T4 Rectal Cancer

Sarah O'Dwyer

Powerpoint File

Chemoradiotherapy

T4 rectal cancers can be downstaged and rendered operable following treatment with radiotherapy alone or combined chemoradiotherapy. Many series have demonstrated that using radiotherapy alone – tumours can be downstaged, inoperable tumours may become operable and on occasions there may be no histological tumour in the resected specimen. The timing of surgery following long course radiotherapy usually allows 6 weeks for shrinkage of the tumour. Overall 45-65% of fixed rectal tumours can be downsized and resected following radiotherapy alone – but almost half will develop local recurrence.

For this reason combined chemoradiotherapy has become the preferred approach.. Overall the evidence suggests that for patients with good performance status and limited comorbidity, chemoradiotherapy leads to shrinkage of T3/T4 tumours offering the potential for radical and curative resection in locally advanced disease. Patients with obstructive symptoms will require a defunctioning stoma during this phase of therapy.

Surgical Approaches

Reassessment of the patient 8 weeks following chemoradiotherapy by EUA and pelvic MRI is valuable in assessing tumour response and determining fixity.

In the male total pelvic extenteration is usually required, as attempts to dissect in the anterior plane risks leaving tumour on the seminal vesicles and prostate. In selected cases it may be possible to combine abdominoperineal excision of the rectum with en-bloc radical prostatectomy without breaching the oncological plane – and so avoiding an ileal conduit.

In females the gynaecological barrier makes posterior clearance alone feasible – particularly if the patient has not had a hysterectomy. Reconstruction in such cases may require either rectus or gracilis flaps.

References

O’Dwyer S. The management of Inoperable Rectal Cancer.

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