Carcinoma Rectum

approach to a patient who presented to us with bleeding per rectum and her follow up

1. Clinical Case Presentation Rectal mass with bleeding PR Dr. Vaibhav (JR) Dr.Revathi (JR) Dr. Ankita (SR) AIIMS Delhi

2. Patient’s history Mrs. X, 58 yr F Delhi O ccupation ? Admitted on 11th August, 2019 P resenting complaints: 1. Bleeding PR X 5 months on & off, fresh red blood, mixed with stools, P assage of clots/mucus/mass? preceding/following defecation?, associated pain? a/w any particular consistency of stools? 2. Altered bowel habit X 5months passed stool once every 2-3 days consistency? a/w any loose stools/mucus? A ny relation with meals? feeling of incomplete evacuation H/o ??significant unintentional weight loss & decreased apetite - loosening of clothes in prior 4 months

3. History contd... No h/o any mass protruding from the anal opening No pain during defecation No h/o fever No h/o bleeding PR other than this period?? No urinary complaints? No h/o chronic cramping abdominal or pelvic pain No h/o jaundice No h/o cough, blood in sputum or difficulty breathing No h/o recurrent blood transfusions . ??

4. History contd.. Past medical history: Had pulmonary TB 15 yrs back - took ATT for 6 months and declared cured. Had suffered chest pain 8 yrs back - stenting in LAD done i/v/o significant stenosis. On low dose aspirin since then No other comorbidities P ersonal & family history: (veg/ nonveg ) h/o altered bowel habit, decresed appetite No h/o alcohol intake/smoking or any other substance abuse No family history h/o cancer??

5. Menstrual & obstetric history: Menarche? menopause at 48 yrs of age No h/o abnormal bleeding PV GPLA? (Describe) Had undergone (open/lap) tubectomy 32 yrs back Previous treatment history (for bleeding pr ??):

6. Time to Unmute! D ifferential diagnosis please? What is hematochezia & how is it different from malena ? C auses? T enesmus? A nything significant in medical history? D id we miss anything? How to approach a patient with massive lower GI bleed in casualty?

7. Causes of lower GI bleed Small intestinal sources Vascular ectasias Neoplasms (stromal tumor, adenocarcinoma etc) Ulcers IBD Infection, ischemia, vasculitis Intussusception, aortoenteric fistulas Meckel’s Colonic sources Hemorrhoids, anal fissures Diverticulosis Neoplasms, vascular ectasias Radiation induced polyps , SRUS

8. Hematochezia & tenesmus add malena Hematochezia is the passage of fresh blood through the anus, usually in or with stools Tenesmus is a feeling of incomplete defecation.

9. Examination General physical examination: D ecubitus, orientation, bluilt, nutrition, PICCLE??( may not right, but say it) Pallor present BMI : 22 kg/m2 KP/ECOG?? Systemic examination: CNS/Respiratory/Cardiovascular system: WNL

10. Examination contd... P/A examination: Abdomen scaphoid Visible infraumbilical scar ( describe verbaly ) No visible fullness or lump No dilated/engorged veins All quadrants moving well with Respiration All hernial sites normal Umbilicus central and inverted Infraumbilical tubectomy scar (semilunar)

11. No tenderness (superficil/deep say only) No palpable organomegaly/ lump Tympanic note on percussion (no e/o free fluid say) Bowel sounds

12. ??? D ifferential diagnosis please? D id we miss anything? How DRE is done? A ny difference in DRE with respect to gender? C an this be haemorrhoids? Role of proctoscopy? Q uadrants of abdomen?

