Health Tips

Rectal Cancer:-
Introduction:-
Rectum is the part of the digestive tract that connects the colon (large intestine) in the anus, where waste (fecal) matter passes out of the body (shown in Figure 1). Such as the colon and rectum is part of the large intestine, cancer of the colon and rectum, often referred to together and cancers of the colon and rectum. While the conditions are part of the same process, disease, and treatment of rectal cancer is different from colon cancer because of its unique anatomical.

Such as colon cancer and colorectal cancer develops slowly over a period of years. Most common types of cancer, start within the tumor, also called adenoma. These tumors are small non-cancerous tissue, which stand out from the lining of the large intestine. Over time, as these polyps grow, they can become cancerous, and begin to invade the layers of tissue that form the wall of the rectum. At this point, it can spread to the lymph nodes, and to other bodies such as lung cancer and liver, a process called metastasis. (See "Patient information: Colon polyps").
Staging rectal cancer :-
Treatment and diagnosis (outcome) of rectal cancer depends on the stage of cancer. Staging of rectal cancer is based on the extent to which the cancer has penetrated into the wall of the rectum, whether the cancer has spread to lymph nodes located throughout the rectum, and whether the cancer has spread through the bloodstream to other organs (called distant spread of mobile).

Preliminary assessment of rectal cancer usually involves a colonoscopy (a test in which a flexible tube with a camera is routed through the rest of the rectum and colon). Abdominal and pelvic CT scans (specialized x-rays) and chest X-ray are often recommended to search for evidence of the spread of cancer within the abdominal cavity and / or lungs. Other possible tests include ultrasound, specialized rectum or magnetic resonance imaging (MRI) scan.

The final stage of rectal cancer is confirmed by the findings during surgery, most accurate way to determine the extent of the tumor.

There are two departure for rectal cancer:

* The system TNM (tumor, nodes, metastases) is the most common .

* Less frequently, and modified Dukes system is used.

The blood test to the antigen carcinoembryonic (CEA, a substance produced from cancers of the colon and rectum, most of which is taking place in the blood) is recommended before initial surgery. And raised CEA level that does not return to normal after surgery may be a sign of the disease persist, and require further evaluation.

Treatment of rectal cancer :-
Most cancers of the rectum and treated with a combination of surgery, radiation therapy and chemotherapy.

* The first phase of rectal cancer - Surgery alone may be curative.

* Phase II or III - Chemotherapy and radiation therapy is usually recommended following surgery (referred to as adjunctive therapy). Recently, chemotherapy and radiation has been recommended more often than before surgery (called therapy neoadjuvant).

* Phase IV - which is dominated by chemotherapy, with or without surgery and radiation therapy.
Rectal cancer surgery :-
Regardless of the extent of the disease, surgery plays an important role in the treatment of cancer of the rectum. For patients with tumors that had not spread beyond the rectum (localized disease), surgery to remove part of cancer in the rectum and the associated lymph nodes. During surgery, the surgeon can examine the abdominal area directly for signs of spread of cancer.

Surgery is sometimes recommended for people who metastases (stage IV rectal cancer, show table 1). This is done to prevent bleeding, and blockage in the intestines, which can develop in people with an expanded treatment of rectal cancer.
Types of surgery :-
Recommended the surgery depends on the extent of participation of the tumor and the location of cancer. For example, some types of cancer rectum is very small and confined to the surface of the lining of the rectum. Other types of cancer has grown through the wall of the rectum and the entire adherent (stuck) to the neighboring structures and organs, such as the wall of the abdomen or pelvis, and sacrum, bladder, or prostate gland. The need for surgery to remove these tumors two different too.

In general, there are four types of operations:

* Transanal excision
* Low amputation Front (Lar)
* Abdominoperineal amputation (April)
* Exenteration pelvic

Most rectal cancers require open surgery, and this means that the incision is made through the abdominal wall to reach the intestines. This incision allows the surgeon to remove the tumor and examine the surrounding tissues. However, some tumors can be removed earlier without opening the abdomen, using a procedure called circumcision transanal.
Transanal excision:-
The simplest type of surgery to remove cancer of the rectum and is without abdominal incision by inserting instruments though the anus. This method can be used to remove polyps or large tumors that are relatively small and located near the anus . Newer technologies such as (Tim (transanal endoscopic surgery) now allows the eradication of small tumors through the anus which is located at the top of the rectum.

