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Transcript Document 7364608
PROFESSOR PANKAJ G. JANI. M.MED., FRCS.
DEPT. OF SURGERY, UNIVERSITY OF NAIROBI. KENYATTA
NATIONAL HOSPITAL
CHAIR. 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 PET
4. CHEMO/RADIOTHERAPY
MOLECULAR BIOLOGY
DNA CHIP TECH. – DNA SEQUENCE
CHECKED
-- APC GENE – FAP
-- MISMATCH REPAIR GENES – HNPCC
SUCH 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)
STAGING
ERUS
T STAGE ACCURACY 60 – 90%
N STAGE ACCURACY 60 – 90%
MRI
T 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
MRI
HIGH RESOLUTION THIN SLICE (<1mm)
DEPTH OF EXTRAMURAL SPREAD ACCURATELY
IDENTIFIED (AIDS CIRCUMFERENTIAL RESECTION
MARGIN)
TRADITIONAL
- PROXIMAL
- DISTAL
RECENT ADV. – CIRCUMFERENTIAL RESEC. MARGINS
IMP.
MRI
INDICATORS OF MALIGNANT
NODAL INVOLVEMENT
L. NODES
-- IRREGULAR BORDER
-- MIXED SIGNAL INTENSITY OF
NODE
MRI
DETECTS 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)
CHEMOTHERAPY
INJ KYTRIL 3mg
2,250/ INJ DEXAMETHAZONE 8mg
385/ INJ FLUOUROURACIL 5500mg
INJ OXALIPLATIN 200mg
187,600/ INJ LEUCOVORIN 100mg
INJ AVASTIN 400mg
Ksh
Ksh
Ksh 12,053/Ksh
Ksh 1,809/Ksh 213,806/Kshs 417903/-
RADIOTHERAPY
EUROPEAN APPROACH
(25G/5CYCLES)
SHORT COURSE – LOW
DOSE – IMMEDIATE
SURGERY
NO CHANGE IN PATH
STAGING
LOWER COST
BETTER COMPLIANCE
DOSE EQUIVALENT TO
30-33G
EXPECT 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
Detail
RESULTED in
-- Bloody operation
-- Increased -- Autonomic Nerve injury
-- Local Rec.
SURGERY - TRADITIONAL
ANT. 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 TECHNIQUE
RECENT 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 SCENARIO
LATE PRESENTATION
ADVANCED TUMORS
ANATOMICAL DISTORTION
LACK OF NEOADJUVENTS
SURGERY MORE DIFFICULT
RESULTS POORER
COMMON PROBLEMS FACING
SURGERY IN AFRICA
• LACK OF GUIDELINES
AND STANDARDS
• INADEQUATE
SUPERVISION
THANK YOU
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.)
SYMPTOMS
RECTAL BLEEDING
LOWER RECT.
TENESMUS
ALT. OF BOWEL HABITS
UPPER.
ANY G.I. SxS (dyspepsia)
RECTAL CANCER