Diagnosis and Multidisciplinary Treatment of Locally Advanced Rectal Cancer

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• Rectal Bleeding Evaluation and Initial Diagnosis
• Multidisciplinary Cancer Center Evaluation
• Staging for Locally Advanced Rectal Cancer
• Neoadjuvant Chemoradiation Therapy
• Sphincter-Preserving Surgery Options
• Postoperative Recovery and Expectations
• Full Transcript

Rectal Bleeding Evaluation and Initial Diagnosis

Rectal bleeding is a common symptom that requires immediate medical evaluation. Dr. Nelya Melnitchouk, MD, describes a typical case where a 50-year-old male presents with this symptom. The first step is always a visit to a primary care physician or general practitioner. A digital rectal exam is performed, but it may not detect all tumors, especially smaller or higher lesions.

The most critical diagnostic step is a colonoscopy. This procedure allows for direct visualization of the entire colon and rectum. In the clinical case discussed by Dr. Melnitchouk, the colonoscopy identified a distal rectal cancer measuring approximately four centimeters. This finding immediately triggers a referral to a specialized cancer care team for further management.

Multidisciplinary Cancer Center Evaluation

A multidisciplinary approach is the cornerstone of modern rectal cancer care. Dr. Nelya Melnitchouk, MD, emphasizes that upon referral, patients are evaluated by a team of specialists. This team includes a surgical oncologist, a medical oncologist, and a radiation oncologist. Each specialist provides a unique perspective on the optimal treatment strategy.

Dr. Anton Titov, MD, and Dr. Melnitchouk discuss the importance of a tumor board. This is a meeting where all the specialists review the patient's case together. The tumor board ensures everyone is aligned on the treatment plan. This collaborative process is vital for achieving the best possible outcomes in complex cases of locally advanced rectal cancer.

Staging for Locally Advanced Rectal Cancer

Accurate staging determines the treatment pathway for rectal cancer. After a CT scan of the chest, abdomen, and pelvis rules out distant metastasis, a rectal MRI is essential. Dr. Nelya Melnitchouk, MD, explains that the MRI provides detailed images of the rectal wall and surrounding tissues. It can identify enlarged lymph nodes and determine the depth of tumor invasion.

In the presented case, the MRI confirmed a T3 tumor with involved lymph nodes. This classifies the cancer as locally advanced. This staging is crucial because it dictates the need for treatment before surgery. The goal is to shrink the tumor and treat any microscopic disease in the lymph nodes to improve surgical outcomes and long-term survival.

Neoadjuvant Chemoradiation Therapy

Neoadjuvant therapy is the standard of care for locally advanced rectal cancer. This means chemotherapy and radiation are administered before surgery. Dr. Nelya Melnitchouk, MD, notes that this approach has several benefits. It can downstage the tumor, making it easier to remove completely. It also treats the lymph node basins and can increase the chance of sphincter preservation.

Patients typically undergo a course of combined chemoradiation. A waiting period of approximately six weeks follows the completion of this therapy. This interval allows for the maximum tumor response and shrinkage. This step is critical for planning the subsequent surgical resection and optimizing the patient's functional results.

Sphincter-Preserving Surgery Options

The surgical goal for rectal cancer is complete removal while preserving function whenever possible. Dr. Melnitchouk, a colorectal surgeon, evaluates the tumor's distance from the anal verge. This measurement determines if the anal sphincter muscles can be spared. In this case, the tumor was distal but above the sphincters, making a sphincter-preserving procedure possible.

The operation performed was a low anterior resection. This procedure removes the cancerous portion of the rectum while preserving the anal sphincter. To protect the new connection (anastomosis) deep in the pelvis, a temporary ileostomy is created. This diverts stool away from the healing area. The ileostomy is typically reversed in a second, smaller operation several months later.

Postoperative Recovery and Expectations

Life after rectal cancer surgery involves a significant adjustment period. Dr. Nelya Melnitchouk, MD, highlights a common condition known as Low Anterior Resection Syndrome (LARS). This syndrome involves altered bowel function, including increased frequency and urgency. Patients may experience "clustering," where they need to use the bathroom multiple times in a short period.

Managing patient expectations is a critical part of pre-operative counseling. Dr. Melnitchouk and Dr. Titov agree that patients must be prepared for these changes. While most patients adapt over time, understanding LARS beforehand helps with coping. This honest discussion about quality of life after treatment is an essential component of comprehensive rectal cancer care.

Full Transcript

Dr. Anton Titov, MD: Is there a clinical situation that you can discuss? Could you describe a clinical case that would illustrate how to establish correct diagnosis in colon cancer or rectal cancer? Perhaps from a physician's perspective and also from a patient's perspective. How to make the best treatment for colorectal cancer? You have a lot of experience in treating colorectal cancer. Perhaps we could think of a composite situation that is relevant for colorectal cancer diagnosis and treatment.