13. PR exam No perianal excoriations, fissure normal anal tone Mucosa normal Fecal and blood staining on gloves present No mass felt

14. Proctoscopy No evidence of hemorrhoids, ulcer, mass or active bleeding seen. PV exam Uterus anteverted Fornices are free No cervical motion tenderness No adnexal mass Provisional diagnosis: ? PR bleed under evaluation Ddx: Colorectal malignancy with no clinical evidence of metastasis

15. Investigations: Hemogram TLC - 9k Hb - 9.6 Hct - 30.3 Plt - 1.84 Serum CEA levels: 102.8 ng/ml KFT/LFT Urea - 15 mg/dl Cr - 0.6 Na+ - 137 K+ - 4.6 T. Bil - 0.5 Albumin - 4.2 g/dl AST/ALT - 22/22

16. Sigmoidoscopy Rectum seen till 15 cm from anal verge Circumferential growth at 15 cm in rectum. Scope non negotiable beyond. Biopsy Features of moderately differentiated adenocarcinoma .

17. I maging: CXRay: CECT Abdomen and Pelvis: Concentric mural thickening and enhancement (10 mm thickening) in sigmoid colon 12.5 cm from anal verge with surrounding fat stranding and nodularity on serosal surface Few subcentimetric LN (4-5 mm) seen along mesenteric vessels Liver: small hypodense lesion measuring 11.5 x 10.7 mm in segment VIII of liver with homogeneous enhancement in portal venous phase. 2 Small non enhancing hypodense lesion 3.5 x 5 x 3.5 mm and 5 x 5 x 5 mm in subcapsular location of segment VII and IVA respectively. Left adrenal gland is slightly bulky (9 mm thickness) with surface nodularity. Rest WNL

18. CECT Chest: Ground glass opacities in posterior segments in bilateral lower lobe lung 2 calcified nodules in apicoposterior segment of left upper lobe. ? Calcified granuloma Small non calcified nodule 3 mm in medial basal segment of left lower lobe. Multiple oval non calcified non necrotic LN in mediastinum. ? Infective/inflammatory etiology. No pleural effusion.

19. Circumferential mural thickening in rectum

20. Please add relevant pictures of imaging (if possible as relatives to click/ take from net whatever findings this pt had on ct ) Add cxray of this pt with film if possible Put a picture of adenocarcinoma microscopic view if possible

21. Brainstorming time!! Sequence of investigations required & its significance? What was missed here? Was it delebrate ? Comments on: Primary disease vs systemic disease. Sites of metastsis ? Common histopathogy found in rectal carcinoma High risk features and its significance? Known risk factors for rectal carcinoma?

22. Evaluation of patient with suspected rectal malignancy Rigid sigmoidoscopy (and biopsy) (flexible not used) Colonoscopy in all patients - rule out synchronous tumours CECT Chest, Abdomen and Pelvis in all patients - principal sites of mets ERUS/Ec MRI for T staging PET not routinely recommended. CEA levels to monitor response to treatment, prognosis (>5 ng/ml) and recurrence . (streamline into heading: to confirm diagnosis, to stage, fitness for sx/t/t)

23. Principal sites of mets in colorectal cancer Liver: 34% Lung: 22% Adrenal: 11%

24. MRI

25. Gross

26. Histopath Signet ring histology associated with poor prognosis.

27. Pathogenesis

28. Management

29. Case summary 58 yr lady, ECOG 2 P ainless fresh irredular bleeding PR with constipation, decreased appetite & unintensional weight loss X 5months P allor, palpable growth on DRE/proctoscopy (describe) A nemia,CEA 102.8 ng/ml Concentric mural thickening in the rectosigmoid junction 12.5cm from the anal verge with surrounding fat stranding and nodularity over serosal surface, lymph nodes 4-5mm along mesenteric vessels Moderately differentiated adenocarcinoma rectum (HPE) Hypodense lesions involving liver segment 8,7,4a(CECT) No lung mets (CECT)

30. How was our pt managed a summary in points here And a follow up of herin another slide

31. NOT true about staging of carcinoma rectum: Dukes classification has 3 stages MRI has high diagnostic accuracy in T staging TNM staging is the optimum staging classification ERUS is superior to MRI for pelvic node assessment TNM staging is T3N1bM0

