RECTAL CANCER – A MULTIDISCIPLINARY APPROACH TO MANAGEMENT Edited by Giulio Aniello Santoro Rectal Cancer – A Multidisciplinary Approach to Management Edited by Giulio Aniello Santoro Published by InTech Janeza Trdine 9, 51000 Rijeka, Croatia Copyright © 2011 InTech All chapters are Open Access articles distributed under the Creative Commons Non Commercial Share Alike Attribution 3.0 license, which permits to copy, distribute, transmit, and adapt the work in any medium, so long as the original work is properly cited. After this work has been published by InTech, authors have the right to republish it, in whole or part, in any publication of which they are the author, and to make other personal use of the work. Any republication, referencing or personal use of the work must explicitly identify the original source. Statements and opinions expressed in the chapters are these of the individual contributors and not necessarily those of the editors or publisher. No responsibility is accepted for the accuracy of information contained in the published articles. The publisher assumes no responsibility for any damage or injury to persons or property arising out of the use of any materials, instructions, methods or ideas contained in the book. Publishing Process Manager Daria Nahtigal Technical Editor Teodora Smiljanic Cover Designer Jan Hyrat Image Copyright sgame, 2011. Used under license from Shutterstock.com First published September, 2011 Printed in Croatia A free online edition of this book is available at www.intechopen.com Additional hard copies can be obtained from orders@intechweb.org Rectal Cancer – A Multidisciplinary Approach to Management, Edited by Giulio Aniello Santoro p. cm. ISBN 978-953-307-758-1 free online editions of InTech Books and Journals can be found at www.intechopen.com Contents Preface IX Part 1 Epidemiology 1 Chapter 1 Rectal Cancer Epidemiology 3 Miguel Henriques Abreu, Eduarda Matos, Fernando Castro Poças, Rosa Rocha and Jorge Pinto Chapter 2 Opportunistic Screening for Colorectal Cancer 19 Xu An-gao Chapter 3 Crohn’s Disease and Colorectal Cancer 29 Andrea Denegri, Francesco Paparo and Rosario Fornaro Part 2 Imaging 47 Chapter 4 Preoperative Staging of Rectal Cancer: Role of Endorectal Ultrasound 49 Miro A.G.F., Grobler S. and Santoro G.A. Chapter 5 Dynamic Contrast Enhanced Magnetic Resonance Imaging in Rectal Cancer 75 Roberta Fusco, Mario Sansone, Mario Petrillo, Antonio Avallone, Paolo Delrio and Antonella Petrillo Chapter 6 Tumour Angiogenesis in Rectal Cancer-Computer-Assisted Endosonographic and Immunohistochemical Methods for Assessment 99 Tankova Ludmila, Daniel Kovatchki, Georgi Stoilov, Antonina Gegova and Ivan Terziev Part 3 Surgical Treatment 117 Chapter 7 Rectal Carcinoma: Multi-Modality Approach in Curative Local Treatment of Early Rectal Carcinoma 119 S. H. Kho, S. P. Govilkar, A. S. Myint and M. J. Hershman VI Contents Chapter 8 Single – Incision Laparoscopic Surgery for Rectal Cancer 137 Orhan Bulut Chapter 9 Intraoperative Sentinel Lymph Node Mapping in Patients with Colorectal Cancer 159 Krasimir Ivanov, Nikola Kolev and Anton Tonev Chapter 10 Is Neo-Rectum a Better Option for Low Rectal Cancers? 183 Fazl Q. Parray, Umar Farouqi and Nisar A. Chowdri Chapter 11 Experimental Evaluation of the Mechanical Strength of the Stapling Techniques: Experimental Study on Animal Model 201 Kentaro Kawasaki, Kiyonori Kanemitsu, Tadahiro Goto, Yasuhiro Fujino and Yoshikazu Kuroda Chapter 12 Management of Locally Recurrent Rectal Cancer 211 Zoran Krivokapic and Ivan Dimitrijevic Chapter 13 Causes and Prevention of Functional Disturbances Following Low Anterior Resection for Rectal Cancer 225 Eberhard Gross Part 4 Adjuvant and Neo-Adjuvant Treatments 251 Chapter 14 Role of Tumor Tissue Analysis in Rectal Cancer Pharmacogenetics 253 Emilia Balboa, Goretti Duran, Maria Jesus Lamas, Antonio Gomez-Caamaño, Catuxa Celeiro-Muñoz, Rafael Lopez, Angel Carracedo and Francisco Barros Chapter 15 Tumor Markers of Neo-Adjuvant Chemo-Radiation Response in Rectal Cancer 277 Jacintha N. O’Sullivan, Mary Clare Cathcart and John V. Reynolds Chapter 16 MicroRNAs and Rectal Cancer 295 Miroslav Svoboda and Ilona Kocakova Chapter 17 