptional
Metastasis higher than the main trunk of the
superior rectal artery occurs only later
 Venous spread

principal sites for metastasis

liver (34%)
lungs (22%)
adrenals (11%)
 Transcoelomic spread

follows penetration of a peritoneal coat

Results in ascites and carcinomatous nodules over
the peritoneum
Stages of progression
 Dukes Staging

A Growth is limited to the rectal wall with good

prognosis

Growth extended to the extrarectal tissues but no

B metastasis with reasonable prognosis

Secondary deposits in the regional lymph nodes

C C1 local pararectal nodes
C2 nodes and the supplying blood vessels

D Distant metastases
 Prognosis

Dukes A 5 year survival rate is 90-100%

Dukes B 5 year survival rate is 50-80%
Dukes C - 5 year survival rate is <50%
 Astler-Coller Modification of
Dukes Staging

A Limited to mucosa No nodes involvement

B1 Extension into muscular No nodes involvement
propria
B2 Extension into entire No nodes involvement
rectal wall
B3 Extension into adjacent No nodes involvement
organ
C1 Extension into muscularis Positive nodes
propria involvement
C2 Extension into entire Positive nodes
rectal wall involvement
C3 Extension into adjacent Positive nodes
organ involvement
D Distant metastases
 TNM Staging

T
~ extent of local
spread

T3
T1 T2 T4
~ invasion through
~ invasion into the ~ invasion into the ~ invasion through
the muscularis
muscularis mucosa muscularis propria the serosa
propria
 N
~ describes nodal
involvement

N0 N1 N2
~ no lymph nodes ~ 1-3 involved ~ 4 or more involved
involvement lymph nodes lymph nodes
 M
~ indicates
metastases

M0
~ no distant M1
metastases ~ distant metastases
 Histological grading

low grade = well-differentiated

average grade = moderately differentiated

high grade = anaplastic tumors/poorly differentiated

Clinical features
 Bleeding per rectum

earliest symptom
slight in amount
occurs at the end of defecation
hemorrhoids can co-exist
 Tenesmus

Feeling of needing to pass stools

spurious diarrhea
passage of flatus
blood stained mucus
 Early morning diarrhea

gets up early in the morning to defecate

passes blood and mucus in addition to the faeces
constipation suffered by patients who has annular
carcinoma
 Pain

late symptom
colicky
caused by some degree of intestinal obstruction
pain at the back occurs when cancer invades the
sacral plexus
weight loss suggest hepatic metastases
History taking Physical examination
Ask about all the risk Local and systemic
factors and symptoms examination
Per rectum examination
 Rectal Examination

neoplasm can be felt digitally nodular with

indurated bases
centre ulcerates edges are raised and everted
finger smeared with blood if had a direct contact
with the carcinoma
vaginal examination in the females
Investigation
 Laboratory investigations
CEA FBC
Carcinogenic embryonic to exclude anemia due to
antigen bleeding
High levels indicates
metastases
Proctoscopy
Lubricated and
inserted into rectum
1 day before the patient
will be given enema to
clear their bowel
 Biopsy
Usage of biopsy forceps
via a sigmoidoscopy
a portion of the tumor
can be removed
 Colonoscopy

to exclude synchronous tumor

Barium enema
Double contrast
barium-enema
Polypoid lesions has an
irregular surface
 EUS

Endorectal USG
To know level of penetration
Detect perirectal lymph nodes involvement
Detect invasion of adjacent structures
Tumor invades into but not through muscularis propria
 CT Scan

Helps to detect the lesion

To know the extension of the tumor
To know the fixation to the adjacent structures
Treatment
 Assess the fitness of the patient before operation
The extent of spread of the tumor
Radical excision of the rectum with mesorectum and
associated lymph nodes should be the aim
3 types of standard treatment
Surgery

Radiotherapy

chemotherapy
 Surgery

Abdominoperineal excision of the rectum

Anterior resection
 Abdominoperineal resection

Removal of the distal section of large intestine

Two incisions are needed which is the anterior and
perineal incision
Done to prolong life and prevent from obstructing
the intestinal tract
Surgery is done by both incisions simultaneously
with 2 sets of surgeon
Midline incision is made by the abdominal surgeon
Liver and peritoneum examined for metastasis
Separate rectosigmoid mesentery from the sacrum
Perineal surgeon close the anus with purse-string
sutures
Perineal incision is made from perineal body to the
coccyx
Denonviliers fascia is divided then rectum and anus
can be removed
 Anterior resection

Surgeons will remove the tumor without affecting

the anus
Laxatives and enema are administered before
surgery
Incision is made on the abdomen and colon is
attached again (coloanal anastomosis)
Colostomy is usually not necessary
 Chemotherapy

Uses drugs to stop the growth of cancer cells

Most commonly used drugs is 5-fluorouracil
Used in combination with folinic acid ( leucovorin)
Infused after primary operation into the portal
vein
Kill malignant cells that are released into
circulation
New drugs are available but remains to be seen
whether they will be effective in adjuvant setting
Irinotecan and oxaliplatin
 Radiotherapy

Uses high energy X-Rays to kill the cancer cells

Can reduce the incidence of local recurrences if
adequate dose is given
Can combined with chemotherapy to shrink the
tumor
Palliative irradiation can be given for inoperable
primary tumors or local reccurence
 REFERENCES

Bailey and Loves Short Practice of Surgery

Browses Introduction To The Symptoms and Signs of
Surgical Disease
http://www.cancercompass.com/rectal-cancer-information/
causes-and-risk-factors.htm
http://www.cancer.gov/cancertopics/types/colon-and-recta
l
http://emedicine.medscape.com/article/281237-overview
http://www.cancer.gov/cancertopics/pdq/treatment/rectal
/Patient/page4
THANK YOU