PROFESSOR PANKAJ G. JANI. M.MED., FRCS.DEPT. OF SURGERY, UNIVERSITY OF NAIROBI. KENYATTA
NATIONAL HOSPITALCHAIR. EXAMINATIONS AND CREDENTIALS COMMITTEE
COSECSA
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. MOLECULAR BIOLOGY 2. SURGERY 3. IMAGING – MRI, CT AND PET4. CHEMO/RADIOTHERAPY
MOLECULAR BIOLOGY DNA CHIP TECH. – DNA
SEQUENCE CHECKED -- APC GENE – FAP -- MISMATCH REPAIR GENES –
HNPCCSUCH 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)
STAGINGERUS
T STAGE ACCURACY 60 – 90% N STAGE ACCURACY 60 – 90%
MRIT 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
MRIHIGH RESOLUTION THIN SLICE (<1mm)
DEPTH OF EXTRAMURAL SPREAD ACCURATELY IDENTIFIED (AIDS CIRCUMFERENTIAL RESECTION MARGIN)
TRADITIONAL- PROXIMAL- DISTAL
RECENT ADV. – CIRCUMFERENTIAL RESEC. MARGINS IMP.
MRIINDICATORS OF MALIGNANT NODAL INVOLVEMENT
L. NODES -- IRREGULAR BORDER
-- MIXED SIGNAL INTENSITY OF NODE
MRIDETECTS EXTRAMURAL VENOUS INVASION (EMVI)
POOR PROGNOSIS WITHOUT CH/RT IF EMVI PRESENT
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)
CHEMOTHERAPYINJ 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/-
RADIOTHERAPYEUROPEAN APPROACH(25G/5CYCLES)SHORT COURSE – LOW
DOSE – IMMEDIATE SURGERY
NO CHANGE IN PATH STAGING
LOWER COSTBETTER COMPLIANCEDOSE EQUIVALENT TO
30-33GEXPECT 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
DetailRESULTED in -- Bloody operation -- Increased -- Autonomic Nerve injury -- Local Rec.
SURGERY - TRADITIONALANT. 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
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 TECHNIQUERECENT 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
EARLY DIGNOSIS WITH
ACCURATE STAGING
CH/RT - FOR SELECTED PTS
- PROCTOSCOPY - SIGMOIDOSCOPY
- DRE - ERUS
- MRI
OUR SCENARIOLATE PRESENTATIONADVANCED TUMORSANATOMICAL DISTORTIONLACK OF NEOADJUVENTSSURGERY MORE DIFFICULTRESULTS 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.)
SYMPTOMSRECTAL BLEEDING LOWER RECT.TENESMUS
ALT. OF BOWEL HABITS UPPER.ANY G.I. SxS (dyspepsia)
RECTAL CANCER
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