Rectum is the name given to the last 15 cm of the large intestine, and cancers that develop here are called rectal cancer.
Difficult defecation, rectal bleeding, thinning of the diameter of the stool, diarrhea or constipation attacks, feeling of incomplete evacuation, etc. Although it causes symptoms, it can also be detected in some patients during screening colonoscopies or tests such as tomography, MRI or PET-CT taken for another purpose.
The main diagnostic method is colonoscopic examination. In colonoscopy, a biopsy (removal of a piece) is made from the tumor tissue to provide a tissue sample for pathological examination.
In addition, it can be understood whether the tumor is at a very early stage or not, and it can be seen whether there is an accompanying lesion in other parts of the large intestine or familial polyposis syndrome.
Before planning rectal cancer treatment, staging should be done, as in every cancer patient. In rectal cancer staging:
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Pelvic magnetic resonance (MR) imaging (must be taken at a special angle for the rectum),
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Upper abdomen MRI
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Thorax (lung) tomography should be performed.
PET-CT is not routinely recommended for rectal cancer staging, only for metastasis (spreading, It is recommended for the evaluation of patients with suspicion of splashing.
In patients who do not have advanced stage disease (early stage), endorectal ultrasound (EUS/ERUS) can be used to evaluate the spread of the tumor in the rectal wall.
Blood values coded as CEA and Ca 19-9 can be used. Although it is not used in staging, it is recommended to study it at the time of initial diagnosis in order to predict the course of the disease and to monitor recurrence after treatment.
Rectum cancer treatment is planned according to the tumor stage, as in every gastrointestinal tumor. Below you can see the main treatment options according to the stages:
Stage1:
-Colonoscopic intervention (endoscopic submucosal dissection - ESD)
-Transanal minimally invasive approach (Vision with surgical instruments intervention through the anal canal below)
- Colorectal surgery (open, laparoscopic, robotic)
Stage 2:
- Colorectal surgery (open, laparoscopic, robotic)
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-Surgery after radiotherapy
Stage 3:
-Radiotherapy ± Chemotherapy -- Colorectal surgery -- Chemotherapy
Stage 4: (Distant organ metastasis)
- Chemotherapy
Additional therapy depending on the region where metastasis develops treatments may be considered. In patients with only lung or only liver metastases, if they can all be removed, rectal surgery and removal of metastases can be planned simultaneously or at different times. In patients with peritoneal (abdominal lining) metastases, HIPEC (hot chemotherapy) can be applied together with cytoreductive surgery after chemotherapy or immediately after diagnosis. Surgical interventions can be planned even in case of simultaneous metastasis in many regions.
Treatment planning at all stages is carried out by the multidisciplinary oncology council, attended by colorectal surgeon, medical oncology, radiation oncology, pathologist, radiologist and other relevant branches, taking into account the characteristics of the patient and the tumor. and should be decided in the light of current scientific data.
The location of the rectum in the pelvis (hip bone) is a factor that makes surgery for rectal cancers difficult. In front of the rectum are the bladder, prostate, on the sides the vessels and nerves that feed the genital and urinary system, urinary tract (ureter), and in the back there are many veins in front of the hip bone. While trying to stay away from these structures prevents possible injuries, it may cause the rectal sheath to rupture and disrupt the rules of oncological surgery. On the other hand, cutting too far away to protect the rectal sheath may lead to injury to surrounding structures, which may lead to additional surgeries, serious bleeding that may be life-threatening, or dysfunction related to sexuality and urination.
Provided that all these surgical rules are followed, rectal cancer surgery can be performed by traditional (open) method, laparoscopic or robotic.
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