Treatment of rectal cancer has its own characteristics and different from the treatment of colon cancer, it is associated with the following factors:
- The rectum is located in the pelvis, close to the other bodies.
- It does not have such an outer shell (serous), as the colon.
This disease is characterized by a high incidence of local recurrence.
To develop treatment programs impact stage of the disease, the location of the tumors, the general state of health. In general apply therapies such as surgery , radiation and chemotherapy. Consider the healing process of colon cancer in one of the largest clinics in Israel - Assuta in stages.
Treatment of colon cancer in Israel stage 0 (in situ)
Surgery is the main method of treatment at this stage. Types of operations performed:
1. Easy removal of a polyp or polypectomy is performed during colonoscopy or sigmoidoscopy with a flexible, electrical, wire loops on the endoscope. Polyp - this is not the stage 0 cancer, but cancer cells can be detected in it. If polyps detected during endoscopic diagnosis, they are removed and examined for pathological segments.
2. Local resection (local excision) conducted during colonoscopy or sigmoidoscopy for the early stages of disease (0, T1, T2, sometimes). It is carried out under general or local anesthesia.
A) Transanal excision is used if:
- The tumor is located in the lower third of the body.
- Malignant process affected less than 40% of the circumference of the rectum.
- Neoplasm is localized at a distance of eight - ten centimeters from the anal sphincter.
- Tumors of low risk.
- No spread of cancer cells through the blood vessels or the lymphatic system.
Produced tumor removal through the anus to the lower 1/3 of the rectum.
B) transanal endoscopic microsurgery (TEM) is used in the treatment of malignant tumors, which are located higher in the rectum, in the upper 2/3 of the body.
Also, for patients at all stages of the disease there is an opportunity to participate in clinical trials.
Treatment of colorectal cancer in Israel in stage I
During treatment the following techniques.
It is the basic method of treatment. Types of surgical interventions:
Local resection is performed during a colonoscopy or sigmoidoscopy. Her options:
1. Transanal excision is carried out if malignant lesions:
- It is in the bottom third of the rectum;
- not captured over 40% of the wall body on the circumference;
- localized at a distance of eight - ten centimeters from the anal sphincter;
- neoplasm is a low risk;
- there is no spread of the organism.
2. TEM is performed when the tumor is higher in the rectum.
The laparoscopic approach
Surgeons are increasingly looking to use this approach. However, it has not been studied to the same extent as in tumors of the colon. The procedure is considered more difficult to perform, because the rectum is located deep in the pelvic area. The operation is carried out several small-sized incisions in the abdomen, through which instruments and a laparoscope is introduced and removed the affected part of the body.
Low anterior resection and total mezorektumektomiya may be performed using laparoscopic techniques.
Total mezorektumektomiya (TME)
TME has become the new standard for surgery of rectal cancer, especially tumors located in the upper two-thirds of the rectum. During this procedure, the tumor is removed together with the entire peritoneal cover body (mezorektumom). Mezorektum - it's fatty tissue around the rectum that contains the main blood vessels and lymph nodes, where often there are metastases. Therefore, removal of peritoneal cover reduces the likelihood of recurrence.
Healthy end of the sigmoid colon is connected to the anal sphincter, thus, normal bowel function can be resumed. Sometimes this is not possible, and create a permanent colostomy .
Localization of the tumor, its size and how far it is from the anus will determine the application operation TME using low anterior resection or proktektomii BPE.
- Low anterior resection is selected if the tumor is localized in the upper two thirds of the body to be able to connect two severed end of the colon to create the anastomosis. This procedure removes part of the colon, sigmoid, in whole or in part of the rectum and its peritoneal covering. Often manages to maintain the normal function of the sphincter and requires only a temporary stoma.
- Abdominal-perineal extirpation of preference, when the tumor is localized in the lower rectum, to be able to complete the removal and re-connect the two ends of the colon. During the surgery removed malignant tumors invading into the muscles around the anus. Performed resection of the sigmoid colon, rectum and its peritoneal covering, anus and anal muscles, creates a permanent stoma.
- Proktektomiya with koloanalnym anastomosis may be applied if the malignant process struck 2/3 lower body. The surgeon removes part or all of the sigmoid colon and completely straight, adds the stored segment or sigmoid colon to the anal sphincter. Usually it is abdominal surgery. After proktektomii generally requires temporary stoma.
Radiotherapy may be proposed at this stage of the disease. The following types:
- Intracavitary radiation instead of surgery for early stage disease, when the size of malignant chamber does not exceed 3 cm.
- External radiation therapy after local resection, together with 5-fluorouracil (Adrucil, 5-FU).
- Brachytherapy, if there is a contraindication to surgery.
Treatment of colorectal cancer in Israel for stage II and III
Surgery remains the primary method of disease therapy. Choosing the type of operation will be driven malignancy, distance from the anus and the degree of cancer.
Total mezorektumektomiya (TME) is performed using one of the methods:
- Low Anterior Resection - if the tumor is localized high in the rectum to allow the creation of an anastomosis with the two ends of the colon.
- BPE - when the tumor is located in the lower rectum, which allows it to completely remove and re-connect the ends of the colon.
- Proktektomiya with koloanalnym anastomosis applied if pathological process struck 2/3 lower body.
This method in the treatment of colorectal cancer in Israel is often used in stages II and III, because it reduces the chance of local recurrence. Kinds:
- Neoadjuvant external exposure, often combined with 5-Fu. It can help to maintain the function of the external sphincter of the anus and avoid the need for a stoma.
- Adjuvant external beam therapy is often given in combination with 5-FU.
This method is used in the treatment of rectal cancer in Israel, II and III stages of the disease, because it reduces the risk of local recurrence. Often, combined with irradiation prior to or after surgery. If the patient is undergoing treatment with cytostatics to surgery with or without radiation therapy, chemotherapy is recommended after. The course can last for six months.