32. Dukes and Modified Astler coller staging

33. TNM staging

34. Radiological findings in staging Circumferential resection margin (CRM ) that provides information on the margin resection status for TME and influences local recurrence and therapy plan. Extramural venous invasion (EMV), a feature that influences prognosis Sphincter complex status to decide sphincter‑sparing surgery as well as the need for preoperative RT Extramesorectal nodes that can impact therapy planning, particularly RT MDCT cannot replace HR‑MRI for local staging Indian Journal of Radiology and Imaging / May 2015 / Vol 25 / Issue 2

35. What would be your preferred management? Supportive care Local therapy Low anterior resection APR with colostomy Neoadjuvant CT

36. Principles of treatment Surgery is the mainstay of curative therapy Early rectal cancers (T1 and good prognosis T2) may be amenable to local transanal excision The primary resection consists of rectal resection performed by total mesorectal excision Most cases can be treated by anterior resection, with the colorectal anastomosis being achieved with a circular stapling gun

37. Low, extensive tumours require an abdominoperineal excision with a permanent colostomy Adjuvant chemotherapy can improve survival in node-positive disease Liver resection in carefully selected patients offers the best chance of cure for single or well-localised liver metastases .

38. Neoadjuvant therapy Clinical stage 2 & 3 mid and lower rectal cancer CRT / SCRT ( 5 wks/ 5 days); 5-FU and oxaliplatin SCRT in resectable synchronous metastases/ tumours in the colon Reduces local recurrence, downstages tumour, enables sphincter preservation for very low rectal tumours. Rectal cancers located in the upper third of the rectum are typically treated like rectosigmoid tumors and are exempt from neoadjuvant treatment.

39. Case: cT3N1bM0 Upper rectal tumour Undergone laparoscopic LOW ANTERIOR RESECTION with DIVERSION LOOP ILEOSTOMY Postoperative chemotherapy and radiotherapy

40. Preoperative preparation Counselling and siting of stomas Correction of anaemia and electrolyte disturbance Group and save of blood Bowel preparation Deep vein thrombosis prophylaxis Prophylactic antibiotics

41. Low anterior resection Lloyd Davis position with the legs carefully padded in stirrups Open LAR is performed through a vertical midline laparotomy incision- followed by Abdominal exploration (to rule out peritoneal disease and liver metastasis) Vascular mobilization Mesenteric dissection TME Rectal transection, colon resection, and colorectal or coloanal reconstruction.

42. Coloanal anastomosis

43. Lap LAR

44. Lap LAR video

45. Benefits and limitations Open versus Lap LAR CLASICC, COLOR II, and COREAN are laparoscopic versus open TME RCTs Demonstrated superiority of the laparoscopic approach Short-term postoperative outcomes Noninferiority of short- and long-term oncologic outcomes Less intraoperative blood loss

46. Morbidity rates for laparoscopic and open TME are similar (30% to 50%) 5% to 12% urinary dysfunction 10% to 35% sexual dysfunction 20% to 30% incidence of fecal incontinence LapLAR- Abdominal extraction site with wound-related complications such incisional pain, superficial and deep wound infection, incisional hernia and prolonged recovery.

47. COMPLICATIONS Most effective way to prevent intraoperative and postoperative complications is by anticipating them during each step of the procedure .

48. Intraoperative complications Hemorrhage – presacral , periprostatic bleeding Rectal perforation Small bowel, colon perforation, vaginal and bladder perforation, vascular injury such as injury to the iliac vessels, and ureteral injury.

49. Urethral injury Urethral injury - specific to taTME. APR- incidence of 1% to 2% In early Surgeon’s learning curve During difficult anterior dissection for very low rectal tumors Patients with bulky anterior rectal tumors or an enlarged prostate. Urethral repair is performed using a perineal approach, or a transabdominal open, laparoscopic, or robotic approach.