Nonoperative Management of Distal Rectal Cancer After Chemoradiation: Experience with the “Watch & Wait” Protocol 317 Angelita Habr-Gama, Rodrigo Oliva Perez, Patricio B. Lynn, Arceu Scanavini Neto and Joaquim Gama-Rodrigues Chapter 18 Systemic Treatment in Recurrent and Metastatic Unresectable Rectal Cancer 337 François-Xavier Otte, Mustapha Tehfe, Jean-Pierre Ayoub and Francine Aubin Contents VII Chapter 19 Side Effects of Neoadjuvant Treatment in Locally Advanced Rectal Cancer 353 Karoline Horisberger and Pablo Palma Chapter 20 New Option for Metastatic Colorectal Cancer: Oxaliplatin and Novel Oral S-1 Combination Chemotherapy 367 Dae Young Zang Chapter 21 Bone Metastasis of Rectal Carcinoma 377 Germán Borobio León, Asunción García Plaza, Roberto González Alconada, Ignacio García Cepeda, Jorge López Olmedo, Alberto Moreno Regidor and David Pescador Hernández Preface Major developments in medicine over last few years have resulted in more reliable and accessible diagnostics and treatment of rectal cancer. Given the complex physiopathology of this tumor, the approach should not limit to a single specialty but involve a number of specialties (surgery, gastroenterology, radiology, biology, oncology, radiotherapy, nuclear medicine, physiotherapy) in an integrated manner. The subtitle of this book “Multidisciplinary Approach to Management” encompasses this concept. We have endeavored, with the help of an international group of contributors, to provide an up-to-date and authoritative account of the management of rectal tumor. Our starting point (Section I) is the epidemiology of the rectal cancer, and this section addresses not only the evolution of rectal cancer epidemiology in the last years based on population-based cancer registry, but also the new AJCC staging classification. Development of screening models for colorectal cancer depends on disease risk stratification of individuals in the population. By performing opportunistic screening among high-risk populations, the average direct cost for each detected case of colorectal cancer is four times less than the cost of systematic screening. Entire Section II is devoted to the various techniques (two-dimensional and three- dimensional endorectal ultrasonography, power-doppler ultrasound, conventional and dynamic magnetic resonance) that may be employed to image the rectal cancer. Endorectal ultrasound has been widely accepted as the reference method for local staging of rectal cancer, and is now proposed as mandatory for preoperative staging purposes in the guidelines of the main scientific societies. The technique has evolved, due to the systematic efforts of researchers, in defining the normal anatomy of rectal wall and perirectal anatomic structures, in differentiating early cancers from advanced neoplasm and in defining pathological from reactive perirectal nodes. The computer- assisted endosonographic Doppler and the immunohistochemical based methods represent rapid, reliable and reproducible ways for quantitative assessment of tumour vascularization. Rectal carcinoma with high angiogenic activity are more likely to have deeper tumor invasion, lymph node metastases and distant metastases. Due to its intrinsic multiparametricity and multiplanarity MRI is considered the most accurate modality in evaluating locally advanced rectal cancer and the presence of a positive circumferential resection margin. Dynamic Contrast Enhanced-Magnetic Resonance X Preface Imaging is gaining a large consensus as a technique for diagnosis, staging and assessment of response to preoperative radiochemotherapy (RCT) due to its capability to detect the strict relationship that links tumor growth to angiogenesis. The common use of total mesorectal excision (TME) and the shift from a postoperative to a preoperative RCT approach have substantially reduced the risk of local recurrences, increasing curative resection and the rate of anal sphincter preservation and improving local control and overall survival rates. The surgical principles in the treatment of rectal cancer are described in details in Section III, including combined modality treatment in early rectal cancer, single-incision laparoscopy, intraoperative