Therapy for Rectal Carcinoma

• Principles of Resection
– biology of rectal adenocarcinoma identical to the
biology of colonic adenocarcinoma,
– Therapeutic decisions,are based on
• the location and depth of the tumor
• Relationship to other structures in the pelvis
• Local Therapy
– distal 10 cm of the rectum are accessible
transanally
– Transanal excision (full thickness or mucosal) ,
excellent approach for noncircumferential,benign,
villous adenomas of the rectum
– Transanal endoscopic microsurgery (TEM) and
transanal minimally invasive surgery (TAMIS)
– Ablative techniques, such as electrocautery or
endocavitary, radiation,
• Radical Resection
– Involves removal of the involved segment of the
rectum along with its lymphovascular supply
– Total mesorectal excision (TME), technique that
uses sharp dissection along anatomic planes to
ensure complete resection of the rectal mesentery
during low and extended low anterior
– resection decreases local recurrence rates and
improves long-term survival rates
• Stage-Specific Therapy (Fig. 29-26)
– Ultrasound
• highly accurate at assessing tumor depth
• less accurate in diagnosing nodal involvement
– MRI is useful to assess mesorectal involvement
• Stage 0 (Tis, N0, M0)
– Villous adenomas harboring carcinoma in situ
(high-grade dysplasia) are ideally treated with
local excision.
• Stage I: Localized Rectal Carcinoma (T1-2, N0,
M0
– patients with T2 rectal cancers received
neoadjuvant chemoradiation followed by
transanal excision, showed a pathologic complete
response rate of 44%.
• Locally Advanced Rectal Cancer (Stages II and
III)
– Stage II: Localized Rectal Carcinoma (T3-4, N0, M0)
• advantages of preoperative chemoradiation
– tumor shrinkage,
– increased likelihood of resection and of a sphincter-sparing
procedure,
– tumor downstaging by treating locally involved lymph nodes,
– decreased risk to the small intestine.
• Disadvantages include
– possible overtreatment of early-stage tumors,
– impaired wound healing,
– pelvic fibrosis
• Stage III: Lymph Node Metastasis (Tany, N1,
M0)
– adjuvant and neoadjuvant therapy for locally
advanced rectal cancer
– neoadjuvant chemoradiation if the radial margin is
threatened or involved by the cancer or if anal
sphincter or other local organ invasion is present.
– Preoperative chemoradiation
• tumor shrinkage/downstaging,
• improved resectability,
• and the possibility of performing a sphincter-sparing
operation
• Stage IV: Distant Metastasis (Tany, Nany, M1).
– Local therapy using cautery, endocavitary
radiation, or laser ablatioto control bleeding or
prevent obstruction
– Radical resection required to control pain,
bleeding, or tenesmus,
• Follow-Up and Surveillance
– The goal : to detect resectable recurrence and to
improve survival.
– most recurrences occur within 2 years,surveillance
focuses on this time period
– 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 performed annually for 5 years
 Anal Canal and Perianal Tumors

• Squamous Intraepithelial Lesions

– Highgrade squamous intraepithelial lesions (HSIL)
include : High and intermediate-grade dysplasia,
AIN2 and AIN3, Bowen’s disease, and carcinoma in
situ.
– Low-grade squamous intraepithelial lesions (LSIL)
include low-grade dysplasia and AIN1
• Epidermoid Carcinoma
– Includes : squamous cell carcinoma, cloacogenic
carcinoma, transitional carcinoma, and basaloid
carcinoma.
– first-line therapy relies on chemotherapy and
radiation (the Nigro protocol: 5-fluorouracil,
mitomycin C, and 30 Gy of external beam
radiation)
• Verrucous Carcinoma (Buschke-Lowenstein
Tumor, Giant Condyloma Acuminata)
– is a locally aggressive form of condyloma
acuminata
– Wide local excision is the treatment of choice
• Basal Cell Carcinoma
– Is rare and resembles basal cell carcinoma
elsewhere on the skin(raised, pearly edges with
central ulceration).
– Wide local excision
• Adenocarcinoma.
– arise from the anal glands or may develop in a
chronic fistula.
– Radical resection with or without adjuvant
chemoradiation is usually required
• Melanoma
– is rare, comprising less than 1% of all anorectal
malignancies and 1% to 2% of melanomas
– wide local excision is recommended for initial
treatment of localized anal melanoma