Generally speaking, patients or family members of colorectal cancer (colon cancer, rectal cancer) are eager to understand the following questions once they learn that they have rectal cancer. Here the author lists the following common questions.
(1) Should the anus be removed?
(2) Is it suitable for anal preservation surgery?
(3) Concerns about radiotherapy.
(4) Should I take chemotherapy?
Each of these questions is discussed below.
It is recognized that the most effective treatment for rectal cancer is surgery.
(1) Should we remove the anus?
If rectal cancer ① is too close to the anus, or ② is too large, or ③ is too malignant, or ④ is widely metastasized around the rectum, or ⑤ is distantly metastasized and not suitable for anal preservation surgery, it is feasible to excavate the anus (Miles surgery). Specifically: Huang Ping, Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University
①Tumor is too close to the anal sphincter, such as tumor is within 4 cm from the anus.
Doctors are restricted by conditions and worry that the cut will not be clean and that it will be difficult to connect the colon to the anus after resection, so for the safety of patients, the anus is removed.
②Low rectal cancer with large tumor
Transabdominal resection is difficult, and excision of the anus (i.e., doing the upper and lower together) provides convenience for resecting the specimen.
Generally speaking, e-colonoscopy reports that tumors longer than 5 cm indicate larger tumors.
③Low rectal cancer with high tumor malignancy
If the surgeon does rectal finger examination shows that the tumor is diffuse (it can be written in the outpatient medical record), the tissue taken under e-colonoscopy and sent for pathological examination is reported as mucinous adenocarcinoma or indolent cell carcinoma. Considering the possibility of local recurrence in the pelvic cavity after surgery, the local recurrence caused obstruction to defecation due to the pressure of the intestinal tube left in the pelvic cavity. In this case, anal preservation surgery is not applicable, and anal excision surgery should be performed.
④Low rectal cancer with extensive lymph node metastasis in the rectal mesentery detected by CT examination
Such patients often have lymph node metastasis outside the scope of resection (outside the pelvic fascia), and local recurrence in the pelvic cavity is more likely after surgery, and local recurrence causes bowel obstruction due to pressure on the intestinal tube left in the pelvic cavity. It is not suitable to perform anal preservation surgery, and it is better to do excisional anus surgery.
Rectal lymph node metastasis, in the pelvic CT manifested as “cotton wool” or “snowflakes” around the rectum, “cotton wool” or “snowflakes The more “cotton wool” or “snowflakes” there are, the more lymph node metastasis in the rectum.
⑤ Low-grade rectal cancer with liver or lung metastasis detected by CT examination.
Although medical oncologists do not advocate excavation surgery, and believe that as long as the primary focus does not cause obstruction or stricture or bleeding, surgery should not be operated, and medical oncologists believe that surgery is more traumatic than radiotherapy or chemotherapy. But in fact, as long as a professional doctor does excavation anal surgery for rectal cancer patients, they will recover in 3-5 days after surgery. In contrast, radiotherapy or chemotherapy has lasting damage to patients, with greater side effects and more pain for patients.
Many scholars believe that: most of the primary lesions without excision will cause obstruction, and once the obstruction is removed, surgery is worse in terms of both surgical risk and tumor removal rate; moreover, the presence of primary lesions is often accompanied by symptoms such as anal mucus flow, discomfort caused by tumor extrusion in the pelvis, tumor consumption, etc. Therefore, it is generally advocated to excise the primary lesions as soon as possible after clear diagnosis, and then see if the metastatic lesions can be treated by other means such as chemotherapy. Therefore, it is generally recommended to remove the primary lesion as soon as possible after clear diagnosis, and then see if the metastatic lesion can be treated by other means such as chemotherapy. In conclusion, excision of the anus greatly improves the patient’s quality of life after surgery.
The biggest advantage of excisional anus is that it is easy to operate and the specimen can be removed from the top down or from the bottom up. However, unless rectal cancer infiltrates the anal sphincter, no cancer cells can be found in the anal and perianal tissues (lymphatic fatty tissue in the sciatic canal space) after the surgery.
(2) Is it suitable for anal preservation surgery?