sentinel lymph node mapping, neorectum for low rectal tumor, salvage surgery for local recurrence and causes and prevention of functional disturbances following low anterior resection. Section IV is focused on neo-adjuvant and adjuvant treatments. The analysis of post- treatment tumor histological features helps to analyze if the mutational mechanisms, produced during tumor development, persist under therapy, and what changes the cells have undergone to be resistant to treatment. The response of rectal adenocarcinoma to neo-adjuvant RCT is limited to a defined group of patients. It is hoped in the future that the therapeutic course will be tailored to each patient based on analyses of initial pre-treatment biopsy assessment, thus minimizing unnecessary treatment for rectal cancer patients. Several microRNAs have been found to be involved in cancer response to therapy. High levels of miR-21 are associated with worse response to treatment, whereas patients bearing miR-21-low-level tumours have reduced risk of recurrent disease within a five-year follow-up period. In the setting of a complete tumor regression after neoadjuvant CRT, surgeons have searched for alternative management of patients in order to avoid the potential consequences of TME with or without abdominal perineal resection. Most patients with metastatic rectal cancer cannot be cured, although patients with liver and/or lung-limited disease are potentially curable with surgical resection of metastases. For other patients, palliative systemic chemotherapy is associated with an increase in survival and quality of life. Since the year 2000, new chemotherapy agents have been approved or are under evaluation in many clinical trials. Treatment must be individualized as always, taking into account goals therapy, and the toxicity profiles of each agent. We wish to express our deep appreciation to InTech for supporting the idea of publishing a book in such an innovative form. Special thanks are due to Ms. Daria Nahtigal for her constant assistance throughout the development of the project, organizing every stage of the editorial work. Special acknowledgements must be given to the authors, who are among the foremost experts with outstanding qualifications in this complex field, and who have contributed to the many chapters of this volume. Without their experience and cooperation, this book would not have been possible. [...]... relatives 10 years younger than the colorectal cancer patient are high-risk population For example, the first-degree relatives aged 50 years or older of a 60-year-old colorectal cancer patient are high-risk population for colorectal cancer. ); 22 Rectal Cancer – A Multidisciplinary Approach to Management Personal History 4 5 6 7 8 9 previous history of colorectal cancer or colorectal adenoma; ulcerative... et al., 2011 Table 5 Comparative analysis of TNM classification of tumours of the rectum, 5th, 6th and 7th edition 12 Rectal Cancer – A Multidisciplinary Approach to Management Stage Stage grouping Stage 0 Stage I Stage II Stage IIA Stage IIB Stage IIB Stage IIC Stage III Stage IIIA Stage IIIA Stage IIIA Stage IIIB Stage IIIB Stage IIIB Stage IIIB Stage IIIC Stage IIIC Stage IIIC Stage IIIC Stage... well Compared to colon cancers, the sensitivity of CT scan for detection of 4 Rectal Cancer – A Multidisciplinary Approach to Management malignant lymph nodes is higher for rectal cancers Any perirectal adenopathy is presumed to be malignant since benign adenopathies are not typically seen in this area (Thoemi, 1997) In a general form, rectal cancer shows predominance in male sex with a global worldwide... colorectal adenoma at an age . RECTAL CANCER – A MULTIDISCIPLINARY APPROACH TO MANAGEMENT Edited by Giulio Aniello Santoro Rectal Cancer – A Multidisciplinary Approach to Management. Rectal Cancer 277 Jacintha N. O’Sullivan, Mary Clare Cathcart and John V. Reynolds Chapter 16 MicroRNAs and Rectal Cancer 295 Miroslav Svoboda and Ilona Kocakova Chapter 17 Nonoperative Management. Maria Jesus Lamas, Antonio Gomez-Caamaño, Catuxa Celeiro-Muñoz, Rafael Lopez, Angel Carracedo and Francisco Barros Chapter 15 Tumor Markers of Neo-Adjuvant Chemo-Radiation Response in Rectal