Basically, in the treatment of colorectal cancer in stage II is used is 5-fluorouracil. It may designate either alone or in combination with other drugs the following regimens:
- FOLFOX - oxaliplatin (Eloxatin) in combination with 5-FU and leucovorin.
- 5-FU and leucovorin.
- 5-Fu and capecitabine (Xeloda).
Treatment of colorectal cancer in Israel in stage IV
At this stage of the disease therapy can be successful, especially if the disease has spread to only one distant organ. Patients with good general health of metastases in only one body are candidates for surgical resection of the primary tumor and metastatic.
If the operation is not considered the possibilities offered by chemotherapy and / or radiation therapy to relieve symptoms.
In clinic Assuta operation can be offered for stage IV colorectal cancer, although the disease has spread to distant organs. The choice of surgery depends on the location of the tumor focus and extent of the disease.
- If the tumor has caused pain, bleeding or obstruction, surgery is used to remove or work around it. When the tumor overlaps rectum, colostomy may be necessary in order to prevent further complications ileus.
- In some cases, use expanding metal stent, to release the lock.
- Sometimes involve laser surgery to destroy tumors in the rectum and eliminate congestion.
- If in addition to the primary tumor has metastasized separated within easy reach and operate, they can be completely removed.
- When metastases are too broad and can not be resected, remove the segments to ease the symptoms. The initial tumor can also be left in place if it is not the cause of pain, bleeding or obstruction.
Total mezorektumektomiya (TME) is carried out using methods:
- Low anterior resection.
In the clinic for patients Assuta stage IV disease are often prescribed chemotherapy alone or in combination with radiation, usually before surgery, and frequently thereafter.
Despite the fact that it can not completely get rid of the disease, chemotherapy slows down cell growth and reduce tumor size. it is also able to prolong and improve quality of life, relieving symptoms of the disease. Sometimes it is possible to reduce the amount of malignancy to a volume when it is possible to completely remove surgically.
Types of drugs used in the treatment of rectal cancer in Israel:
- FOLFOX - oxaliplatin (Eloxatin) combined with 5-FU and leucovorin.
- FOLFIRI - irinotecan in combination with 5-FU and leucovorin.
- oxaliplatin and capecitabine
- irinotecan and capecitabine
- 5-FU and leucovorin
- FOLFOXIRI - a combination of irinotecan, oxaliplatin, 5-FU and leucovorin.
It is used in the treatment of rectal cancer in the fourth stage. It may designate separately or combined with cytostatics. It slows down the progression of the disease, reducing tumor size, improves quality of life.
Used in the clinic Assuta targeted therapies:
1. Bevacizumab (Avastin) is assigned as first-line therapy in combination with one of the following drugs or schemes:
- oxaliplatin and capecitabine
- 5-FU and leucovorin
2. Cetuximab (Erbitux) may be used as second or third line therapy of the disease at this stage. Prescribed alone or in conjunction with one of the following cytostatic drugs or treatment regimens:
- oxaliplatin and capecitabine
3. Panitumumab (Vectibix) is also among the drugs of the second or third line therapy, the disease did not respond to other chemotherapeutic agents.
This kind of treatment of colorectal cancer in the fourth step may recommend either alone or in combination with chemotherapy. Attract external radiotherapy, intracavitary brachytherapy. In palliative radiation to be appointed:
- with a view to adjusting the growth of malignant focus and relieve the pain;
- for the control of bleeding, when there is a contraindication to the surgery or the patient is opposed to surgery.
Treatment of secondary foci in the liver
If colorectal cancer has spread to the liver, and it is impossible to resort to surgery, apply one of the following methods:
- Provides delivery regional chemotherapy drugs directly into the liver via the hepatic artery. Floxuridine (FUDR) is assigned more often.
- Radiofrequency ablation - a relatively new procedure that uses high-frequency electrical current to destroy cancer cells.
- Cryosurgery uses low temperatures to destroy abnormal cells or tissues.
- Laser surgery is in the fight with cancer using high intensity rays.
- External exposure is also in order to effectively control tumor growth.
relapse treatment of rectal cancer in the Assuta
Treatment is usually aimed at alleviating the symptoms of the disease and prolong life. When the disease is returned to the primary tumor, surgery followed by administration of cytotoxic drugs to help prolong the life, and sometimes completely cured. If secondary lesions in pelvic area, liver or lung limited, they can also be surgically removed.
When the recurrence of colorectal cancer is observed in the area of initial focus, surgical treatment is used. Remove the extra health field in order to reduce the risk of the disease returning. Necessity stoma will depend on how closely a tumor was located from the anal sphincter. Operations are performed:
1. The total mezorektumektomiya (TME) using 3 methods:
- low anterior resection;
Pelvic exenteration is performed when the disease spreads to the pelvic cavity - in the urinary system (bladder and urethra), fertility (the ovaries, fallopian tubes, uterus, and cervix in women, prostate in men). During this procedure, make the removal of the sigmoid colon, straight, anus, pelvic organs and regional lymph nodes. It creates a permanent stoma and urostomy for the excretion of urine.
2. If the recurrence of cancer in the rectum causes pain, bleeding, and obstruction, resection is performed to remove or bypass the tumor. To prevent complications of intestinal obstruction may create a stoma.
3. Also stenting operation applies.
4. If distant metastases, but it is possible to remove them (e.g., liver, lung, or ovary), produced resection. In some cases, surgery is performed to chemotherapy to try to reduce the size of the hearth.
5. If too extensive metastases resected segments to relieve symptoms.
Chemotherapy targeted therapy, radiation treatment and secondary foci in the liver similar to IV treatment stage colorectal cancer.