Carcinoma Rectum-Standard Treatment Guidelines

Colorectal cancer is common in developed countries such as the USA and Japan, and lower in frequency in developing countries like Africa and Asia. The incidence is slightly higher in men than women, and is highest in African American men. Colon and rectal cancer is the third most common cancer in both women and men in the US. Incidence rates range from 25.3 per 100,000 in Eastern Europe to 45.8 per 100,000 in Australia. The crude incidence of rectal cancer in the European Union is ∼35% of the total colorectal cancer incidence, i.e. 15–25/100 000 per year. The mortality is 4–10/100 000 per year with lower figures in women and the higher ones for men.

Following are the major recommendations of the guidelines issued by the ministry of health and family welfare on the topic of Carcinoma Rectum

Case definition

A patient with bleeding per rectum and/or tenesmus with or without change in bowel habit who on rectal examination/proctoscopy or sigmoidoscopy is found to have a mass which on biopsy is a cancer.

INCIDENCE OF THE CONDITION IN OUR COUNTRY

The incidence rates of colorectal cancers in India are low––about 2 to 8 per 100,000. The incidence of rectal cancer in India has been constant over the past few years. Hospital- and population-based data also show that the incidence rates for rectal cancer are higher than colon cancer in all parts of India. However, a high incidence of these cancers is seen in the urban population. Data is limited.

DIFFERENTIAL DIAGNOSIS

a.Haemorrhoids
b.Ulcerative colitis
c.Solitary rectal ulcer
d.Rectal prolapse
e.Radiation proctitis

PREVENTION AND COUNSELING

No specific intervention for primary prevention is known. However, the following dietary and lifestyle changes may play a role in prevention: physical activity, folate, fruits and vegetables, calcium, vitamin D, high fiber diet, weight reduction, avoidance of red and processed meat, stopping smoking.

For secondary prevention, 2 broad groups have been identified

1. High risk individuals (those with a history of adenomas or cancers, family history or genetic syndrome, or inflammatory bowel disease)


2. Average risk individuals (all others)

Among the high risk groups: a colonoscopy 3 years after removal of an adenoma/polyp and if this is normal then after 5 years.

Previous Colorectal Cancer and Family History of Colorectal Cancer - The first surveillance colonoscopy at 1 year following cancer resection - If normal, the interval can be increased to 3 years. However, if additional disease is noted on postoperative colonoscopy, more frequent examinations are warranted.

Patients with a family history of colorectal cancer or adenoma, including affected first-degree relatives - should undergo screening with colonoscopy beginning at 40 years of age or earlier, when they are 10 years younger than their affected family member(s) were at age of initial diagnosis.

Patients with long-standing IBD - In patients with pancolitis surveillance colonoscopy should begin after 8 years of symptoms. Surveillance can start later in those patients with left-sided colitis, generally after 12 to 15 years of disease. Colonoscopy should be performed every 1 to 2 years.

Patients from FAP families who have not been tested for an APC mutation should begin routine screening at puberty with annual flexible sigmoidoscopy. If polyps are not identified by age 40 years, then the frequency of examinations can be decreased to every 3 years. On the other hand, individuals who express the phenotype require upper endoscopy to examine the periampullary region. Patients with a known genetic mutation or members of an FAP kindred should undergo colectomy when they develop polyps, because stage-specific survival of colorectal cancer appears to be the same for polyposis patients as for those who have sporadic bowel cancers.

Colorectal screening for patients with HNPCC - endoscopy should thus be performed every 1 to 2 years. For individuals with known mutations or family history consistent with the Amsterdam Criteria, screening should begin at 21 years of age. Screening for extracolonic disease should be performed as well, including urine cytology, pelvic ultrasound, and periodic endometrial biopsy.

a. Average risk individuals

Combination of fecal occult blood test (FOBT) with flexible sigmoidoscopy at 5-year intervals after the age of 50 years

Optimal Diagnostic Criteria Investigations, Treatment And Referral Criteria

Diagnosis

History: Rectal bleeding is the commonest symptom. Other symptoms include tenesmus, altered bowel habits and mucus discharge, weight loss and loss of appetite.