Dr. Nelya Melnitchouk, MD: Yes, sure. Let's imagine that we have a 50-year-old male who developed rectal bleeding. The first step would be to go to your primary care doctor. That's what this patient did. He went to a primary care doctor. His general practitioner did digital rectal exam, but he did not feel anything.

The next important diagnostic step was to send this patient for colonoscopy. Colonoscopy was performed. Colonoscopy did find a rectal cancer that was distal in the rectum. Cancer was about four centimeters in size. Then this patient came to see a surgeon and medical oncologist and radiation oncologist.

That's what usually happens when the patient with rectal cancer gets evaluated. There is a multidisciplinary evaluation. Exactly. When these patients get referred to one of the cancer centers, medical oncologist, a radiation oncologist, and surgeon see this patient. We also discuss the patients at our multidisciplinary tumor board afterwards. Everybody is on the same page how to treat the patient.

This is what happens when this patient comes to see me. I am, as a surgeon, I'm trying to evaluate his cancer. I'm trying to determine a stage of rectal cancer in this patient. I'm trying to see how distal is this rectal tumor. In other words, how distal rectal cancer is. That will guide my surgical method of treatment that I can offer to that patient.

Let's say the patient has no metastatic disease. He got CT scan of the chest, abdomen, and pelvis. He had no metastatic disease, but they were able to see some enlarged lymph nodes on a CT scan. Given this is rectal cancer, we are going to offer this patient rectal MRI. Rectal MRI was performed. It did show enlarged lymph nodes. It was T3 rectal tumor.

We call this rectal cancer to be locally advanced. A discussion of treatment options with medical oncologist and radiation oncologist will happen. This patient will be offered a neoadjuvant chemotherapy and radiation therapy. There are different nuances to chemotherapy and radiotherapy. This I will not discuss right now.

But it is important for me as a surgeon also to see how far this rectal tumor is located from anal verge. Meaning is it involving anal sphincter muscles? I may be able to give this patient the sphincter-preserving surgical resection of rectal cancer. Alternatively, this patient needs abdominoperineal resection and permanent colostomy.

Even though the rectal cancer was distal, but it was still just above the sphincter muscles. Patient received the chemotherapy and radiation therapy. We waited six more weeks after completion of radiotherapy and chemotherapy. Surgeons were able to perform a low anterior resection of rectal cancer tumor. This is anal sphincter-preserving procedure.

This patient had temporary ileostomy. Because you have to protect you connection between ends of bowel that are sutured together down there in the pelvis. Then you can reverse that ileostomy later on. There is an important thing to know for the patients with rectal cancer. It is especially relevant for patients with distal rectal cancer.

Surgeons can remove majority of the rectum or the whole rectum. After surgery, bowel function postoperatively is not how it used to be before. These patients have more frequent bowel movements. They have what is called “clustering". Patients go to the bathroom once. Then ten minutes later they have to go again. And ten minutes later they need to go again.

Majority of patients end up adjusting to this reduction in anal sphincter function. And they do okay. But that's something to keep in mind after rectal cancer surgical operation. This is what was known as LARS syndrome, Low Anterior Resection Syndrome. Exactly.

When you see a patient with rectal cancer, it's very important to discuss all the post-operative outcomes that could potentially happen. It is important to discuss LARS syndrome. Because it's something that the patient should be prepared for after the completion of treatment of rectal cancer. Discussion of patient’s expectations after the treatment is a very important step.

Colorectal surgeon and other physicians participating in the treatment plan creation have to discuss all these issues with the patient. Exactly! There's a lot of things in the rectal cancer treatment to discuss. There is a need for the neoadjuvant chemotherapy and radiotherapy. Sometimes lymph nodes are borderline for cancer. That is why having a tumor board-based discussion of patient’s situation is important.

You are meeting with medical oncologist, radiation oncologists, multiple other surgeons. It's very important in the management of patients with colorectal cancer. But perhaps we can circle back to the initial rectal cancer diagnosis event. Sometimes a person notices the rectal bleeding or some sort of a discomfort. Then it's very important to follow up on these symptoms.

It is crucial to not pretend that it could be just "hemorrhoids". That unfortunately often happens. It is important to really make sure that this is not something more serious, as you discussed in this hypothetical rectal cancer diagnosis case.

Dr. Anton Titov, MD: Exactly correct, that's exactly right! Sometimes the rectal bleeding gets dismissed as a hemorrhoid bleeding, or something more benign. It's very important to perform a colonoscopy to rule out colorectal cancer.

Dr. Melnitchouk, thank you very much for this conversation. It's very important for patients and their families around the world to really understand the decision-making process in colon cancer and rectal cancer. It is complicated to find optimal treatment of colorectal cancer. It's very important to be thorough, and to make sure that the best results of the colon cancer treatment are achieved. Thank you very much!

Dr. Nelya Melnitchouk, MD: Thank you for talking with me!