ANAL/RECTAL CANCER

ERIN KRUPA

LOWER GI ANATOMY/PHYSIOLOGY

ANATOMY/PHYSIOLOGY CONT.
Rectum

ANUS

Begins at the 3rd sacral vertebrae

Connects to the rectum at the

Covered by peritoneum on its lateral

anal verge
3-4 cm in length
Comprised of musculature that
helps evacuate waste material
Produces mucus which acts as a
lubricating fluid

and anterior surfaces

3 transverse folds divide rectum into
the upper, middle, and lower valves

6 inches in length
Stores waste material until it is
expelled via the anus

ASSOCIATED LYMPH NODES

Superior half of rectum: peri-

rectal, sacral, sigmoidal, inferior

mesenteric
Inferior half of rectum: peri-rectal,
internal iliac, hypogastric, external
iliac
Low rectum: may drain to inguinal
as well
Anus: inguinal, internal iliac and
sacral nodes

EPIDEMIOLOGY
Rectal Cancer

ANAL CANCER

3rd most common cancer diagnosed in both men and women in the U.S.

3 leading cause of cancer deaths in the U.S.

rd

~7,270 new cases in 2014 (4,630 in women and 2,640 in men)

~39,610 estimated new cases in 2015

~49,700 estimated deaths during 2015

Slightly more common in males than females

Average age at diagnosis ~60 y/o

1 in 20 chance

Much more rare than colorectal cancers

~1,010 deaths in 2014 (610 in women and 400 in men)

Occurs more often in females than males

Most common in Caucasian females/African American males

Average age at diagnosis ~60 y/o

1 in 500 chance

ETIOLOGY
HPV
Lowered immune system (HIV/AIDS)
Cigarette smoking
History of ulcerative colitis or Crohns disease
History of polyps
History of hemorrhoids
Family history of colorectal cancer
Type 2 diabetes
Increasing age
Diets high in red and processed meats
Heavy alcohol consumption
Lack of exercise
Obesity

PRESENTING SIGNS AND SYMPTOMS

Rectal bleeding
Hematochezia
Change in bowel habits
Pencil thin stools
Constipation or diarrhea
Tenesmus
Pain
Unintended weight loss
Abnormal discharge
Rectal urgency
A lump or mass at the anal opening
Abnormal routine colonoscopy

DIAGNOSTIC WORK-UP
Barium Enema: to initially assess motility
CBC/Liver Function tests
Endorectal Ultrasound: to assess depth

of invasion
Anoscopy/Colonoscopy: to assess the size

and location, also used to obtain a biopsy

Chest X-ray/ CT of chest
MRI of the pelvis
PET

ROUTES OF SPREAD
Local invasion
Lymphatics
Hematogenous spread
Peritoneal seeding

COMMON SITES FOR DISTANT METASTASIS

Liver
Lungs

hematogenousl
y

Bone
Brain
Other pelvic organs via direct invasion

STAGING

TREATMENT BY STAGING
Rectal Cancer
Stage 0 polypectomy (removing the

polyp), local excision, or transanal

resection only
Stage I local excision alone for TI

lesions; adjuvant chemo + RT for T2

lesions
Stage II/III preop chemo + RT,

surgical resection, then more chemo

Stage IV chemo + RT

ANAL CANCER
Stage 0 local excision
Stage I/II local excision then

postop chemo + RT
Stage III Surgery or chemo + RT
Stage IV chemo + RT

SURGICAL OPTIONS
Rectal Tumors:
Polypectomy = removal of a polyp(s)
Local Excision
Transanal Resection: patient is awake
during procedure and receives local
anesthetics
Transanal Endoscopic Microsurgery
Coloanal anastomosis

SURGICAL OPTIONS CONT.

Local Excision
Abdominoperineal Resection: 2

incisions are made, 1 in the

abdomen and 1 near the anus
to remove the anus and rectum.
The end of the colon is then
brought through the abdominal
incision, creating an ostomy. A
bag is attached to the outside
of the skin to collect waste
material that exits the bowel.

