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rectal carcinoma

Pathology: 1) adenocarcinoma 2) squamous cell carcinoma 3) retroperitneal location & lack of serosa (peritoneal covering) result in high local recurrence [4] Genetics: - implicated genes CCNDBP1 Special laboratory: - colonoscopy [11] - biopsy of rectal mass to confirm rectal carcinoma - evaluate for colonic lesions prior to excision of rectal carcinoma Radiology: - MRI sensitive for predicting clear margins after surgical resection [3] - endorectal ultrasonograpy Staging: TNM staging - stage 1: T1/T2, N0, M0 - stage 2A: T3, N0, M0 - stage 2B: T4, N0, M0 - stage 3A: T1/T2, N1, M0 - stage 3B: T3/T4, N1, M0 - stage 3C: T any, N2, M0 - stage 4: T any, N any, M1 also see staging of colorectal carcinoma Management: 1) surgical resection is 1st-line therapy 2) stage 1 rectal cancer* [4] a) surgical resection alone - total mesorectal excision is superior to local excision for stage 1 rectal carcinoma - transanal total mesorectal excision comparable to open or laparoscopic total mesorectal excision [9] - examination of mesorectal tissue & lymph nodes to confirm stage 1 rectal carcinoma b) reassess tumor stage as indicated [4,5] 2) all rectal cancers beyond stage 1 [4] a) neoadjuvant chemotherapy with 5-fluorouracil or capecitabine b) surgery with post-operative radiation & adjuvant chemotherapy [4] c) neoadjuvant chemoradiation therapy followed by surgery [10] 3) deeply invasive of node-positive rectal cancer a) pelvic pre-operative irradiation (30-50 Gy) 1] reduces recurrence at 1 year 2] does not increase 5 year survival b) total neoadjuvant therapy: chemoradiation & chemotherapy administered prior to surgery [6,8] c) adjuvant chemotherapy with 5-fluorouracil 4) chemoradiation with a watch-and-wait strategy for patients with locally advanced rectal cancer (T2,T3, including node-positive) who sustain a clinical complete response results in low 3-year recurrence [4,8] 5) liver metastases: resection if metastases restricted to a single lobe of the liver with or without adjuvant chemotherapy [4] 6) prognosis: a) rectal carcinoma tends to have worse prognosis than colon cancer b) 45% 5 year survival c) 25% 10 year survival * see staging. T2,N0 is stage 1

Related

adenocarcinoma of the colon &/or rectum rectum squamous cell carcinoma (SCC) of the anus

General

gastrointestinal (GI) cancer anorectal disease carcinoma

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 670-671
  2. Journal Watch 21(23):187, 2001 Colorectal Cancer Collaborative Group. Adjuvant radiotherapy for rectal cancer: a systematic overview of 8,507 patients from 22 randomised trials. Lancet 358:1291, 2001 PMID: 11684209 - Minsky BD Adjuvant radiation therapy for rectal cancer: is there finally an answer? Lancet 358:1285, 2001 PMID: 11684204
  3. MERCURY Study Group. Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: Prospecitve observational study. BMJ 2006, 333:779 PMID: 16984925 - Finlay I. Preoperative staging for rectal cancer. BMJ 2006, 333:766 PMID: 17038713
  4. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  5. Garcia-Aguilar J, Holt A. Optimal management of small rectal cancers: TAE, TEM, or TME? Surg Oncol Clin N Am. 2010 Oct;19(4):743-60 PMID: 20883951
  6. Cercek A, Roxburgh CSD, Strombom P et al Adoption of Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer. JAMA Oncol. Published online March 22, 2018 PMID: 29566109 https://jamanetwork.com/journals/jamaoncology/fullarticle/2675916 - Hong TS, Ryan DP. Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer - The New Standard of Care? JAMA Oncol. Published online March 22, 2018 PMID: 29566113 https://jamanetwork.com/journals/jamaoncology/fullarticle/2675911
  7. Allegra CJ, Yothers G, O'Connell MJ Neoadjuvant 5-FU or Capecitabine Plus Radiation With or Without Oxaliplatin in Rectal Cancer Patients: A Phase III Randomized Clinical Trial. J Natl Cancer Inst. 2015 Sep 14;107(11). PMID: 26374429 Free PMC Article
  8. Fernandez LM et al. Conditional recurrence-free survival of clinical complete responders managed by watch and wait after neoadjuvant chemoradiotherapy for rectal cancer in the International Watch & Wait Database: A retrospective, international, multicentre registry study. Lancet Oncol 2021 Jan; 22:43 PMID: 33316218 https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(20)30557-X/fulltext
  9. Caycedo-Marulanda A, Lee L, Chadi SA et al Association of Transanal Total Mesorectal Excision With Local Recurrence of Rectal Cancer. JAMA Netw Open. 2021;4(2):e2036330 PMID: 33533932 Free article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2775826
  10. Nassoiy S, Christopher W, Marcus R et al Treatment Utilization and Outcomes for Locally Advanced Rectal Cancer in Older Patients. JAMA Surg. 2022;157(11):e224456. PMID: 36169964 PMCID: PMC9520439 (available on 2023-09-28) https://jamanetwork.com/journals/jamasurgery/fullarticle/2796756
  11. NEJM Knowledge+ Gastroenterology
  12. Rectal Cancer (PDQ): Treatment http://www.nci.nih.gov/cancertopics/pdq/treatment/rectal/HealthProfessional