After rectal cancer is detected, only patients who meet the requirements of (1) good anal function, (2) good general condition, and (3) relatively good tumor characteristics can be suitable for anal preservation surgery. Such patients are not prone to local recurrence in the pelvis after anal preservation surgery, and the anus can control exhaustion and defecation well. Huang Ping, Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University ① Good anal function: Only preoperative rectal finger examination shows that the patient has good anal contraction function, and such patients can control exhaust and defecation after anal preservation. Occasionally, elderly and thin patients with poor anal contraction function are not suitable for anal preservation surgery ② Good whole body condition: preoperative CT examination does not reveal distant metastases (such as liver and lung metastases), and patients with good physical condition can do anal preservation surgery. The recovery of bowel function often takes about 6 months (3-12 months) to be close to or similar to that of a normal person after anal preservation surgery; before recovery, the stool is often frequent or constipated, and frequent stools are more common, sometimes 5 to 10 times a day, because the original rectum has been basically removed, the “new rectum” is in the compensatory period, and patients with poor health This is because after the original rectum has been largely removed, the “new rectum” is in the period of compensation, poor health patients need to frequent the toilet and not too much to eat. Patients with distant metastases often die soon after their bowel function is restored and before they can fully enjoy the fruits of anal preservation surgery. The tumor characteristics are relatively good: a. The general pathology is limited, not “overwhelming” growth, i.e., not diffuse growth, generally occupying no more than 1/2 week of the intestinal wall, with a depth not exceeding the thickness of the rectal mesentery and not infiltrating the pelvic wall (at this time, rectal finger examination shows that the tumor is active). b. The histopathology is well differentiated rectal adenocarcinoma, not poorly differentiated mucinous adenocarcinoma or indolent cell carcinoma. c. Tumor with the lower edge more than 5 cm from the anus, i.e., tumor with 1 cm distance from the upper edge of the anal sphincter, not rectal cancer that has infiltrated the anal sphincter. Under special circumstances, early rectal cancer located within the submucosal layer at a distance of 3 cm from the anus is also feasible for anal preservation surgery through the sphincter gap.
(iii) Concerns about radiotherapy
The most effective treatment for rectal cancer is surgery, which is recognized by the medical profession.
① In the general theory of oncology, radiotherapy and chemotherapy are generally preferred for squamous or basal cell carcinoma of the anus, while rectal cancer is classified as a tumor with relatively poor sensitivity to radiotherapy and chemotherapy. Preoperative radiotherapy or postoperative radiotherapy has certain effect on rectal cancer; however, it has certain side effects and even serious complications.
②The sensitivity of tumor to radiotherapy is closely related to the lack of oxygen cells, which are less sensitive to radiotherapy. The smaller the tumor is, the more sensitive it is to radiotherapy; the larger the tumor is, the less sensitive it is, mainly because the larger the tumor is, the more oxygen-depleted cells there are in it. Often, surgeons find that rectal cancer is larger, and they think it is difficult to operate and give up the operation, and hand over to radiotherapists to deal with it, hoping that the tumor will become smaller and then be removed surgically. However, it is not known that the sensitivity of large tumor to radiotherapy is very poor, and the tumor does not become smaller after a long time of radiotherapy. Huang Ping, Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University
③The anal canal is about 4 cm; the rectum is about 12 cm, divided into low, middle and high. Middle and high rectum refers to rectum more than 8 cm from the anus, which has been located above the peritoneal regurgitation, and there is small intestine above the peritoneal regurgitation. The effective dose of radiotherapy for rectal cancer is at least 45 Gy or more, but the small intestine is not tolerated by more than 20 Gy (manifested as abdominal pain, intestinal obstruction and intestinal perforation), so we should be cautious whether the patients with middle and high rectal cancer above 8-12 cm from the anus are suitable for radiotherapy. Huang Ping, Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University
④ It is believed that after preoperative radiotherapy, about 25% of tumors are completely regressed (but more than 50% of cancer cells are still found to remain after surgery), 50% of tumors are reduced in size, and 25% of tumors have no effect. However, the metastatic pathway of rectal cancer lymph nodes is mainly the rectal mesentery and develops to the base of the sigmoid mesentery, so radiotherapy does not cover the base of the sigmoid mesentery, so radiotherapy cannot replace surgery. If patients with rectal cancer are treated with preoperative radiotherapy, surgery is still needed after radiotherapy.