Rectal tumors that can be successfully treated by transanal excision are usually the first stage, and has a favorable appearance when examined under a microscope. "The appearance of favorable" means that the tumor tissue is forming or beginning to form normal gland structures. The medical term for this is "well differentiated" or "moderately differentiated" cancer. "Poorly differentiated" cancers have lost the ability to form normal gland structures, these tumors tend to be more aggressive.

Superficial rectal cancer is the most suitable for transanal excision, although the identification of patients with T2 tumors may be eligible for this approach as well.

When the tumor is removed through the rectum excision transanal, and will be analyzed tissues under a microscope to determine whether there is a need for further surgery. This test also determines if postoperative (adjuvant) treatment is necessary; treatment after surgery usually involves a combination of radiotherapy and chemotherapy (see "Postoperative therapy" below).
Low amputation Front (Lar):-
Amputation of lower front - a procedure called a low amputation of the front (Lar) is used whenever possible to preserve the rectum and anus, which allows the patient to a normal bowel movements. However, you must be a tumor located high in the rectum for this procedure to be recommended. The surgeon makes the abdomen is cut to remove the cancerous tissue and then connecting the colon and rectum to remain below, or in some cases, the upper anus.

In some cases, small intestine or colon is temporarily taken out of the skin of the abdominal wall, where feces are collected in a bag of Foreign Affairs. This is what is called a temporary ileostomy or colostomy. This procedure may be necessary to allow the delivery of tissue to heal. After six to eight weeks, and ileostomy or colostomy is closed and foreign minister is no longer needed to collect the stool. The patient is then able to bowel movements in a normal fashion (through the anus). If required Adjuvant chemotherapy after surgery, and the closure of a temporary ostomy may be delayed for several months.

Lar during the procedure, the surgeon also removes all the lymph nodes (also called lymph glands) associated with the rectum. This is necessary because cancer cells have the ability to travel through the body using the lymphatic system. Remove the lymph nodes helps to ensure that cancer cells are not able to increase the spread of the disease. And tissues taken from the lymph nodes is checked to determine if further treatment will be needed after surgery.
Abdominoperineal amputation (April):-
Abdominoperineal amputation - amputation and abdominoperineal (April) when used in tumors can not be completely removed by using the Lar, most commonly because the tumor is very close to the anus. April requires the abdomen is cut, as well as construction to remove the anus. This results in a need for permanent colostomy (see: "Life with a colostomy" below).

During the APR, in the lymph nodes in the vicinity of the rectum is removed, just as in Lar.
Exenteration pelvic:-
Pelvic exenteration - If colorectal cancer has invaded nearby organs, a large operation may be needed. In this case, it is often necessary for surgery to remove part of certain organs such as the bladder. If the function of these organs can not be saved because of the involvement of the tumor, the entire body may need to remove it.

Rarely, all of the tissues and organs within the pelvis (including the bladder and prostate [in men], and / or uterus [women]) must be removed successfully in the treatment of cancer. This is a large-scale operation called pelvic exenteration.

Most patients undergoing pelvic exenteration require a permanent colostomy. If the bladder is removed, the patient may also need to urostomy, an artificial opening on the front of the abdomen that allows urine to leave the body. pelvic exenteration can cause a number of complications and may not cure a person due to the nature and widespread of rectal cancer.

For many people with locally advanced rectal cancer, an alternative to pelvic exenteration is to get the chemotherapy and radiation therapy before surgery. Can often shrink the tumor, allowing the surgeon to perform Laar, and the Rwandan Patriotic Army, or the process is large, and this depends on how much cancer remains after chemotherapy and radiation therapy. This type of treatment is discussed in more detail below.
Bowel function after rectal cancer surgery:-
Gut function after rectal cancer surgery depends on the specific process that have been implemented and whether radiation therapy was also used. After Laar, and many people find it difficult to control bowel movements at first, even if the anal sphincter (the valve that controls elimination of stool) has been preserved. You may feel the need to pass stool frequently. For most people, and bowel function improved over time (even up to two years), although it may not be the same as it was before surgery.

If the connection between the colon and rectum is very close to the anus, there is very little "rectal reservoir" (room to store faeces) before needing to move the intestines. These people need to have bowel movements more frequently and may have difficulty emptying the bowel. In some cases, can be created the largest reservoir out of the colon (colon J-pouch) before being delivered to the lower rectum or anus. This provides more space to store fecal matter and can allow the person to be the best and bowel function.

