RECENT ADVANCES IN THE MANAGEMENT OF RECTAL CARCINOMA

1. RECENT ADVANCES IN THE MANAGEMENT OF RECTAL CARCINOMA PROFESSOR PANKAJ G. JANI. M.MED., FRCS.DEPT. OF SURGERY, UNIVERSITY OF NAIROBI. KENYATTA NATIONAL HOSPITAL CHAIR. EXAMINATIONS AND CREDENTIALS COMMITTEE COSECSA INT. ONCOLOGY CONF. NAIROBI, OCTOBER 2011

2. THEME Translating recent advances into local practice/clinical care

3. RECTAL CANCER Progress in MULTIMODAL THERAPY of Rectal Cancer is one of the BEST examples of success of Clinical Research in the last 2 decades.

5. RECTAL CARCINOMA – RECENT ADVANCES -- OVERALL 1.SPHINCTER SAVING PROCEDURES – UP FROM 15% TO 50% -- NO COLOSTOMY (IMPROVED QOL) 2. OVERALL FIVE YR SURVIVAL – UP FROM 30% TO 60% 3. DEPTH OF INVASION – DECREASED BY 40%-60% WITH ADJUVANT Rx 4. LYMPH NODE STATUS AND REC. FREE SURVIVAL - SAME

6. RECENT ADVANCES • 1. MOLECULAR BIOLOGY • 2. SURGERY • 3. IMAGING – MRI, CT AND PET • 4. CHEMO/RADIOTHERAPY

7. MOLECULAR BIOLOGY • DNA CHIP TECH. – DNA SEQUENCE CHECKED -- APC GENE – FAP -- MISMATCH REPAIR GENES – HNPCC • SUCH PTS.(5%) PUT ON A SURVEILLANCE PROG. --PROPHYLACTIC SURGERY

8. MOLECULAR BIOLOGY • DNA SEQUENCE OF MICROSATELLITE INSTABILITY -- GOOD RESPONSE WITH 5 FU CHEMO. • P21 MARKER POSITIVE – RADIOSENSITIVE

9. MOLECULAR BIOLOGY • P53 PROTEIN MUTANT EXPRESSED -- RADIORESISTANT • KRAS, DCC, AND P53 -- IF +ve – POOR PROGNOSIS • MICROSATELLITE INSTABILITY OR LOW Cox2 EXPRESSION & P21 MARKER – IF +ve – GOOD PROGNOSIS

11. SURGICAL CHALLANGES • I - STAGING • II - USE OF CH/RT • III - SURGICAL TECHNIQUE

12. I - STAGING DECIDES –TRANS ANAL LOCAL EXCISIONAPR . NEOADJUVANT CH/RT

13. TRADITIONAL STAGING • DIGITAL RECTAL EXAMINATION • CT SCANS

14. NEWER STAGING METHODS • DRE • ERUS – NODES • CT

15. RECENT ADVANCES • DRE • ERUS • MRI

16. RECENT ADVANCES DRE

17. RECTAL CA. RECENT ADVANCES

18. RECENT ADVANCES ERUS • ERUS ------ BEST FOR NODAL STATUS ( OPERATOR DEPENDANT)

19. STAGING • ERUS • T STAGE ACCURACY 60 – 90% • N STAGE ACCURACY 60 – 90% • MRI • T STAGE ACCURACY 60 – 90% • N STAGE 40 --- 80% • ( NODES > 5mm)

20. CHALLANGE • PICK UP NODES < 5mm (33%OF ALL • NODES) • PICK UP MICRO METS • USE OF CH/RT

21. MRI • HIGH RESOLUTION THIN SLICE (<1mm) • DEPTH OF EXTRAMURAL SPREAD ACCURATELY IDENTIFIED (AIDS CIRCUMFERENTIAL RESECTION MARGIN) • TRADITIONAL - PROXIMAL - DISTAL • RECENT ADV. – CIRCUMFERENTIAL RESEC. MARGINS IMP.

