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ECR 2019 / C-1683
Magna Cum Laude
Minimally invasive surgery for early rectal cancer - what the radiologist needs to know
Congress: ECR 2019
Poster No.: C-1683
Type: Educational Exhibit
Keywords: Cancer, Surgery, Staging, Ultrasound, MR, Colon, Outcomes
Authors: K. A. Watt1, T. Tolley2, M. J. Strugnell2, D. Shetty2; 1Plymouth/UK, 2Truro/UK
DOI:10.26044/ecr2019/C-1683

Background

Colorectal cancer is currently the third most common cancer and the fourth most common cause of cancer-related deaths (1). There are approximately 41,000 new cases of colorectal cancer in the United Kingdom every year (2013-2015). The National Cancer Institute’s database quotes the five-year relative survival rate for stage I rectal cancer to be 88%, dropping to 81% for stage IIa disease and 58% for stage IIIc disease.

 

 

Trends toward earlier diagnosis due to screening

 

Bowel screening programmes for colorectal cancer are in place throughout the world. In England, bowel screening is currently offered to adults from 60 to 74 years of age using the faecal occult blood test (FOBt) (2), soon to be replaced by the introduction of the faecal immunochemical test (FIT). High-risk groups excluded from the screening programme include those with a history of colorectal cancer, adenomas, inflammatory bowel disease, a strong family history or pre-disposing hereditary conditions.  Patients with an abnormal FOBt result are offered either an optical colonoscopy or CT colonography. Any suspicious lesion is biopsied, and then referred urgently for management if the biopsy confirms colorectal cancer.  Those with a normal screening test are then offered another faecal occult blood test every two years until they reach the maximum age for the screening cohort. Beyond this age, patients may be screened every 2 years upon their own request.

 

 

It is therefore perhaps unsurprising that although the incidence of colorectal cancer is increasing in the UK, the mortality is declining (3). This is almost certainly due to a combination of factors, including the national bowel screening programme, the increasing sensitivity of pre-operative imaging, the development of neoadjuvant chemotherapy, and improving surgical techniques.

 

 

Current T-Staging of Colorectal Cancers: TNM 8 (4)

 

 

T Stage

Features

   

TX

Primary tumour cannot be assessed

T0

No evidence of primary tumour

Tis

Carcinoma in situ

T1

Tumour invades submucosa

T2

Tumour invades the muscularis propria

T3

Tumour invades through muscularis propria into the pericoloretal tissues

T4 – T4a

Invades through visceral peritoneum

    - T4b

Invades or directly adheres to other adjacent organs or structures

 

 

N Stage Features
   

NX

Lymph nodes cannot be assessed

N0

No regional lymph node metastases

N1

   

 

Metastases in 1 – 3 regional lymph nodes

 

N1a

1 lymph node

N1b

2 – 3 lymph nodes

N2

 

 

Metastases in 4 or more regional lymph nodes

 

N2a

4 – 6 lymph nodes

N2b

7+ lymph nodes

 

 

M Stage Features
   

M0

No evidence of metastasis in other sites or organs

– defined by imaging

 

M1

Distant metastasis

 

M1a

Confined to 1 organ/site without peritoneal metastasis

M1b

Metastasis to 2 or more sites/organs, without peritoneal metastasis

M1c

Metastasis to the peritoneum

 

 

Surgical Management

 

Abdominoperioneal (AP) or anterior resection has traditionally been the mainstay of surgical management with curative intent for patients with rectal cancer. However, due to earlier diagnosis with the advent of bowel screening, rectal EUS and improved rectal MRI sensitivity, there is increasing utilisation of minimally invasive and sphincter preserving surgical techniques including transanal endoscopic operations (TEOs) and transanal total mesenteric excision (taTME) in curative-intent resection of rectal cancer.

 

Traditional Radical Resection of Rectal Cancer

 

Abdominoperioneal (AP) resection (including ExtraLevator AP Resection - ELAPE) and anterior resection are forms of radical resection that have traditionally been the mainstay of surgical management with curative intent for patients with rectal cancer. All radical resections with curative intent also include total mesenteric excision, involving precise dissection and removal of the entire mesorectum as an intact unit. A brief summary of the indications, procedure overview and complications are included below:

 

Abdominoperineal (AP) resection and ELAPE

 

Indication:

  • Low rectal tumours (lower third of rectum)
  • Anal carcinoma

Procedure overview:

  • Removal of the anus, rectum, regional lymph nodes and part of the sigmoid colon
  • Formation of an end colostomy.

Complications (5):

  • Intra-abdominal or pelvic sepsis: affects up to 32% of patients with early complications (5)
  • Perineal wound
  • Nerve injury
  • Urologic injury (e.g. if the dissection of Denonvilliers’ fascia is too close to the prostate)
  • Sexual dysfunction

 

Low Anterior Resection 

 

Indication:

  • Tumours of the upper two thirds of the rectum

Procedure Overview:

  • Anastomosis between the remaining rectum and sigmoid colon
  • Preservation of the internal sphincter.

Complications:

  • Anastomotic leak
  • Abdominal wound infection
  • Pelvic abscess
  • Haematoma

 

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