⑤ Generally, it takes 1 month for preoperative radiotherapy, and 1 month of rest is needed before surgery. Although radiotherapy may shrink the tumor, some people worry that 2 months may increase the chance of distant metastasis of cancer cells to liver, lung and other distant organs.
(6) Although postoperative radiotherapy does not delay the surgery. However, if postoperative radiotherapy exceeds 45Gy, the side effects of radiotherapy increase significantly. Early complications: radioactive cystitis, radioactive proctitis, radioactive small bowel inflammation, intestinal perforation; late complications: intestinal fistula, rectal-vesical fistula, intestinal obstruction, etc. These complications cause a lot of pain to the patients, and radiotherapists are definitely handed over to surgeons at this time, but experienced surgeons usually do not dare to accept patients to the surgical ward, and even if they accept down, they do not dare to operate.
(7) Heald, a famous surgical expert, reported that the local recurrence rate after radical total mesorectal resection without radiotherapy for rectal cancer was less than 5%.
(D) Should I take chemotherapy?
One of the most common issues considered by patients’ families after surgery for colorectal cancer (colon cancer, rectal cancer) is the use of chemotherapy to prevent recurrence, so we will talk about whether chemotherapy after surgery for colorectal cancer (colon cancer, rectal cancer) is meaningful or not.
1. Tumors are divided into three, six, nine, etc. Among all tumors, it has been recognized by the medical profession that some tumors are suitable for chemotherapy: such as lymphoma, seminoma, leukemia, choriocapillary epithelial carcinoma, malignant staphyloma, breast cancer, etc.; some tumors are sensitive to radiotherapy: such as nasopharyngeal carcinoma, anal basal cell carcinoma, anal squamous carcinoma, esophageal cancer, etc.; some tumors are suitable for surgery: such as colorectal cancer, papillary thyroid cancer, etc. In the general theory of oncology, colorectal cancer (colorectal cancer) belongs to the category of less sensitive to chemotherapy. So far, the most effective treatment for colorectal cancer is recognized as surgery. No patient with colorectal cancer has ever been seen to be cured by chemotherapy without surgery.
Some surgical experts of Shanghai Cancer Hospital hold the same view.
2. After radical surgery for colorectal cancer (colon cancer, rectal cancer) (about half of the patients have lymph node metastasis reported by postoperative pathology) some patients survive for more than 5 years or a lifetime due to poor economic conditions without chemotherapy, and some patients with very good economic conditions often die from chemotherapy side effects or excessive chemotherapy. The most authoritative and famous international colorectal cancer specialist Heald also does not give chemotherapy or radiotherapy to patients, Heald reported that local recurrence after radical total mesorectal resection does not exceed 5%.
3, through the follow-up of patients after radical resection of colorectal cancer, there are foreign literature reports in favor of chemotherapy, and there are also many literature reports that chemotherapy is ineffective. There are also reports of drug resistance after one course of chemotherapy (clinically, patients are often given 6 months and 6 courses of the so-called regular course of chemotherapy). Many patients who have had regular chemotherapy come to our clinic with relapse, which means that chemotherapy is not effective for this group of patients. There is also the possibility that chemotherapy not only fails to kill cancer cells, but also damages the patient’s immune system, which in turn encourages the spread and growth of cancer cells.
4. In the early stage after radical surgery for colorectal cancer (colon cancer, rectal cancer), it is difficult to assess whether chemotherapy is effective or not because the target location cannot be detected by ultrasound or CT imaging. If there are no cancer cells in the body after radical surgery, chemotherapy is definitely a superfluous act and an added burden. If there are residual cancer cells in the body, theoretically speaking, they cannot be cured by chemotherapy, because chemotherapy kills cancer cells exponentially and cannot kill all of them. Therefore, theoretically speaking, there may be no difference between early chemotherapy and late chemotherapy, both of which cannot cure all cancer cells.
If distant metastases are found and cannot be removed surgically, there is no other way to try chemotherapy. The effect of treatment can be evaluated by ultrasound, CT and other imaging examinations, and chemotherapy should be stopped if there is no effect. If there is effect, imaging review should be performed regularly to find out when the tumor will become drug resistant.
6. Doctors dare not guarantee that chemotherapy after radical surgery for colon cancer (colon cancer, rectal cancer) will have significant effect. It depends on the patient’s family’s attitude whether to have chemotherapy or not.