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Gastrointestinal cancer-11-Rectal


Welcome to the eleventh part of educational series on GastroIntestinal Cancers. We learned in parts 8-9-10 about treatment of colon cancer, including the fact that many patients in stage 4 can also achieve a good prolongation of life and a significant number can also be cured.

Question: Now Dr. Chiragbhai, what about RECTAL cancer? Is there a difference in approach?

Answer: Yes. Even though, most of the treatment principles are same, especially with respect to medical management, there are some important differences.

Que: What are these differences?

Ans: They are mainly related to the fact that unlike colon cancer, there are significant differences with respect to local anatomy. Important points are: 1. Closeness of rectum to surrounding pelvic organs 2. Lack of serosa 3. Reduced ability in this region to obtain wide surgical margins.

Because of these factors, locoregional treatment is very important, rather than only systemic therapy. Advances in locoregional treatment have markedly improved results.

Que: What are these advances?

Ans: First is the change in surgical technique i.e. TME – total mesorectal excision is now standard of care and must be practiced in all patients.

Second is Adjuvant (postoperative) Chemotherapy and Radiotherapy, given concurrent further improve results. This is an integral part of most rectal cancers, except very early stages.

Que: What about loss of sphincter and permanent colostomy? Is it for every patient, and any advance in this area?

Ans: First of all, every patient does not need permanent colostomy, only for patients with tumors very close to sphincter. Secondly, colostomy care has significantly improved over years, and most patients live fairly normal life. Occasional patients do have frequent local problems, however, and can be very disturbing. Also, it is very difficult for most patients initially to accept this.

Preoperative ChemoRadiotherapy has now become standard for T3 tumors and patients with positive nodes radiologically – most of the patients in India fall in this category. This is mainly done to provide better surgical results, but it also helps in avoiding colostomy in some patients.

One of our recent patients with T3N2 disease had a doctor relative in USA, and he consulted several of his colleagues (over 20) there. Interestingly, every one of them advised preoperative chemoradiation there, emphasizing the fact that it is now a standard of care, at least in USA. We treated him here with preoperative chemoradiation. Patient is now in USA and I received news yesterday that his evaluation shows complete regression of disease radiologically. He is now due for surgery and is likely to achieve a much better surgical result and overall survival. Surgery first approach would have significantly compromised his chances. Other good news is that he would have had permanent colostomy with primary surgery, whereas now there is a good chance that he would be able to avoid this.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 98243 12144, 98988 31496

Diplomate American Board of Oncology and Hematology. Ahmedabad.

Shyam Hem-Onc Clinic. 402 Galaxy, Near Nehrunagar Circle, Ahmedabad.