Life with colostomy:-
A colostomy can alter the body image, which can be a challenge, both physically and emotionally. However, with education and support, it could lead to an active life with a colostomy. And collective effort, which include colon and rectal surgery, oncology, treatment enterostomal (ET) nurse, is invaluable in advising and educating you and your family before surgery, and also in the care and recovery is required after the operation. United Ostomy Associations of America also a good source of information and support.

Chemotherapy and radiation:-
Chemotherapy and radiation for rectal cancer - chemotherapy and radiation therapy is recommended in addition to surgery for most people with stage II or III rectal cancer. These treatments improve the likelihood of survival from cancer. Even when all visible signs of cancer had been removed by the surgeon, between 20 and 50 percent of people will have their cancer recurrence if treated with surgery alone.

One reason for the relatively high rates of repetition is that the pelvic area where the path is the space "tight" and it is sometimes difficult for the surgeon to remove enough tissue surrounding the tumor, and this means that both had cancer cells in the surrounding tissues can not be removed. In addition, the cells had survived a very small cancer of the lymph nodes and spread to other organs. A combination of chemotherapy and radiation and help to reduce the risk of recurrence by targeting any remaining cancer cells.

There are two general management of chemotherapy and radiation in people who have rectal cancer:
Postoperative Therapy:-
Post-surgery and treatment - post-surgery (adjuvant) therapy is usually recommended for patients who underwent surgery to remove the cancer of the rectum. Commonly used treatment protocol (system) is as follows [1,2]:

* Monthly courses of chemotherapy with anti-cancer drug 5 - fluorouracil (abbreviated 5-fu) is given five days in a row, once per month. This is followed by:

* Radiation therapy is over five or six weeks. During this time, and the continued flow of intravenous administration of 5 Fu managed. This approach requires that the person has access to the central catheter (often called a port) surgically into one of the major blood vessels in the chest and portable chemotherapy pump at home (referred to as mobile injection pump). This pump is very small, battery-operated, and fits into a package that a person can wear around his waist, and allow freedom of movement during the treatment period.

* Two more chemotherapy with a 5-Fu given five days in a row, once per month.

If ambulance injection pump treatment is not feasible, the alternative method of combining chemotherapy and radiation is to give one large dose of 5 Fu for three days during the first and last weeks of radiotherapy. However, it may be more toxic side effects with this approach [3]

Another alternative is the increasingly popular to give a daily dose of medication via oral Xeloda ® (capecitabine). Although this system is more convenient for the patient, it is not yet proven that treatment with the equivalent of 5 infusional Fu.

Benefits:-
Use a combination of chemotherapy and radiation after surgery reduces the risk of death from rectal cancer by about 30 percent [4]. This benefit is relatively large, with the result that, with all of the material assistance and chemotherapy and radiation after surgery is a standard approach if the tumor involves the lymph nodes (Stage III), or grown across the entire intestinal wall (phase II).
Preoperative chemotherapy and radiation:-
Prior to surgery, chemotherapy and radiation - to give a combination of chemotherapy and radiation therapy (called chemoradiotherapy) prior to surgery is called neoadjuvant or induction chemoradiotherapy. This treatment may be given to reduce the size of the tumor before it is removed. This approach is recommended if the tumor stage T3 or T4 (view table 1). In this case, you may chemoradiotherapy neoadjuvant following benefits:

* Reduces the risk of local recurrence
* The smaller number of short-term and long-term side effects (compared to postoperative chemoradiotherapy)
* Provides a better chance to avoid a permanent colostomy [5]

Other patients may benefit from chemoradiotherapy before surgery, including the following:

* Patients with tumors located in the low rectum and amputation abdominoperineal (April) is likely to be needed. The main goal of treatment before surgery in this circumstance is to try to preserve the anal sphincter and avoid a permanent colostomy.

* If the tumor is less advanced (ie, T1 or 2), but there are positive lymph nodes

* If the preliminary studies indicate that the organization of surgery may not successfully remove all of the tumor

However, in these cases, the benefits of chemoradiotherapy prior to surgery is not justified, and the decision to pursue this treatment must be based on a case by case basis in each case. We must consider the following issues:

* When the first surgical procedure, there will be need only chemoradiotherapy after surgery if lymph nodes are involved or the tumor has grown through the entire wall in the intestines.

