32 year old women presented with 9 months history of rectal bleeding . No history of loss of appetite and loss of weight . She has no any urinary symptoms . History of two cesarean sections is present . Rectal examination : - lower edge is palpable 1 cm above the internal sphincter . Ultrasound examination and blood chemistry are normal . CEA is normal limits . Histopathology of rectal growth is moderately diffentiated adenocarcinoma .
We can do a MR pelvis and abdomen/ CT abdomen & chest to stage the disease........ >T3/N+ tumor can be treated with preop therapy.........if circumferential resection margin is supposed to +ve in in imaging a full course neoadjuvant chemoradiation is preferable..........if CRM is supposed to be negative on imaging a short course radiation(SCRT) of 25 Gy can be given preoperatively over 5 days and the patient can be taken for surgery just 7 days after SCRT.........mostly this patient will require an APR.......how much above this tumor is from anal verge?
Depends of whether you would like just to follow the guidelines or would like to include a patient in a research protocol. In both occasions sphincter preservation can be achieved if the sphincter is not directly invaded by the tumor. In low risk cases neoadjuvant CRT followed by transanal endoscopic microsurgery is also option. However I will not recommend that if there is not possibility to intensively follow up this pt.
Kindly do a TNM staging. Depending on the T stage and whether or not the patient desires sphincter preservation and taking into consideration the chance of follow up, the decision on the type of surgery can be made.
But, for all practical purposes, in our situation, an APR with colostomy would be advisable. Though, Chemoradiation followed by laparoscopic sphincter preserving surgery or TEMS is possible.
The short answer is it depends: she will certainly need an MRI and staging CT. Trans-rectal US is only of use if it is a T1 lesion and you are considering a TEMS.
Some people (e.g. Eric Rullier) advocate an intersphincteric dissection (ISD) but the function is poor (especially if you subject them to LC-CRT which some advocates of ISD do to get clearance). Is she a primigravida? I don't believe in neoadjuvant Rx use to "shrink" back cancer as you can still cut through microscopic disease. She is young, so the prioirty will be oncological cure.
I think that she will best benefit from an APER for cancer and for functional reasons (one can debate ELAPE vs Miles - I'd tend to go for ELAPE but MRI can help) . The only indication for LC-CRT would be a threatened CRM (which is possible as the mesorectum will have tapered out at that level).
Habr-Gama and TEMS for non-T1 are slightly off mainstream at present and I wouldn't recommend for this case. The debate about SCRT vs LC-CRT still goes on but, personally, I don't feel SCRT adds more than LC-CRT. If you are worried about CRM then I'd go for LC-CRT but that may affect giving adjuvant therapy afterwards (Bosset Lancet Feb 14).
I'd get the staging investigations (full obs history/any hx of faecal incontinence etc) and then decide. I think an ISD if she's had children/occult sphincter injury, though may get an R0 (risky), will result in poor function and would err on the side of an ELAPE.
Hope that helps,
JB.
After complete staging a adequat therapy is possible. If T3 or N+ disease, preoperatieve CRT is the normal route. If T2 or non aggresive T3 primary surgery is the option. Proper palpation and inspection under anesthesia is the first step. If sfincter preservation is possible one might opt for a TAMIS TME procedure.
Once it is a low rectal cancer you have to start with neoadjuvant chemotherapy followed by either APR or low anterior resection according to staging and MRI pelvis and endorectal ultrasound
MRI and endorectal ultrasound are the first diagnostic tools we need, so we could perform staging. Aggressive neoadjuvant multimodal treatment would be necessary depending the young age, but however, its decision would be made according to the exact stage and probably additional molecular prognostic markers. The adequate surgical procedure varies from the derived clinical and pathological answers: wait and see, some types of sparing or extirpation procedures. As in younger population the disease have obviously worse course I would not hesitate to perform more extensive surgery, with the believe to safe the life as a primary goal. The chance to have primary impaired sphincter function would be another reason running the conservative approach away. Finally, if the neoadjuvant answer is good, mini-invasive or sparing surgery would be probably the best option for the patient.
MRI and endorectal US, tumor markers , ovules restoration and then, CT scan of head, thorax , abdomen followed by a total bone scan ( systematic circulation is the primary road to..hell). I would do a neo adjuvant radio-chemo therapy and removal of rectum with a coloproctal anastomosis with a loop ileostomy as well , histology for the tumor depth-CPR , so if I am not happy a APR in a second operation .Of course I would give the proper information so if my patient were to consent for a APR as the unique operation, I would do it!
