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Carcinoma Rectum
Budhi Nath Adhikari
Clinical Evaluation :
History
Often asymptomatic
Symptoms occur late
Rectal complaints, non specific
Risk factors
Physical Examination
DRE – palpable mass
Liver enlargement, previous operations
Assessment of the patient's anal
sphincter
Investigation
Rigid proctosigmoidoscopcopy
feasibility of local excision and obtain an
adequate tissue biopsy
Endorectal ultrasound
Preoperative staging - depth and nodal
enlargement
Confirmation of nodal metastasis with
ultrasound-guided needle biopsy is less
reliable
Overstaging
less able to distinguish accurately T1 from T2
cancers, stenotic lesions and in patients with
prior radiation
CT scans
Regional tumor extension, lymphatic and
distant metastases, and tumor-related
complications such as perforation or fistula
formation.
Less accurate than endoluminal scan (local
spread, adjacent organ invasion) better
for distant metastasis and recurrent
disease detection
MRI
Larger field of view, less operator- and
technique-dependent, allows study of stenotic
tumors
Discriminate small-volume nodal disease and
subtle transmural invasion , local recurrence
Identifies involved perirectal nodes on the
basis of characteristics other than size
Identifies foci not only within the mesorectum
but also outside the mesorectal fascia
Double-contrast MRI may permit more accurate
T staging
Tumour marker
CEA
Up to 95% of patients with advanced
hepatic metastasis will have a CEA level
above 20 ng/mL.
Normal preoperative CEA levels will
identify patients who will not benefit
from following CEA levels
postoperatively
PET
Assessing the extent of pathologic response of
primary rectal cancer to preoperative
chemoradiation and may predict long-term
outcome.
Detection of recurrence of rectal cancer after
surgical resection and full-dose external-
beam radiation therapy
Relatively inaccurate for nodal metastases
Histopathologic examination of the specimen
obtained via biopsy or local excision
Chest x-ray or chest CT scan to exclude
pulmonary metastases
Subjective and objective assessment of
the patient's anal sphincter function
Prostate-specific antigen
Baseline investigations
TNM Staging
Describe the anatomic extent, planning
treatment, evaluating response to treatment,
comparing the results of various treatment
regimens, and determining prognosis
stage I, the tumor invades upto the muscularis
propria
stage II, the tumor invades completely through
this layer.
stage III, lymph node metastasis
stage IV, metastatic disease
TNM Staging
Poor prognostic
Poorly differentiated cancers
factors
Direct tumor extension into adjacent structures
(T4 lesions)
Lymphatic, vascular, or perineural invasion;
and
Bowel obstruction
Principles of Treatment