* If chemoradiotherapy given before surgery, the patient is given from four to six months of chemotherapy after surgery, even if the contract is negative and the tumor has not grown through the bowel wall. This is because most tumors shrink as a result of pre-treatment and surgery, which makes it impossible to ascertain the stage of the disease based on the emergence of tissue removed in surgery.

Thus, the selection for chemoradiotherapy before surgery may be required to treat the patient more than he or she will need surgery if it were implemented first. This is a difficult decision, which should be shared between the patient and the doctor.

Administering chemotherapy:-
Power chemotherapy - the use of chemotherapy, in addition to radiotherapy is crucial to the success of treatment neoadjuvant. The most common way to give chemotherapy and radiation before surgery is to give 5 continuous intravenous infusion pump with a few that are used in the house during radiotherapy. This pump house is called ambulatory infusion pump.

Increasingly popular alternative is to give a daily dose of oral Xeloda ® during radiation therapy, largely because it is more appropriate for the patient. Although the guidelines for a national network of comprehensive cancer control (NCCN) endorse this approach is acceptable as a substitute for 5 infusional Fu, a study showed long-term outcomes are equivalent. Studies are under way to help answer this question.

Patients who have undergone chemotherapy and radiation therapy neoadjuvant should receive an additional six months of chemotherapy alone after surgery. There are several reasonable options, including:

* Participation of the Under-5-Fu alone, intravenously daily for five days every four weeks
* Oral treatment with Xeloda ® (capecitabine)
* A combination of 5 Fu and leucovorin, with both drugs given once a week for six of every eight weeks
* Use of three drugs, including oxaliplatin, 5 - Fu, and leucovorin (This system is called FOLFOX)
Side effects :-
Both radiation and chemotherapy can cause side effects, especially when used together.
Chemotherapy :-
The most common side effects with a 5-Fu are diarrhea, mucositis (soreness in the mouth), and temporary low blood counts. 5, when few are down, it can cause "hand-foot syndrome", which causes soreness, redness and peeling skin of the palms and soles of the feet. Supplemental vitamin B6 (also called pyridoxine) may provide benefit in this case.

Orally active 5 Fu derivatives such as Xeloda ® share the same side effects of intravenous 5 Fu, although diarrhea and mucositis is less common with Xeloda ® while hand-foot syndrome is somewhat more common.

Most patients tolerate chemotherapy reasonably well, many of them able to continue to work during the treatment period, and often with a timetable for the reduction of hours due to fatigue. Hair loss is an uncommon side effects of chemotherapy drugs used for cancer of the rectum.

Combination of chemotherapy and radiation :-
Possible side effects of 5-Fu radiation include diarrhea, irritation or inflammation of the intestinal tissue, leading to a sense of bowel urgency, bleeding and discomfort in passing stool, and irritation of the skin around the anus.

Diagnosis of rectal cancer :-
with all patients with various cancers, and it is impossible to predict what can be expected in the future. Before and after cancer treatment, it is important to discuss the ongoing management, and changing patterns of life, and treatment options in the future.

General diagnosis depends on the stage of cancer at the time it is removed. Rectal cancer that is identified and treated early have a better prognosis. Greater risk of death with more advanced rectal cancer. The average survival for a period of five years from the stage of approximately [6]:

* Phase I - 66 to 78 percent
* Phase II - from 55 to 62 percent
* The third phase - from 31 to 42 percent
Follow-up after treatment of rectal cancer :-
The term surveillance for follow-up testing recommended after a person has completed treatment of cancer of the rectum. It is recommended that surveillance to detect recurrence of cancer or cancer of the colon and rectum new. The following recommendations for the control reading (view Table 3) [7].

* Patients should see my bed every three to six months for the first three years, and annually thereafter. And medical history is done to determine whether there were signs or symptoms of a cancer recurrence. This should include physical examination, the rectal examination for patients who underwent amputation of lower windshield.

* Antigen blood test for carcinoembryonic (CEA, a substance produced by most colon cancers that circulates in the blood) should be obtained every month or three in patients with stage II and III of the disease at least in the first three years after amputation of the primary. An increase in the CEA may be the first sign of a recurrence of cancer. This is true even if the levels of CEA before surgery normal.