50. Postoperative complications Anastomotic leak with pelvic sepsis Anastomotic strictures Transient urinary dysfunction, including urinary retention and urinary incontinence- 0% to 27% Sexual dysfunction Fecal incontinence, tenesmus, and fecal urgency LAR syndrome

51. LAR syndrome LARS score or Wexner Score Multifactorial Colonic dysmotility Decreased rectal sensibility Disappearance of the anorectal reflex Reduction of rectal tone Damage to the pelvic nerves or internal sphincter. Rx- Dietary recommendations, antimotility agents, and fiber supplements. pelvic floor strengthening exercises and biofeedback, sacral nerve stimulation

52. Symptoms of LARS may include some or all of: Increased frequency of stool Urgency with or without incontinence of stool Feeling of incomplete emptying Fragmentation of stool (passing small amounts little and often) Difficulty in differentiating between gas and stool

53. Transanal Total Mesorectal excision

54. APR Ernest Miles Indications: Tumour involving anal sphincters Tumour too close to sphincters for adequate margins Sphincter preserving surgery not possible – unfavourable body habitus or poor preoperative sphincter control.

55. Rectum and sigmoid colon are mobilized through an abdominal incision The pelvic dissection is carried to the level of the levator ani muscles Perineal portion of the operation excises the anus, anal sphincters, and distal rectum .

56. Surgical anatomy

57. Transanal Approaches to Early Rectal Cancer INDICATIONS • T1N0 tumors located in the lower rectum (<10 cm from the anal verge) Mobile and polypoid lesions Tumors involving less than 1/3 of rectal circumference Tumors less than 3 cm in diameter G1-2 tumors No evidence of lymphovascular invasion (even though the preoperative evaluation of this parameter is challenging)

58. Surgical technique Placed in high lithotomy position Anterior lesion – Prone jacknife position Lone star retractor placed to evert the anus Mucosa is scored circumferentially by using conventional monopolar electrocautery to adequately define the resection margin (at least 0.5 cm). Full-thickness excision of the tumor is performed down to the perirectal fatty tissue Procedure ends with closure of the rectal wall defect using interrupted resorbable sutures.

59. POSTOPERATIVE COMPLICATIONS Rectal bleeding Perirectal infection Pain in case of resection reaching the dentate line Anorectal stenosis Prostate or vagina injury in case of anterior rectal tumors

60. Post operative course Case: Postoperative period patient had lower mild abdominal pain * 3 days No rectal bleeding/ urinary complaints No evidence of abdominal distension, difficulty in evacuation of stools or tenesmus Patient was discharged on POD 6

61. HPE and adjuvant therapy Final staging IIIB Adjuvant chemoradiotherapy is planned Received 2 cycles of CAPEOX f/b 4 cycles of FOLFOX regimen till date No long term complications like fecal incontinence, tenesmus/urinary difficulties

62. Factors Associated With a High Risk of Relapse for Colorectal Cancer TUMOR FACTORS Disease stage High-grade tumor (poorly differentiated) Tumor location (more distal) Obstruction/perforation Lymphovascular invasion Perineural invasion Mucin production Diminished stromal immune reaction Low microsatellite instability TECHNICAL FACTORS Inadequate resection margins (circumferential radial, distal, mesorectal) Implantation of exfoliated cells Anastomotic leak Tumor location (tumors in pelvis and splenic flexure are anatomically and technically more difficult)

63. Adjuvant therapy For people with stage III colon cancer (pT1-4, pN1-2, M0) or stage III rectal cancer (pT1-4, pN1-2, M0) treated with short course radiotherapy or no preoperative treatment, offer: Capecitabine in combination with oxaliplatin (CAPOX or XELOX) for three months, or if this is not suitable Oxaliplatin in combination with 5-fluorouracil and folinic acid (FOLFOX) for three to six months

64. Follow up Colonoscopy should be performed within 12 months. If that study is normal, colonoscopy should be repeated every 3 to 5 years thereafter. Local resection of rectal tumors should be followed with frequent endoscopic examinations (every 3–6 months for 3 years, then every 6 months for 2 years). CEA is often followed every 3 to 6 months for 2 years. CT scans are often performed annually for 5 years,

65. Management of colorectal hemorrhage

66. Screening

67. Overview

68. BUZZ