RECTUM CANCER TREATMENT PATIENT GUIDE
Surgical removal of the cancer tissues is the most frequently applied treatment method in rectum cancer. Surgery can also be performed in case of a tumor that causes intestinal obstruction or if the cancer has spread to other parts of the body.
There are different surgery types and surgery techniques. Your physician will decide the technique based on the stage of your cancer, location of the tumor in the rectum and your general health condition.
Whole tissue removed by the surgeon during the operation is sent to pathology. Tests evaluate whether there is cancerous cells on the edges of this part (surgical boundaries) and its adjacent region. If there are cancer cells on the surgical boundaries, this means that cancerous tissues are not or could not have been completely removed during the surgery. Although this is not a common situation, second surgery or radiotherapy may be needed.
Main feature separating rectum from colon is the difference in their localization. In addition, biological behavior of rectum cancer is also different. Therefore, different treatment options are used in rectum cancer compared to colon cancer. The most important criteria for operation selection is in which portion of the rectum (upper, middle, lower rectum) is the tumor located at. Another important criteria is, especially in lower rectum cancers, the stage of the tumor. Therefore, clinical staging, performed with imaging techniques prior to the surgery, is of significant importance for the planning of proper treatment.
OPERATION TECHNIQUES IN RECTUM CANCER
1) LOCAL EXCISION IN RECTUM CANCER
Rectum cancers that are limited to the inner wall of rectum and not spread to other locations are defined as Stage I. Generally, cancers that develop inside a polyp are in this stage. Some selected small Stage I cancers and pre-cancer polyps can be removed via anal route using transanal endoscopic microsurgery methods without entering into the abdominal cavity. This procedure is the removal of the cancer and a small amount of healthy tissue surrounding it. Surgeon performs this procedure by inserting an endoscopy device that has a light source and a video camera at its tip into the rectum. Tumors that are suitable and located up to 15 cm inside the anus can be removed without an incision on the abdomen by using endoscopic hand tools. If the pathological evaluation of the surgically removed tissue also confirms that the disease is at Stage I, it won?t be necessary to add chemotherapy and/or radiotherapy to the treatment.
Local excision method with TAMIS technique in early stage rectum cancer
In cases where cancer is located very close to anus, surgeon may not need to use an endoscope. Surgeon can remove the cancerous tissue directly from the anus and this method is called transanal resection.
Giant villous polyp that causes bleeding in the rectum that has not yet developed cancer
In the pathological evaluation of the surgically removed tissue, it may be seen that cancer is in a more advanced stage or that cancerous cells remained on the boundary. In that case, surgical methods that use abdominal route should be applied.
2) TOTAL MESORECTAL EXCISION IN RECTUM CANCER
Surgery applied for the removal of a cancer in the rectum is the total mesorectal excision (TME) that is performed laparoscopically or by open method from the abdomen. Surgeon removes whole or part of the rectum together with some healthy tissues depending on the size and localization of the cancer. Fatty tissue that surrounds the rectum with blood vessels and lymph nodes, which is called mesorectum, must also be removed; cancer cells may be spread into the mesorectum. Complete removal of mesorectum and having surgical boundaries distant from cancer significantly decreases the risk of leaving cancer cells behind. TME surgery can be successfully performed with laparoscopic method. All tissues that are inside the area designated with black dots are removed during TME operation.
TOTAL MESORECTAL SURGERY TYPES IN RECTUM CANCER
Your surgeon determines the best operation for you by evaluating the localization of the cancer within the rectum, tumor size and its proximity to the anus.
1) LOWER ANTERIOR RESECTION
This method is used for cancers that situated upper, middle and sometimes lower part of the rectum. Whole or majority of the rectum is removed. 5 cm of mesorectum portion beneath the lower boundary of the tumor is also included in the removed region. A ligation procedure called anastomosis is applied between colon and remaining rectum, or if the rectum is completely removed, between colon and anus. A temporary stoma (generally ileostomi) is opened for protection purposes during this operation. If stoma is opened, intestine is placed back inside the abdomen with a stoma closing surgery after a few months later.
In rectum cancer, the tumor with completely obstructed lumen can be seen on the specimen removed via laparoscopic surgery specimen lumen
2) ABDOMINOPRINEAL RESECTION (APR)
This surgery is generally preferred for the treatment of cancers that are located in lower rectum, close to anus. In this method, which is applied for patients who need removal of anus together with the rectum in order for cancer to be completely removed, patients live with a permanent stoma (generally colostomy) for the rest of their lives.
In addition to the surgical incision on abdominal wall, there is a second incision site where anus is removed.