Diagnosis: A digital rectal examination, proctoscopy and/or sigmoidoscopy with biopsy for histopathological examination. Tumours with distal extension to ≤15 cm (as measured by rigid sigmoidoscopy) from the anal margin are termed rectal tumours, while more proximal ones are called colonic.

Staging: Complete blood count, liver and renal function tests and a full colonoscopy to evaluate for synchronous lesions (present in up to 5% of colorectal cancers), rigid proctoscopy (to define the level of the tumour), abdominal CT and chest X-ray to evaluate for metastases, and baseline serum carcinoembryonic antigen (CEA) level. A PET-CT may be done to evaluate suspected extrahepatic metastasis. The depth of penetration can be estimated by digital rectal exam (superficial tumours are mobile, whereas fixed lesions have deeper infiltration), and endorectal ultrasound (ERUS) or MRI with endorectal coil can provide a good assessment of the extent of invasion of the bowel wall. ERUS for early tumours (T1–T2) or rectal MRI for all tumours, including the earliest ones, is usually suggested prior to planning treatment and extent of surgery.

Histopathological examination of the surgical specimen should assess the proximal, distal and circumferential margins and regional lymph nodes (at least 12 lymph nodes should be examined). Also, vascular and neural invasion should be assessed.

Treatment

Localized disease

Low anterior resection or abdominlperineal resection as required

Advanced disease

Locally advanced disease may require neoadjuvant therapy in an attempt to downstage the tumour and attempt sphincter preservation. Preoperative radiotherapy (short course or long course) may be used.

Situation 1

At Secondary Hospital/Non-Metro situation: Optimal Standards of Treatment in Situations where technology and resources are limited.

Clinical diagnosis:

In a patient who presents with bleeding per rectum, a thorough history and clinical examination should be undertaken especially in the elderly. A history of tenesmus, change in bowel habits, anorexia and weight loss should be asked as also a family history of colorectal cancer. Next, a rectal examination/proctoscopy and if necessary a sigmoidoscopic examination should be done and if found to have a mass, a punch biopsy should be done. If on pathology this shows a malignancy then it confirms the diagnosis.

 

Investigations

Haemogram, liver function test, CEA levels, sigmoidoscopy, chest X-ray, CT abdomen and pelvis.

Treatment

All patients who have confirmed rectal cancer should have a surgical resection (anterior resection or abdomino-perineal resection). Neoadjuvant therapy if required for sphincter preservation may be used.

Standard Operating procedure

All investigations can be done as outpatient/day care procedures. However, if the general condition of patient is not good, hospitalization may be needed.

All surgical procedures require hospitalization.

Referral criteria

All patients with borderline resectability or where a low/ultralow anterior resection is required, or those with metastatic liver disease may benefit by referral to GI Surgery centres for complete evaluation and definitive management.

Situation 2

At Super Specialty Facility in Metro location where higher-end technology is available

Clinical Diagnosis:

Patients with rectal bleeding along with a suggestive history should be evaluated for colorectal cancer. All patients referred as cases of rectal cancer should have their diagnosis confirmed.

Investigations:

Review of all previous investigation including blocks and slides followed by colonoscopy to rule out synchronous lesions. Haemogram, liver function test, CEA levels, Sigmoidoscopy, chest X-ray, CT abdomen, MRI pelvis/ERUS, PET-CT.

Treatment:

Operable/potentially operable

Anterior resection or abdominoperineal resection

Advanced disease

If both primary and metastatic tumours are considered resectable, multidisciplinary teams should consider initial systemic treatment followed by surgery. If not resectable, consider palliative chemotherapy along with a palliative resection/diverting colostomy.

Standard Operating procedure

All investigations can be done as outpatient/day care procedures. However, if the general condition of patient is not good, hospitalization may be needed.

All surgical procedures require hospitalization.

Guidelines by The Ministry of Health and Family Welfare :

Ameet Kumar
Peush Sahni
Department of GI Surgery and Liver Transplantation
All India Institute of Medical Sciences
New Delhi