MRI and endorectal USG for staging Then either if possible Low anterior resection/Neoadjuvant chemoradiation then LAR
MRI for staging. If T3 or any T, but N+ - CRT. Then assessing TRG. We must do everything to avoid APR.
As experts suggested, she needs accurate staging of local and distant disease.
Once that is established, surgery should be considered.
choices are:
1- Sphincter preservation i.e Low AR ( coloanal anastomosis ) Even there is talk about poor function, but we think , if oncologically good surgery can be performed than continuity of GI tract is good for young group of patients.
2- APER
Most important what is wants.
In such patient we are performing robotic resections ( Coloanal) and results (short-term) are acceptable.
Adequate staging first:
- abdominopelvic CT (local spread and distant mets); chest CT (pulmonary mets); tumormarker: CEA (determine its usefulness for follow up); rectal MR or US to determine the T and N stage.
Treatment depends on the results of staging.
Surgical conduct to prevent neoplasia desemination to nieghboring organs if there's still limitation, with funcional conservation and hemodynamic control of consequence of bleeding.
To make first a good image study with a CT thoraco-addominal and after that applies local radiotherapy and finally and abomino-perineal resection with permanent colostomy
After careful assessment and taking in to consideration of socioeconomic factors and assessment during surgery, Lap APR was done and pt was discharged on POD3.
thankyouall,
Excellent - good job - as I said I think this is the right decision. ISD would leave the patient with very poor function. What was the pathology and pre-op imaging stage?
T3N1M0 -CT staging,sorry I missed to mention,HP report is awaited ,
this is going to be the vital thing is staging of the rectal cancer in accurate path. if you want to do like this a surgeon runs for pelvic MR. then you can make a desicion if the tumorinvades the structure 8like sphincter mechanism) and tissues along with. if it is (means stage III or advanced) preoperative CRT (perhaps RT following CT -capeox or folfox) is going to be delivered. Abd-Thoracal CT is also required to make distant metastasis diagnosed.
at the end of preoperative tratment (neoadj.matter) 8-12 weeks can be give to a patient till surgery will be done. other pelvic MR imagind is going to be necessary to restage the tumor to make downsizing or downstaging cleared. you can get three way to go possible. 1 is about no shircage whatsoever you can run for APR. if you can get the tumor pathologically dissappered (means complete pathologic response) you can make the operation what you have decided before the CRT. on the other hand you can do something like local resection transanaly (TAMIS or TEO operations). at that time it is important what your patient wants. you can explain pro-cons of the surgery or no to be done to make your patient decided about "wait and see" policy. it is hard to say something like tumor response not as good as assumed. I think oyu can do the surgery what you made desicon before all.
We follow NACTRT protocol based on German trial for all locally advanced ca rectum instead of upfront surgery. However, most of japanese surgeons go for upfront surgery, but there is a difference between theirs surgery and ours. They routinely go for lateral pelvic node dissection, which we do not do.
Also the benefit of NACTRT would be some 10 % PCR rates which have better prognosis than those who do not achieve. Hence i would have gone for NACTRT followed by surgery and followed by adjuvant chempotherapy.
An uT3N1M0 is an advanced lesion. One (1) cm. of margin lesion in a 32 yo woman is an important issue in this young patient, a neoadjuvant therapy is completly adviced and then a radical surgery is suggested.The functional and prognostic issues must be taken in count regarding this particular patients.
Lets supposed that she had a complete regresion of the lesion, she must be adviced for an APR procedure, no matter how (open, lap or robotic) this really does not matter, what it really matter, is the life and function.
If preoperativly CRT had"nt been done, now you must consider not only adjuvant CRT, but chemotherapy too.
I think Endorectal ultrasound with provide valuable information in this case. It will give information about T stage and Lymphadenopathy. Based on these findings, she will need chemo/RT and then reassess for the response to treatment. Surgical management should be based on how she responds to Neoadjuvant treatment.
She needs a very low anterior resection after completion of neoadjuvant treatment
Chemotherapy and Radiation: then restaging for possible SSR. 10% of cases complete response : in that situation surgery anyway.
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