Adenocarcinoma case with lower rectum location, before APR surgery
Adenocarcinoma case
APR surgery in lower rectum cancer
APR surgery
RADIOTHERAPY AND CHEMOTHERAPY IN RECTUM CANCER
Post-op local relapse risk is higher due to the absence of outermost layer on the rectum wall unlike colon, higher lymphatic circulation and being located in the anatomically narrow bone structures. Chemotherapy and/or radiotherapy applied prior to the surgery is called neo-adjuvant treatment. It is aimed to decrease tumor size and invasion depth and increase the removability of the tumor with the application of neo-adjuvant treatment to local advanced stage (T3, T4 or patients with lymph node metastasis) rectum tumor in selected patients; this way, local relapse risk is tried to be minimized. An important indication of pre-op chemo-radiotherapy is the lower rectum tumors that are advanced up to anus muscles. After such an APR surgery, the patient will have to live with colostomy for life, but anus can be protected in some patients by reducing the size of the tumor through pre-op chemo-radiotherapy.
Rectum cancer may be spread to adjacent organs when it is first diagnosed. In that case, larger scale surgeries called pelvic exenteration, where uterus, tubes, ovaries, vagina and even the bladder are removed together with the rectum, may be required after the neo-adjuvant treatment.
Radiotherapy is a frequently used treatment method in rectum cancer treatment. In this method, cancer cells are destroyed by using high energy x rays. Radiotherapy is often applied together with chemotherapy drugs. Chemotherapy directly destroys cancer cells as well as increases the effectiveness of radiotherapy. And it is commonly used to destroy cancer cells that remain in the operation region after the rectum cancer surgery. Post-op chemotherapy is used to destroy cancer cells that have potential to spread and the microscopic tumor focals that cannot be visually seen, and to reduce the relapse risk of the cancer.
Although patients don?t feel anything during radiotherapy, effects of radiation gradually increase in time. Most of the patients may feel prostration during the treatment. Softened stool or diarrhea may also occur. Patient may frequently need to urinate. Some patients may have alopecia in genital region or rash on the skin. In case radiotherapy and chemotherapy are applied together, patients may suffer from severe diarrhea. Rarely, hospitalization or even surgical intervention may be necessary due to an obstruction in small intestinal level.
TREATMENT IN RELAPSED RECTUM CANCER
Cancer may relapse during the post surgery period. This relapse may occur in the region of the first cancer (local relapse) as well as in distant organs such as liver or lungs. Relapses are generally seen in second or third years after the surgery.
LOCAL RELAPSE AFTER RECTUM CANCER OPERATION
If the relapsed cancer is local, meaning that in the region where rectum is removed, it should be surgically removed for suitable cases. The operation performed for this is generally a larger scale surgery. In that case, radiotherapy application may be preferred during the operation (intraoperative radiotherapy).
Rectum cancer may be spread to adjacent organs. In that case, larger scale surgeries called pelvic exenteration, where uterus, tubes, ovaries, vagina and even the bladder are removed together with the rectum, may be required. Chemotherapy may be administered after the surgery and radiotherapy can be added if not previously used.
TREATMENT OF RECTUM CANCER WITH DISTANT METASTASIS
Metastasis is defined as spread of cancer cells to other organs. Tumor is spread to distant organs such as liver or lungs in Stage IV, terminal stage rectum cancers. In these patients, it is possible to extend survival by using different treatment methods. Treatment options vary depending on the level of spread of the disease.
If it is possible to completely remove cancerous tissues, for example in the presence of several metastasis in the liver or lungs, preferred treatment approaches are;
Chemotherapy is applied (in some cases accompanied by radiotherapy) following the surgical removal of tumor in the rectum and distant organ metastases.
Chemotherapy, then surgical removal of the tumor and distant organ metastases, and subsequent chemo-radiotherapy administration.
Chemotherapy, then chemo-radiotherapy, and then surgical removal of the tumor and distant organ metastases. Then treatment can be continued with chemotherapy again.
Chemo-radiotherapy, and then surgical removal of the tumor and distant organ metastases. Then treatment can be continued with chemotherapy again.
In some patients where tumor spread is only limited to the liver, surgical removal of the cancerous region in the liver (liver resection) can provide significant benefit for the treatment of the patient. This operation can be simultaneously applied with rectum cancer operation or in a gradual manner.
If the distant organ metastasis is only in the liver, administration of chemotherapy directly into the vessel going into the liver can be a treatment option for patients who are not suitable for surgical treatment. This method provides a more effective treatment than normal application methods of chemotherapy.
If it is not possible to surgically remove the liver tumors, tumor cells can be attempted to be destroyed by using ablation or embolization methods. In some cases, surgery and ablation methods can be used in combination.
Primary treatment in lung metastasis is chemotherapy, however, lung metastases must be evaluated to see whether they can be removed surgically. Removal of the lung part where tumor located can be beneficial for the patients where the metastasis is limited in number and extent.
If the cancer is in a widespread level and cannot be surgically removed, treatment options are evaluated depending on whether the tumor causes an obstruction in the intestines. If such condition exists, immediate surgical intervention is required. If not, surgery is not considered at all and treatment in maintained with chemotherapy or target-specific drugs.
These treatment approaches to rectum cancer that are local or distant relapses can help patients to live longer, and in some cases, disease can be completely cured.