|Year : 2012 | Volume
| Issue : 1 | Page : 60-61
Advances in rectal malignancy
N Subbarao, K Vidya
Department of Surgery, Andhra Medical College, Visakhapatnam, Andhra Pradesh - 530 002, India
|Date of Web Publication||21-Mar-2012|
Department of Surgery, Andhra Medical College, Visakhapatnam, Andhra Pradesh - 530 002
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Subbarao N, Vidya K. Advances in rectal malignancy. J NTR Univ Health Sci 2012;1:60-1
Advances are taking place at a rapid pace in rectal malignancy. Now there is better understanding of its natural history, the pattern of recurrence, and about the precise reporting of histopathology. It is no more a single-handed approach, and for better results, a multidisciplinary team  headed by a surgeon is needed.
| Anatomical Considerations|| |
In 2001, a National Cancer Institute panel of US has limited rectum up to 12 cm from anal verge on rigid proctoscopy. This is important, because T2 stage at the time of presentation is only 25% in colonic carcinoma, whereas nearly 50% present at that stage in carcinoma rectum. Lymph nodal spread is also nearly two-thirds in the rectum at presentation. 
| Staging|| |
Accurate staging is important for correct assessment of prognosis. Currently, out of the many systems, American Joint Committee on Cancer (AJCC) staging proposed in 2002, which further sub-divides stage III, is followed. 
TNM system as per AJCC Cancer Staging Manual, Sixth Edition, 2002
| Diagnosis|| |
Digital rectal examination continues to be the main tool to assess fixity and probability of sphincter preservation, though its accuracy is only 65%. 
Transrectal ultrasound (TRUS) is increasingly used for locoregional disease, though it tends to over stage large tumors and cannot assess stenotic lesions. With an overall accuracy of 75%,  it is ideal for mainly T1 and T2 tumors. It can even identify lymph nodes nearby.
MRI is mainly useful in conditions where TRUS cannot be done. Its accuracy in identifying local tumor and lymph nodes is almost equal to TRUS. The MRI and Rectal Cancer European Equivalence (MERCURY) study in 2007 has concluded that its T staging is similar to histopathology. 
Colonoscopy in all stages has increased the yield of synchronous tumors,  which are around 5-10%.
The earlier enthusiasm of diagnostic laparoscopy with ultrasound is now limited mainly to detect occult liver metastases. CT continues to be the gold standard. PET CT is more often used now because of its ability to pick up occult metastases. 
| Surgery|| |
There is steady progress in the surgical approach to carcinoma rectum from the earlier days of Kraske's local excision. In 1908, Miles revolutionized the treatment with his concept of "zone of upward spread" and abdominoperineal resection (APR).  Further development occurred when Heald (1978) described the "holy plane" and total mesorectal excision, which involves excision with mesorectal fascial envelope that should extend 5 cm below the lesion. 
In 1991, Jacobs and Leahy approached the tumor laparoscopically,  and now robotic surgery is the new field of interest (Weber performed the first robotic lap colectomy in 2001). 
Another development is the preservation of sphincter. Patients are offered ultra-low anterior resection now for lesions as low as 4 cm from anal verge, for which routinely APR was performed earlier. This is made possible by the National Surgical Adjuvant Breast and Bowel Project (NSABP) study (which concluded that 1-2 cm distal margin is enough) and the availability of end-to-end anastomosis staplers. 
Stress is now given also to circumferential resection margin, which is the radial width from tumor to surface. Ideally, >2 mm is required which is much more than an R0 resection. 
Lymph nodes, important in assessing prognosis, are also more carefully resected and identified (optimum number being 12). Incomplete removal and inspection leads to under-staging.
The advantage of approaching laparoscopically is established for colonic carcinoma, but some concerns like prolonged time of surgery, more positive margins, port site recurrences, urogenital dysfunction, and conversion leading to worse outcome slowed down the pace of laparoscopy in carcinoma rectum. But the advantages of good illumination, direct vision, magnification, and less tissue handling, thereby less morbidity, have renewed the interest. 
Local excision has gained attention again with the introduction of transanal endoscopic microsurgery, which is mainly useful for T1 and T2 lesions and also for those with T3 who refuse APR. 
Neoadjuvant therapy is now standard practice for T4 and N stages and consists of chemoradiation. It has resulted in more sphincters being preserved. Newer techniques like intensity-modulated (IMRT), image-guided (IGRT), stereotactic body (SBRT), and intra-operative (IORT) radiation therapy are increasingly being used.  Chemotherapy has witnessed a sea change with introduction of newer regimens and drugs. The Multi-center International Study of Oxaliplatin/5-FU/Leucovorin in Adjuvant treatment of Colon Cancer (MOSAIC) study has established the FOLFOX regimen. Monoclonal antibodies like cetuximab and bevacizumab are under evaluation..
Locally advanced and obstructed lesions
Hartmann's procedure used to be the only recourse. Now, various methods like laser, cryotherapy, and self-expandable metallic stents are offering new hope.
Now, even unresectable liver metastases are first down staged with chemotherapy and brought to resectable status. 
| Prognosis|| |
With the recent advances in all fields, particularly with early detection, the resectability rate is now 95% and the operative mortality has come down to 5%. Nearly 50% are surviving 5 years. 
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