COMMON CHEMO AGENTS

For Rectal Cancers:
FOLFOX: 5-FU, leucovorin, and

oxaliplatin
CapeOx: Capecitabine and
oxaliplatin
5-FU and leucovorin
Capecitabine
For Anal Cancers:
5-FU + mitomycin
5-FU + cisplatin

**Leucovorin aka folonic acid is a vitamin

like drug that aids in the effectiveness of 5FU
**Capecitabine is an oral chemo agent that
turns into 5-FU when it reaches the tumor
site
**Chemotherapy cycles generally last about
2 to 4 weeks, and patients usually receive at
least several cycles of treatment
**Chemotherapy can be used as neoadjuvant
or adjuvant regimens

RADIATION THERAPY
3 field pelvis: PA + RT/LT Laterals
IMRT
VMAT
Rectum
Treat whole pelvis to 4500 cGy
180 cGy/fx for 25 fxs
Boost to total of 5040 5400 cGy
Anus
Small tumors < 3cm 3000 4000 cGy
Tumors > 3cm 4000-4500 cGy
Boost to 5000-6500 cGy

PHOTODYNAMIC THERAPY
Patients are sensitized with a hematoporphyrin derivative through an injection
Tumor cells uptake the radiosensitizer
24-72 hours after the injection, phototherapy is performed using a laser beam applied through

a flexible optical fiber directed at the tumor

The laser sensitizes the protoporphyrin which ultimately induces apoptosis, essential killing
the tumor cells
Each photosensitizer is activated by light of a specific wavelength. This wavelength
determines how far the light can travel into the body. Thus, doctors use specific
photosensitizers and wavelengths of light to treat different areas of the body with PDT.
Candidates for PDT include:
Patients with tumors at the skins surface or just within anal cavity
Patients with T1 or T2 tumors as the light wavelengths can only travel 1/3 of an inch into

tissue
Patients with early staged lesions

ENDOCAVITARY RADIATION THERAPY

Sphincter-preserving procedure
4 doses of 3000 cGy per fx, separated by 2-week intervals
Outpatient visit
Uses a 50-kVp contact unit
Treatments delivered directly to the tumor via an applicator inserted into the

rectum
Candidates for Endocavitary RT include:
Patients with low to middle third rectal cancers that are confined to the wall of the

bowel
Tumor must not have extension beyond the bowel wall
Tumor must be no larger than 3 x 5 cm
Tumor must be well to moderately well differentiated

COMPARING POSSIBLE SIDE EFFECTS

Surgery

CHEMOTHERAPY

Damage to nearby organs during the operation

Bleeding

Vomiting

Blood clots in the legs

Nausea

Loss of Appetite

Skin infections at the incision sites

Hair loss

Localized pain

Diarrhea

Scar tissue formation

Mouth sores

Fatigue

Increased risk of infection

COMPARING POSSIBLE SIDE EFFECTS CONT.

External Beam RT/Endocavitary
RT

Damage to healthy tissue

Burns

Nausea

Swelling

Vomiting

Scarring

Loss of appetite

Bleeding

Weight loss

Skin reaction

Fatigue

PHOTODYNAMIC THERAPY

Cramping
Diarrhea

Decreased blood counts

Perforation

BEST FORM OF TREATMENT??

A combination of chemo, EBRT, and transanal surgery:
Decreased chance of recurrence
Better quality of life when the anus is conserved
Side effects are temporary
However..
There is no routine rectal/anal cancer
Each patient must decide what is the best treatment for them

when taking the side effects into consideration

PROGNOSIS AND SURVIVAL

CITATIONS
Hackworth R. Colorectal-Anal Presentation. The Ohio State University. 2015.
Signs and Symptoms of Colorectal Cancer. American Cancer Society. 2015. Available at:

http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-signs-and-symptoms. Accessed November 1,

2015.
Signs and Symptoms of Anal Cancer. American Cancer Society. 2015. Available at:
http://www.cancer.org/cancer/analcancer/detailedguide/anal-cancer-signs-and-symptoms. Accessed November 1, 2015.
Metastatic Colorectal Cancer Symptoms. Cancer Treatment Centers of America. 2015. Available at:

http://www.cancercenter.com/colorectal-cancer/symptoms/tab/metastatic-colorectal-cancer-symptoms/. Accessed November 1, 2015.

Anal Cancer. American Cancer Society. 2015. Available at: http://www.cancer.org/acs/groups/cid/documents/webcontent/003083-

pdf.pdf. Accessed November 1, 2015.

Colorectal Cancer. American Cancer Society. 2015. Available at: http://www.cancer.org/acs/groups/cid/documents/webcontent/003096-

pdf.pdf. Accessed November 1, 2015.

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