1. Karcinom rektuma- management
Eminagić dr Đenana
KCU Sarajevo
Karcinom rektuma- management

2. Stage and Prognosis Stage 5-year Survival (%) 0,1 Tis,T1;No;Mo > 90
I T2;No;Mo
II T3-4;No;Mo
III T2;N1-3;Mo
III T3;N1-3;Mo
III T4;N1-2;Mo
IV M1 <3

3. 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.

4. 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%
4. LYMPH NODE STATUS

5. 1. MOLECULAR BIOLOGY 2. SURGERY 3. IMAGING – MRI, CT AND PET
RECENT ADVANCES
1. MOLECULAR BIOLOGY
2. SURGERY
3. IMAGING – MRI, CT AND PET
4. CHEMO/RADIOTHERAPY

6. STAGING !
DECIDES –TRANS ANAL LOCAL EXCISIONAPR .
NEOADJUVANT CH/RT

7. SURGICAL CHALLANGES
I STAGING
II USE OF CH/RT
III SURGICAL TECHNIQUE

8. RECENT ADVANCES
DRE
ERUS
MRI

9. RECENT ADVANCES ERUS
ERUS
BEST FOR NODAL STATUS

10. STAGING ERUS T STAGE ACCURACY 60 – 90% N STAGE ACCURACY 60 – 90% MRI
( NODES > 5mm)

11. 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.

12. MRI DETECTS EXTRAMURAL VENOUS INVASION (EMVI)
POOR PROGNOSIS WITHOUT CH/RT IF EMVI PRESENT

13. 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)

14. 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

15. RECTAL CANCER – RECENT ADVANCES
CAREFUL ASSESSMENT 
EARLY DIGNOSIS WITH
ACCURATE STAGING
CH/RT - FOR SELECTED PTS
- PROCTOSCOPY
- SIGMOIDOSCOPY
- DRE
- ERUS
- MRI

16. ANATOMICAL DISTORTION LACK OF NEOADJUVENTS th. SURGERY MORE DIFFICULT
OUR SCENARIO
LATE PRESENTATION
ADVANCED TUMORS
ANATOMICAL DISTORTION
LACK OF NEOADJUVENTS th.
SURGERY MORE DIFFICULT
RESULTS POORER

17. GOALS OF THERAPY FOR RECTAL CARCINOMA
DECREASE LOCAL RECURRANCE
OPTIMISE Q.O.L. AVOID COLOSTOMY

18. Incidence of local failure in RC
T1-2,No,Mo <10%
T3,No,Mo %
T1,N1,Mo %
T3-4,N1-2,Mo %

19. Local recurrence Alone or in combination with distant metastases
Nodal metastases and deep bowel wall penetration are significant risk factors for locoregional failure.
The use of TME significantly reduces this risk of local recurrence; however, local recurrence remains a concern in patients with stages II and III disease.
Local recurrence in the pelvis is complicated by involvement of contiguous organs, soft and bony tissues, and deep nodal disease.
Local recurrence in the absence of metastatic disease is more common in rectal cancer than in colon cancer.

20. Predicting risk of recurrence in RC
Surgery-related
-Low anterior resection
-Excision of the mesorectum
-Extend of lymphadenectomy
-postoperative anastomotic
leakage
-Tumor perforation
Tumor-related
-Anatomic location
-Histologic type
-Tumor grade
-Pathologic stage
-radial resection margin
-neural, venous, lymphatic invasion

21. Risk of local recurrence
Characteristics of rectal tumors predicted by MRI
High
A threatened (<1 mm) or breached resection margin or
Low tumors encroaching onto the inter‑ sphincter plane or 
with levator involvement
Moderate
Any cT3b or greater, in which the potential surgical margin is not threatened or
Any suspicious lymph node not threatening the surgical resection margin or
The presence of extramural vascular invasion
Low
cT1 or cT2 or cT3a and
No lymph node involvement

22. Purpose of Radio(chemo)therapy in Rectal Cancer
to lower local failure rates and improve survival in resectable cancers
to allow surgery in primarly inextirpable cancers
to facilitate a sphincter-preserving procedure
to cure patients without surgery: very small cancer or very high surgical risk

25. Management CaR KCUS Multidisciplinary approach DRE, endoscopy
PHD biopsy
MRI/CT /chest Xray
ERUS ?
PET CT ?
cStage III –neoadjuv. Kt/Rt „long course”
Postth. evalutation:
MRI/CT
Endoscopy

26. Onkologija KCUS
2 LinAc Siemens
2 Cobalt
HDR bracytherapy