This preview shows page 96 - 100 out of 270 pages.
12.3 DiagnosisDominant symptoms include rectal bleeding (70.3%), change in bowel habits (66.4%), abdominal pain/discomfort (60.0%), intestinal obstruction (43.6%), mucus discharge (24.3%) and tenesmus (30.8%). Majority (91%) are palpable on digital rectal examination. Proctoscopic/Sigmoidoscopic biopsy and histopathology completes the diagnosis. 12.4 Staging and Risk AssessmentFor local staging of rectal cancer MRI and EUS (or Contrast enhanced CT pelvis if not available) are recommended. Chest X ray with liver US or CT Chest and abdomen are recommended for distant metastases. Complete colonoscopy should be done before or after surgery. The surgical specimen is evaluated for surgical margins (proximal, distal, circumferential), examination of at least 12 nodes and vascular and nerve invasion. Rectal cancer is staged using the TNM system (table 1). Stalked and sessile adenomas should be classified using the Haggit system (Table 27)
National Guidelines for Cancer Management Kenya77Table 25: TNM Staging for Rectal CarcinomaPrimary Tumor (T)TX primary tumor cannot be assessedT0 no evidence of primary tumorTis carcinoma in situ: intraepithelial or invasion of lamina propriaT1 tumor invades submucosaT2 tumor invades muscularis propriaT3 tumor invades through muscularis propria into subserosa or into nonperitonealized pericolic or perirectal tissuesT4 tumor directly invades other organs or structures and/or perforates visceral peritoneumRegional Lymph Nodes (N)NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 metastasis in one to three regional lymph nodesN2 metastasis in four or more regional lymph nodesDistant Metastases (M)MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisTable 26: Stage Grouping AJCC Staging for Rectal CarcinomaTNM Classification DukesStages StagesStage 0 Tis N0 M0Stage I T1 N0 M0 AT2 N0 M0 B1Stage II T3 N0 M0 B2Stage III T1, T2 N1 or N2 M0 C1Stage IV Any T Any N M1 DStage VT3, T4 N1 or N2 M0 C2T4 N0 M0 B2
National Guidelines for Cancer Management Kenya78Table 27: Haggit system for polyps with invasive cancerLevel 0 Carcinoma in situ, not invading muscularis mucosaLevel 1 Invasion into submucosa, limited to head of polypLevel 2 Cancer invades neck of polypLevel 3 Cancer invades stalk of polypLevel 4 Cancer invades submucosa of bowel wall = T1All sessile polyps with invasive Cancer are level 4 by Haggitt’s criteriaLevel 1-3 are limited to polyp wall and do not involve normal bowel wall12.5 Management12.5.1 Treatment of localised diseaseThe aim of treatment is complete (R0) resection with sphincter preservation. The treatment is planned in a multidisciplinary setting. Surgical options include local, anterior and abdominoperineal resections. Total Mesorectal Excision (TME) must be performed to remove all mesorectal fat and all involved nodes and reduce local recurrence.
National Guidelines for Cancer Management Kenya79Table 28: Treatment Options by StagesMalignant polyps; (Haggit 1-3; T1 sm1 N0)Early cancer (cT1–2, some cT3, N0) and