22. MRI INDICATORS OF MALIGNANT NODAL INVOLVEMENT L. NODES -- IRREGULAR BORDER -- MIXED SIGNAL INTENSITY OF NODE

23. MRI • DETECTS EXTRAMURAL VENOUS INVASION (EMVI) • POOR PROGNOSIS WITHOUT CH/RT IF EMVI PRESENT

25. II USE OF CH/RT (NEOADJUVANT/ADJUVANT) • PTS WITH POOR HISTOLOGY • PTS WITH EXTRA MURAL SPREAD (MRI) • PTS WITH INVOLVED NODES (ERUS) • PTS WITH EMVI (MRI)

26. CHEMOTHERAPY • INJ KYTRIL 3mg Ksh 2,250/- • INJ DEXAMETHAZONE 8mg Ksh 385/- • INJ FLUOUROURACIL 5500mg Ksh 12,053/- • INJ OXALIPLATIN 200mg Ksh 187,600/- • INJ LEUCOVORIN 100mg Ksh 1,809/- • INJ AVASTIN 400mg Ksh 213,806/-Kshs 417903/-

27. RADIOTHERAPY • EUROPEAN APPROACH • (25G/5CYCLES) • SHORT COURSE – LOW DOSE – IMMEDIATE SURGERY • NO CHANGE IN PATH STAGING • LOWER COST • BETTER COMPLIANCE • DOSE EQUIVALENT TO 30-33G • EXPECT 66% REDUCTION IN LOCAL RECURRENCE • AMERICAN APPROACH • (45 – 54G/28 CYCLES) • PROLONGED COURSE – HIGH DOSE – DELAYED SURGERY • BETTER SURGICAL TOLERANCE • MORE TUMOR REGRESSION • EXPECT >80% REDUCTION IN LOCAL RECURRENCE

29. III SURGICAL TECHNIQUE TRADITIONAL • PROCTECTOMY PERFORMED -- In the DARK -- Using BLUNT Dissection -- Without attention to ANATOMIC Detail RESULTED in -- Bloody operation -- Increased -- Autonomic Nerve injury -- Local Rec.

30. SURGERY - TRADITIONAL • ANT. RESECTION – UPPER ⅓ RECTAL CA • LOW ANT.RESCETION - MID ⅓ RECTAL CA • A.P.R. - LOWER ⅓ RECTAL CA • ANY TUMOR 10cms FROM ANAL VERGE -- APR

31. ANATOMY OF RECTUM • CHANGED FROM TRADIOTIONAL 22 CMS FROM ANAL VERGE TO 15 CMS • ABOVE THAT IS ALL COLON

32. RECTAL CARCINOMA RECENT ADVANCES • >100 YEARS SINCE MILES DESCRIBED ABDOMINO-PERINEAL-RESECTION • >25 YEARS SINCE HEALD DESCRIBED TOTAL MESORECTAL EXCISION

33. III SURGICAL TECHNIQUERECENT ADV. TOTAL MESORECTAL EXISION ( EXICISION OF FASCIA ENVELOPING THE FAT PAD AROUND THE RECTUM.) SAUSAGE APPEARANCE

34. SURGERY – RECENT ADVANCES • LOW-ANT RESECTION – UPTO ≏ 6cms FROM ANAL VERGE • APR – ONLY IF SPHINCTOR FUNCTION COMPROMISED

35. RECTAL CANCER – RECENT ADVANCES • CAREFUL ASSESSMENT OF SxS  EARLY DIGNOSIS WITH  ACCURATE STAGING  CH/RT - FOR SELECTED PTS -PROCTOSCOPY - SIGMOIDOSCOPY - DRE - ERUS - MRI

36. OUR SCENARIO • LATE PRESENTATION • ADVANCED TUMORS • ANATOMICAL DISTORTION • LACK OF NEOADJUVENTS • SURGERY MORE DIFFICULT • RESULTS POORER

37. COMMON PROBLEMS FACING SURGERY IN AFRICA • LACK OF GUIDELINES AND STANDARDS • INADEQUATE SUPERVISION

40. THANK YOU

41. VEINS OF SMALL & LARGE INTESTINES

42. CAECAL CANCER RESECTION

43. GOALS OF THERAPY FOR RECTAL CARCINOMA • DECREASE LOCAL RECURRANCE • OPTIMISE Q.O.L. AVOID COLOSTOMY

44. CA. RECTAM (ESP. LOWER TUMORS) • SHOULD BE DIAGNOSED EARLY • SHOULD GIVE GOOD RESULTS WITH EARLY THERAPY

45. LOCAL EXPERIENCE • 31 CASES OF RECTAL CA • 25 APR DONE • 6 LOW ANT RESECTIONS (2 Local Rec.)

46. SYMPTOMS • RECTAL BLEEDING LOWER RECT. • TENESMUS • ALT. OF BOWEL HABITS UPPER. • ANY G.I. SxS (dyspepsia)

47. RECTAL CANCER