INT. ONCOLOGY CONF.

NAIROBI,
OCTOBER 2011

THEME
Translating recent
advances into local
practice/clinical care

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.

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

RECENT
ADVANCES
1.
2.
3.
4.

MOLECULAR BIOLOGY
SURGERY
IMAGING MRI, CT AND PET
CHEMO/RADIOTHERAPY

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

MOLECULAR BIOLOGY
DNA SEQUENCE OF MICROSATELLITE

INSTABILITY
-- GOOD RESPONSE WITH 5 FU CHEMO.
P21 MARKER POSITIVE RADIOSENSITIVE

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

SURGICAL
CHALLANGES
I-

STAGING

II -

USE OF CH/RT

III

SURGICAL TECHNIQUE

I - STAGING
DECIDES TRANS ANAL LOCAL
EXCISIONAPR
.
NEOADJUVANT CH/RT

TRADITIONAL STAGING

DIGITAL RECTAL EXAMINATION

CT SCANS

NEWER STAGING
METHODS
DRE
ERUS NODES
CT

RECENT ADVANCES
DRE
ERUS
MRI

RECENT ADVANCES

DRE

RECTAL CA. RECENT

ADVANCES

RECENT ADVANCES
ERUS
ERUS

------ BEST FOR NODAL

STATUS
( OPERATOR DEPENDANT)

STAGING
ERUS

T STAGE ACCURACY 60 90%

N STAGE ACCURACY 60 90%
MRI
T STAGE ACCURACY 60 90%
N STAGE
40 --- 80%
( NODES > 5mm)

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

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.

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

MRI
DETECTS EXTRAMURAL VENOUS

INVASION (EMVI)
POOR PROGNOSIS WITHOUT

CH/RT IF EMVI PRESENT

II
USE OF CH/RT
(NEOADJUVANT/ADJUVAN
T)
PTS WITH POOR HISTOLOGY
PTS WITH EXTRA MURAL SPREAD (MRI)
PTS WITH INVOLVED NODES (ERUS)
PTS WITH EMVI (MRI)

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/-

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

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.

SURGERY TRADITIONAL
ANT. RESECTION UPPER

RECTAL CA
LOW ANT.RESCETION - MID
RECTAL CA
A.P.R. - LOWER RECTAL CA
ANY TUMOR 10cms FROM ANAL

VERGE -- APR

ANATOMY OF RECTUM
CHANGED FROM TRADIOTIONAL 22

CMS FROM ANAL VERGE TO 15 CMS

ABOVE THAT IS ALL COLON

RECTAL CARCINOMA
RECENT ADVANCES
>100 YEARS SINCE MILES DESCRIBED

ABDOMINO-PERINEAL-RESECTION

>25 YEARS SINCE HEALD DESCRIBED

TOTAL MESORECTAL EXCISION

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

SURGERY RECENT
ADVANCES
LOW-ANT RESECTION UPTO

6cms FROM ANAL VERGE

APR ONLY IF SPHINCTOR

FUNCTION COMPROMISED

RECTAL CANCER RECENT

ADVANCES
CAREFUL ASSESSMENT OF SxS

- PROCTOSCOPY
EARLY DIGNOSIS WITH
- SIGMOIDOSCOPY

- DRE
ACCURATE STAGING
- ERUS
- MRI

CH/RT - FOR SELECTED PTS

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

COMMON PROBLEMS FACING

SURGERY IN AFRICA
LACK OF GUIDELINES

AND STANDARDS
INADEQUATE

SUPERVISION

VEINS OF SMALL &

LARGE INTESTINES

CAECAL CANCER
RESECTION

GOALS OF THERAPY FOR

RECTAL CARCINOMA

DECREASE LOCAL RECURRANCE

OPTIMISE Q.O.L. AVOID

COLOSTOMY

CA. RECTAM (ESP. LOWER

TUMORS)
SHOULD BE DIAGNOSED
EARLY

SHOULD GIVE GOOD RESULTS

WITH EARLY THERAPY

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

SYMPTOMS
RECTAL BLEEDING

LOWER RECT.
TENESMUS
ALT. OF BOWEL HABITS

UPPER.
ANY G.I. SxS (dyspepsia)

RECTAL CANCER