Table Of ContentModern Management of Cancer of the Rectum
Springer-Verlag London Ud.
Riccardo A. Audisio, James G. Geraghty and
Walter E. Longo (Eds)
Modern Management of
Cancer of the Rectum
, Springer
Riccardo A. Audisio, MD
University of Liverpool
Department of Surgery, Whiston Hospital, Prescot,
Merseyside L35 5DR, UK
James G. Geraghty, MD, PhD, MCh, FRCS (Irel)
Professorial Department of Surgery, Nottingham City Hospital,
Hucknall Road, Nottingham NG5 lPB, UK
Walter E. Longo, MD, FACS, FASCRS
Saint Louis University Health Sciences Center, Department of Surgery,
SectÎon of Colon and Rectal Surgery, 3635 Vista @ Grand Blvd.,
PO Box 15250, Saint Louis, M0631 10-0250, USA
British Library Cataloguing in Publication Data
Modern management of cancer of the rectum
1. Rectum - Cancer - Treatment
1. Audisio, Riccardo A. II. Geraghty, James G. III. Longo, WaIter
616.9'9435'06
ISBN 978-1-4471-1070-5
Library of Congress Cataloging-in-Publication Data
Modern management of cancer of the rectum/Ricardo Audisio, James Geraghty, and
Walter Longo (eds.).
p.;cm.
Includes bibliographical references and index.
ISBN 978-1-4471-1070-5 ISBN 978-1-4471-0331-8 (eBook)
DOI 10.1007/978-1-4471-0331-8
1. Rectum - Cancer. 1. Audisio, Riccardo A. II. Geraghty,J.G. (James G.), 1955-
III. Longo, Walter E.
[DNLM: 1. Rectal Neoplasms - therapy. 2. Rectal Neoplasms - diagnosis. 3. Rectal
Neoplasms - surgery. WI 610 M689 2001]
RC280.R37 M632001
616.99'435 - dc21
00-053782
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ISBN 978-1-4471-1070-5
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© Springer-Verlag London 2001
Originally published by Springer-Verlag London Berlin Heidelberg in 2001
Softcover reprint of the hardcover Ist edition 2001
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Typeset by EXPO Holdings, Malaysia
28/3830-543210 Printed on acid-free paper SPIN 10682016
To Frank W. Longo, M.D.
a 31-year survivor of rectal cancer
Foreword
The management of rectal cancer has changed very considerably over the last twenty
years. New imaging techniques have improved pre-operative assessment which have
facilitated treatment planning that should lead to a reduction in local recurrence.
Radiotherapy used in appropriate cases has been shown to reduce local treatment failure
which is also potentially reducible by modern surgery based upon anatomical and patho
logical principles of locoregional spread.
Modern Management of Cancer of the Rectum covers the entire field of the disease
from the history of its development to aetiology, pathology, imaging, treatment, quality of
life and palliative care. Radiotherapy is considered in two excellent chapters devoted to
pre and post-operative treatment respectively. There are separate chapters on aspects of
surgical technique dealing with restorative and non-restorative major procedures, laparo
scopic resection and minimal access surgery. The role of chemotherapy is described with
a clear review of the present position. The important question of follow up is considered
in detail and there are chapters on the management of treatment failure both local and
distant.
Each chapter is written by acknowledged experts of world standing reputation. The
referencing is excellent supplying a bibliography including classical publications leading
on to an invaluable list of modern citations. The book is well laid out with excellent tables
and illustrations. As a statement of the present position regarding all aspects of rectal
cancer, this is an excellent book which will be an invaluable source of information,
opinion and references to all practitioners involved in management of the disease. It
shows the importance of multidisciplinary care from screening to treatment of the
primary disease and the management of failure.
