Recent Management of Anorectal Carcinoma

Abstract

Worldwide, rectal cancer is the third most common form of cancer. In 2012, there were an estimated 1.36 million new cases of colorectal cancer and 694,000 deaths. The incidence of rectal cancer increased 3.8% per year. (Abraham et al., 2004) Accurate staging provides crucial information about the location and size of the primary tumor in the rectum, and if present, the size, number and location of any metastases. Accurate initial staging can influence therapy by helping to determine the type of surgical intervention and the choice of neoadjuvant therapy to maximize the likelihood of resection with clear margins. (Schmidt et al., 2007) Clinical evaluation and staging procedures include the following: Digital-rectal examination (DRE), Colonoscopy, Computed tomography (CT) , Magnetic resonance imaging (MRI) , Endorectal ultrasound , Positron emission tomography (PET) and Carcinoembryonic antigen (CEA). (Libutti et al., 2011) The primary treatment for patients with anorectal cancer is surgical resection of the primary tumor. Neoadjuvant therapy for rectal cancer, using preoperative chemoradiation therapy, is the preferred treatment option for patients with stages II and III disease. However, postoperative chemoradiation therapy for patients with stage II or III rectal cancer remains an acceptable option. (Sauer et al., 2004) Many new surgical trends are being developed for management of ano rectal cancer such as laparoscopic surgery and robotic surgery. (Kaufmann et al., 2007) Laparoscopic colon surgery for cancer has become the gold standard. Laparoscopic colon resection for cancer, in experienced hands, can be performed safely and reliably with many short-term benefits to the patients while resulting in at least equivalent long-term outcomes as open surgery. Other potential, but less conclusively demonstrated benefits include better preservation of cell-mediated immune function and reduced tumor cell proliferation. Although a similar level of evidence does not yet exist for the laparoscopic rectal surgery for cancer, the evidence to date suggests that it is likely that the ongoing large randomized trials will demonstrate clinical benefits of laparoscopic rectal cancer surgery. (Kim et al., 2014) There is little debate about the appropriateness of laparoscopy in the management of operable colon cancer. However, the surgical treatment of rectal cancer is not immediately comparable to that of the colon. The confined space of the pelvis, the more intimately related surrounding structures and the different pathological spread all contribute to making laparoscopic rectal cancer surgery a formidable task. Yet improved training and technology have led to comparable oncological and functional outcomes. This surgery may not be suitable for all rectal cancers, but laparoscopic rectal resection can be safe and successful in selected patients when performed by suitably experienced surgeons. (Sng et al., 2013) Robotic surgery for rectal cancer is a novel technique that has advanced the treatment of rectal cancer. Robotic surgery seems to address most of the shortcomings of laparoscopic surgery and is proven to be safe, easy to learn, and physical less taxing for surgeons. However, the high cost of robotic surgery is a major drawback. Robotic surgery may not become widespread until its obvious superiority over other methods is demonstrated in terms of oncologic and functional outcomes. (Kim et al., 2014) Presently, randomized trials to support robotic-assisted surgery for rectal cancer such as the Robotic versus Laparoscopic Resection for Rectal cancer (ROLARR) trial and Comparison of Laparoscopic-Assisted vs. Robot-Assisted surgery for rectal cancer study Group (COLARAR) trial are ongoing to address this issue. We expect that the results from these trials will help establish the robotic approach as the new standard treatment in rectal cancer surgery. (Sng et al., 2013)