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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
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THEME
Translating recent advances into local practice/clinical care
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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.
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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
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RECENT ADVANCES 1. MOLECULAR BIOLOGY 2. SURGERY 3. IMAGING – MRI, CT AND PET4. CHEMO/RADIOTHERAPY
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MOLECULAR BIOLOGY DNA CHIP TECH. – DNA
SEQUENCE CHECKED -- APC GENE – FAP -- MISMATCH REPAIR GENES –
HNPCCSUCH PTS.(5%) PUT ON A
SURVEILLANCE PROG. --PROPHYLACTIC SURGERY
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MOLECULAR BIOLOGY
DNA SEQUENCE OF MICROSATELLITE INSTABILITY
-- GOOD RESPONSE WITH 5 FU CHEMO.
P21 MARKER POSITIVE – RADIOSENSITIVE
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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
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SURGICAL CHALLANGES
I - STAGING
II - USE OF CH/RT
III - SURGICAL TECHNIQUE
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I - STAGING
DECIDES –TRANS ANAL LOCAL EXCISIONAPR
.
NEOADJUVANT CH/RT
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TRADITIONAL STAGING
DIGITAL RECTAL EXAMINATION
CT SCANS
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NEWER STAGING METHODS
DRE
ERUS – NODES
CT
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RECENT ADVANCES
DRE
ERUS
MRI
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RECENT ADVANCES
DRE
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RECTAL CA. RECENT ADVANCES
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RECENT ADVANCES ERUS
ERUS ------ BEST FOR NODAL STATUS
( OPERATOR DEPENDANT)
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STAGINGERUS
T STAGE ACCURACY 60 – 90% N STAGE ACCURACY 60 – 90%
MRIT STAGE ACCURACY 60 – 90% N STAGE 40 --- 80% ( NODES > 5mm)
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CHALLANGE
PICK UP NODES < 5mm (33%OF ALL
NODES)
PICK UP MICRO METS
USE OF CH/RT
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MRIHIGH RESOLUTION THIN SLICE (<1mm)
DEPTH OF EXTRAMURAL SPREAD ACCURATELY IDENTIFIED (AIDS CIRCUMFERENTIAL RESECTION MARGIN)
TRADITIONAL- PROXIMAL- DISTAL
RECENT ADV. – CIRCUMFERENTIAL RESEC. MARGINS IMP.
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MRIINDICATORS OF MALIGNANT NODAL INVOLVEMENT
L. NODES -- IRREGULAR BORDER
-- MIXED SIGNAL INTENSITY OF NODE
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MRIDETECTS EXTRAMURAL VENOUS INVASION (EMVI)
POOR PROGNOSIS WITHOUT CH/RT IF EMVI PRESENT
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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)
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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/-
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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
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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.
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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
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ANATOMY OF RECTUM
CHANGED FROM TRADIOTIONAL 22 CMS FROM ANAL VERGE TO 15 CMS
ABOVE THAT IS ALL COLON
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RECTAL CARCINOMA RECENT ADVANCES
>100 YEARS SINCE MILES DESCRIBED ABDOMINO-PERINEAL-RESECTION
>25 YEARS SINCE HEALD DESCRIBED TOTAL MESORECTAL EXCISION
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III SURGICAL TECHNIQUERECENT ADV.
TOTAL MESORECTAL EXISION
( EXICISION OF FASCIA ENVELOPING THE FAT PAD AROUND THE RECTUM.)
SAUSAGE APPEARANCE
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SURGERY – RECENT ADVANCES
LOW-ANT RESECTION – UPTO 6cms FROM ANAL VERGE≏
APR – ONLY IF SPHINCTOR FUNCTION COMPROMISED
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RECTAL CANCER – RECENT ADVANCES
CAREFUL ASSESSMENT OF SxS
EARLY DIGNOSIS WITH
ACCURATE STAGING
CH/RT - FOR SELECTED PTS
- PROCTOSCOPY - SIGMOIDOSCOPY
- DRE - ERUS
- MRI
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OUR SCENARIOLATE PRESENTATIONADVANCED TUMORSANATOMICAL DISTORTIONLACK OF NEOADJUVENTSSURGERY MORE DIFFICULTRESULTS POORER
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COMMON PROBLEMS FACING SURGERY IN AFRICA
• LACK OF GUIDELINES AND
STANDARDS
• INADEQUATE SUPERVISION
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VEINS OF SMALL & LARGE INTESTINES
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CAECAL CANCER RESECTION
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GOALS OF THERAPY FOR RECTAL CARCINOMA
DECREASE LOCAL RECURRANCE
OPTIMISE Q.O.L. AVOID COLOSTOMY
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CA. RECTAM (ESP. LOWER TUMORS)
SHOULD BE DIAGNOSED EARLY
SHOULD GIVE GOOD RESULTS WITH EARLY THERAPY
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LOCAL EXPERIENCE 31 CASES OF RECTAL CA
25 APR DONE
6 LOW ANT RESECTIONS (2 Local Rec.)
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SYMPTOMSRECTAL BLEEDING LOWER RECT.TENESMUS
ALT. OF BOWEL HABITS UPPER.ANY G.I. SxS (dyspepsia)
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RECTAL CANCER