R.J. Nicholls
MA, MB, M.Chair, FRCS(Eng), FRCS(Glasg)
Consultant Surgeon, St Mark's Hospital, London
Professor of Colorectal Surgery, Imperial College of Science,
Technology and Medicine, London
vii
Contents
List of Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi
1. Evolution of the Surgical Management of Rectal Cancer
A.A. Shelton and S.M. Goldberg. . . . . . . . . . . . . . . . . . . . . . . . . . .. 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1
Perineal Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1
Transanal Excision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2
Transsacral Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 2
Abdominosacral Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
Abdominoperineal Resection. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
Abdominoanal Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
Anterior Resection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
The Present. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 5
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2. Pathology and Staging
K.R Birbeck, A. Cairns and P. Quirke . . . . . . . . . . . . . . . . . . . . . . . .. 7
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 7
Resection Specimen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 7
Total Mesorectal Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 7
Histological Features of Rectal Cancer and Their Prognostic Significance . . .. 8
Histological Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 8
Tumour Differentiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9
Invasive Growth Pattern and Peritumoral. . . . . . . . . . . . . . . . . . ., 9
Lymphocytic Infiltration . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9
Completeness of Excision. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9
Serosal Involvement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9
Lymph Node Metastases. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9
Extramural Vascular Invasion. . . . . . . . . . . . . . . . . . . . . . . . . .. 9
Surgical Resection Margins and Local Recurrence . . . . . . . . . . . . . . . .. 10
Local Recurrence ................................. , 10
Longitudinal Resection Margin. . . . . . . . . . . . . . . . . . . . . . . . .. 10
Circumferential Resection Margin. . . . . . . . . . . . . . . . . . . . . . .. 10
Staging of Rectal Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11
Staging Systems Currently in Existence . . . . . . . . . . . . . . . . . . . .. 11
Dukes' Staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 12
TNM Staging System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 12
Dukes' Staging Versus TNM. . . . . . . . . . . . . . . . . . . . . . . . . . .. 14
Role of Pathology in Assessing the Quality of Rectal Cancer Surgery . . . . . .. 14
Quality of Preoperative Imaging and Pathology Reporting, and the
Use of Reporting Proformas . . . . . . . . . . . . . . . . . . . . . . . . .. 16
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 18
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ix
x Contents
3. Genetics, Screening and Chemoprevention
J. Puig-La Calle and J.G. Guillem . . . . . . . . . . . . . . . . . . . . . . . . . .. 21
Introduction .................................... " 21
Genetics ...................................... . 21
Tumor Suppressor Genes . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 22
MMR Genes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 24
Oncogenes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 24
Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 25
Average Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26
Moderate Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 26
Increased Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26
Chemoprevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 28
NSAIDs ..................................... " 28
Calcium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 29
Antioxidant Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 30
Circumin ..................................... . 30
Perillyl Alcohol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Oltipraz ...................................... . 30
Selenium ..................................... . 30
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4. The Role of Imaging in the Diagnosis and Staging of Primary and
Recurrent Rectal Cancer
S. Sironi, C. Ferrero, L. Gianolli, C. Landoni, A. Del Maschio, F. Fazio and
A.P. Zbar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 33
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 33
Diagnostic Imaging in the Staging of Primary Rectal Cancer . . . . . . . . . .. 33
Clinical Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 33
Contrast Examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 34
Endorectal Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 35
Computed Tomography. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 36
Magnetic Resonance Imaging. . . . . . . . . . . . . . . . . . . . . . . . . .. 38
Positron Emission Tomography . . . . . . . . . . . . . . . . . . . . . . . .. 41
Radioimmunoscintigraphy . . . . . . . . . . . . . . . . . . . . . . . . . . " 43
Diagnostic Imaging in the Diagnosis and Staging of Recurrent Rectal
Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 43
Ultrasound Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 44
Computed Tomography. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 44
Magnetic Resonance Imaging. . . . . . . . . . . . . . . . . . . . . . . . . .. 44
Positron Emission Tomography and Immunoscintigraphy . . . . . . . . .. 45
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 45
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5. Neo-adjuvant Therapy
B.D. Minsky, C.H. Kohne and C. Greco . . . . . . . . . . . . . . . . . . . 51
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 51
Preoperative Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 51
Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 51
Predictors of Response to Preoperative Therapy . . . . . . . . . . . . . . .. 51
Results ofpreoperative Therapy . . . . . . . . . . . . . . . . . . . . . . . .. 52
Intensive Short Course Preoperative Radiation . . . . . . . . . . . . . . . " 53
Sphincter Preservation with Preoperative Radiation . . . . . . . . . . . . .. 54