At the level of the Insurance Commission can help in the detection of recurrence that can be amenable to curative surgery as well. May, therefore, levels, periodic analysis is not necessary in patients who will not be able to submit to the eradication of cancer recurring.

* All patients with rectal cancer and should have a complete colonoscopy either before or amputation surgery in a few months after the amputation. This will exclude polyps and other types of cancer that may be present in other regions of the colon.

Additional screening colonoscopy is recommended after one year to assess the treatment of cancer or polyps new [8]. If it is not disclosed, the next colonoscopy is recommended in three years, then once every five years thereafter. Colonoscopy may be needed in some other times, if there are symptoms or laboratory values that suggest recurrence. For patients who have to amputate abdominopelvic, a colonoscopy is done through the colostomy.

* For patients who underwent the eradication of front-end low-level radiation to the pelvis and rectal cancer, sigmoidoscopy flexible (Scope of the examination only on the lower part of the small intestine) is recommended every six months for a period of five years. Flexible sigmoidoscopy is not needed for patients who received radiotherapy in the pelvis.

* The 2005 American Society of Clinical Oncology guidelines suggest that patients with stage II or III rectal cancer should be a CT scan on the chest and abdomen once per year for three years. If not given radiation, and pelvic CT scan is also recommended once a year over the first three years after treatment [7]. As is the case with CEA levels (see above), and a CT scan that is used to detect the recurrence of which can be treatable with further surgery. May, therefore, periodic CT scanning is not necessary in patients who will not be able to undergo surgery to remove the cancer recurring.

However, CT is not perfect and can detect microscopic disease.

If the CEA becomes elevated the patient or the development of symptoms of concern (such as abdominal pain, bloating, inability to pass stools), abdominal CT is recommended to determine if there is visible metastases.

The following tests are not necessary for routine surveillance:

* Microscopic examination of the quantities of blood in the stool cards (guaiac or stool)
* Trial scanning (positron emission tomography scan)
* Liver function tests (a panel of blood tests)
* Complete blood count (blood test)
* Annual chest X-ray
Options for recurrent rectal cancer:-
cancer - if recurrence of colorectal cancer in the rectum, and the best treatment depends on several factors, including what treatments were previously used, and where the new cancer. Treatment options are similar to those used in the treatment of rectal cancer first, and include surgery, chemotherapy and radiation therapy.

Patients with advanced cancer or metastatic rectal and depends on the extent and location of the participation of the tumor. Although the majority of patients can not be cured by any treatment, some patients may recover with limited involvement on the part of another operation. In other cases, chemotherapy is the best option.
Clinical trials :-
The progress made in the treatment of cancer requires identification of the best treatments is through clinical trials carried out in all parts of the world. And clinical trials is a way to accurately monitor to study the effectiveness of new treatments or new combinations of therapies known. Request more information about clinical trials, or read about clinical trials at the following address:
Implications for colorectal cancer family :-
The diagnosis of cancer of the rectum can be devastating for the patient, as well as for their families. The best way to deal with all these issues vary from person to person and between families. Do not underestimate the importance of good support, but is something that should be discussed with each patient with his or her health care team.

An important issue for the relatives (siblings, parents or children) of a person with cancer of the colon and rectum is the risk of colon cancer themselves. This also applies to the family of persons with certain types of polyps, called adenomatous polyps.

Relatives should understand the following information:

* People who have one first degree relative (parent, brother, sister, or child) with colorectal cancer or adenomatous polyps at an early age (before age 60 years) or two first-degree relatives diagnosed at any age should begin colon to detect the cancer earlier, typically at the age of 40 or 10 years younger than the earliest diagnosis in their family, whichever comes first, the examination should be repeated every five years. (See "Patient information: Colon cancer screening").

* People who have one first degree relative (parent, brother, sister, or child) who suffered from colorectal cancer or adenomatous polyps at age 60 or later should begin screening at age 40, and the examination should be repeated at a medium-risk people.

* People with her aunt in the second degree relative (grandparent, or aunt or uncle) or third-degree relative (great grandparent or cousin) with colorectal cancer are screened average-risk people.

Some circumstances (such as nonpolyposis colorectal cancer and hereditary familial polyposis adenomatous) are associated with a greater risk of polyps in the colon cancer or family members, and require more aggressive screening for family members. Patients and their families should discuss these issues with the health care provider who is experienced in these areas.