Is Adjuvant Therapy Necessary in Patients Undergoing a Total Mesorectal
Resection? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 57
Investigational Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 58
Altered Radiation Fractionation Schemes. . . . . . . . . . . . . . . . . . .. 58
New Chemotherapeutic Agents. . . . .................... " 58
Contents xi
Summary .. 58
References. . . . 59
6. Restorative Procedures
J. W. Milsom and H.J. Cho. . . . . . . . . . . . . . . . . . . 63
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 63
Relevant Anatomy of the Rectum and Perirectal Tissues . 63
Surgical Options in Restorative Procedures . . . . 65
Preoperative Evaluation and Patient Preparation . . . 66
Oncologic Principles in Rectal Surgery. . . . . . . . . . . . 67
Extent of Resection . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Radial Margin and Complete Mesorectal Resection . . . . . . . . 69
Final Preparations for Restorative Procedures . . 70
Technical Details . . . . . . . . . . . . . . . 71
Proctosigmoidectomy. . . . . . . . . . . . . . 71
Low Anterior Resection . . . . . . . . . . . . . . 73
Special Consideration: Coloanal Anastomosis. . . . . . . . . . . . . . . 74
Special Consideration: Colonic Reservoir (I-Pouch) ............ . 75
Outcome After Low Anterior Resection Versus Abdominoperineal resection. . 75
Laparoscopic Rectal Cancer Surgery . . . . . . . . 76
Conclusions. . . . . . . . . 76
References. . . . . . . . . . . . . . . . . . 76
7. Abdominoperineal Resection
D.]. Schoetz and P.L. Roberts. . . . . . . . . . . . . . . . 79
Introduction . . . . . . . . . . . . . . . . . . . . . . . . 79
Selection Factors for Abdominoperineal Resection. . . 79
Tumor-Related Factors . . . . . . . . . . 80
Patient Factors . . . . . . . . . 80
Intraoperative Considerations 80
Preoperative Preparation . . . . . 80
Operative Technique. . . . . . . . . . . 81
Intraoperative and Postoperative Complications 85
Bleeding ...................... . 85
Unhealed Perineal Wound. . . . . . . . . . . 85
Inadvertent Perforation of the Rectum ..... 86
Perineal Hernia . . . . . . . . . . . . . 86
Urogenital Complications. 86
Urethral Injury. . . . . . . 87
Colostomy Complications. 87
Other complaints. 87
Concluding Remarks. . . . .. ..... . 87
References. . . . . . . . . . . . . . . . . . . 87
8. Total Mesorectal Excision with Autonomic Nerve Preservation: "Optimized
Surgery"
N.J. Kafka and W.E. Enker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Rationale of Total Mesorectal Excision and its Relationship to the Anatomy
of Spread of Rectal Cancer. . . . . . . . . . . . . . . . . . . . . . 89
Technique of Total Mesorectal Excision with Autonomic Nerve
Preservation . . . . . . . . . . . . . . . . . . 91
Outcome of Total Mesorectal Excision . . . . . . . . . . . . . . . 93
Morbidity of Total Mesorectal Excision . . . . . . . . . . . . . . 96
Sexual and Urinary Function After Total Mesorectal Excision . . 96
Extended Lateral Lymphadenectomy. . . . 97
Role of the Colonic J- Pouch. . . . . . . . . . . . . . . . . . . . . 97
xii Modern Management of Cancer of the Rectum
Role of Total Mesorectal Excision in Upper Rectal Cancer . . . . . . . . . . . .. 98
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 98
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 98
9. Laparoscopic Resections for Large Bowel Malignancy:
Laparoscopic Colectomy
D. Rosenfeld and R. W. Beart. . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Laparoscopic Colectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Physiologic Aspects of Laparoscopic Surgery. . . . . . . . . . . . . . . . . . 102
Laparoscopic Surgery for Benign Colonic Disease . . . . . . . . . . . . . . . 103
Laparoscopic Surgery for Malignant Colonic Disease . . . . . . . . . . . . . 106
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Laparoscopic Rectal Cancer Surgery
H.]. Cho and]. w. Milsom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Laparoscopic Surgery for Rectal Carcinoma. . . . . . . . . . . . . . . . . . . 108
Procedures of Laparoscopic Proctosigmoidectomy. . . . . . . . . . . . . . . 109
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
10. Minimal Access Surgery for Rectal Cancer
v.w. Fazio and F. Lopez-Kostner. . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Preoperative Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Tumor Invasion .................................. 115
Patient Selection for Local Treatment. . . . . . . . . . . . . . . . . . . . . . . . . 116
Size ......................................... 116
Exophytic Lesions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Mobile Lesions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Depth ........................................ 117
Favorable Histology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Margin of Excision ................................. 118
Therapeutic Modalities for Local Treatment. . . . . . . . . . . . . . . . . . . . . 118
Local Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Contact Radiotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Electrocoagulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Adjuvant Therapy after Local Treatment. . . . . . . . . . . . . . . . . . . . . . . 122
Salvage Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Palliative Local Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
11. Postoperative Adjuvant Combined Modality Therapy
B.D. Minsky, C.H. Kohne and C. Greco . . . . . . . . . . . . . . . . . . . . . . . . 127
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Postoperative Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Rationale of Postoperative Combined Modality Therapy . . . . . . . . . . . 127
Results of Postoperative Therapy. . . . . . . . . . . . . . . . . . . . . . . . . 127
Functional Results with Postoperative Therapy. . . . . . . . . . . . . . . . . 129
Decreasing the Toxicity of Pelvic Radiation Therapy . . . . . . . . . . . . . . . . 129
Is Adjuvant Therapy Necessary after Total Mesorectal Excision? . . . . . . . . . 130
Investigational Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Altered Radiation Fractionation Schemes. . . . . . . . . . . . . . . . . . . . 131
New Chemotherapeutic Agents. . . . . . . . . . . . . . . . . . . . . . . . . . 131
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
