Diagnostic and treatment of Rectal cancer

Rectal cancer is a malignant tumor of the mucous membrane of the corresponding organ. This is the distal part of the intestine about 15 cm long. Rectal cancer can be posterior ampullary (the tumor appears at a distance of up to 5 cm from the edge of the anus), lateral ampullar (5-10 cm) and anterior ampullar (10-15 cm). The localization of the tumor affects the choice of surgical treatment method for the disease. Rectal cancer is successfully treated abroad with surgery, radiation, and chemotherapy. In the advanced stages, targeted immunotherapies are carried out, as well as ablation, chemoembolization, and radiation therapy to suppress distant metastases.

Content

1. Diagnostics of rectal cancer
2. Treatment of rectal cancer by stages
3. Drug therapy
4. Targeted therapy for metastases
5. Why you should undergo treatment abroad
6. Treatment in Europe with Booking Health

Diagnostics of rectal cancer

Most countries carry out screening for rectal cancer. The tumor can be detected in time using laboratory and instrumental methods. Doctors do stool tests for occult blood, fecal DNA, digital rectal examination, bowel CT, sigmoidoscopy, or colonoscopy.

Endoscopic examination of the intestine is the most common method of diagnosis. With the help of sigmoidoscopy or colonoscopy, the doctor can examine the colon, including in the distal section, detect a tumor and perform a biopsy – obtain a tissue fragment for histological examination using forceps.

Its clarification is required after confirming the diagnosis. Doctors should determine the stage of cancer: assess the depth of invasion of the rectal tumor and the presence of metastases in the lymph nodes and distant organs. It is also necessary to determine the histological type of cancer, the degree of malignancy, and the presence of mutations in genes – they make cancer a target for targeted or immunotherapy.

To assess the characteristics of the primary tumor, the following diagnostic options are used:

• Endoanal ultrasound
• Endorectal MRI
• Pelvic CT
• Chest X-ray
• Abdominal ultrasound
• Positron emission tomography (if distant metastases are suspected)

Genetic tests detect KRAS, NRAS, and BRAF mutations, as well as microsatellite instability (MSI).

Treatment of rectal cancer by stages

The earlier the disease is detected, the less traumatic the treatment will be for the patient and the less required treatment procedures. The chances of curing the disease are much higher in the initial stage, although doctors achieve good results at stages 3-4.

In situ cancer is limited to the mucosa and requires minimally traumatic endoscopic treatment. The doctor inserts a tube with a camera through the anus and removes a polyp or a section of the mucous membrane along with the tumor. The resection margins are then examined. If the cancer has not spread deeply and the resection margins are clean, the scope of treatment is considered adequate. The patient is monitored, but he does not need additional medical procedures.

Stage 1. The cancer has already penetrated deep into the intestinal wall but has not yet spread beyond the rectum. In some patients, treatment may still be minimally invasive and endoscopic. Doctors perform transanal resection or use transanal endoscopic microsurgery. The tumor is removed through the anus. In other cases, a lower anterior resection (LAR), proctectomy (removal of the rectum) with a coloanal anastomosis, or abdominoperineal resection (APR) is performed depending on where the rectal tumor is located. As a rule, no other treatment than surgery is required for the patient.

Stage 2. Rectal cancer has not yet spread to the lymph nodes but has already penetrated through the wall of the rectum. The treatment is usually combined. It involves not only surgery but also radiation therapy and chemotherapy. Radiation and chemotherapy are often used simultaneously as part of chemoradiotherapy. The treatment begins with it in many patients, and then surgical intervention is performed – when the rectal tumor decreases in size. After chemoradiotherapy, the most common surgeries are abdominoperineal resection, low anterior resection, or proctectomy with coloanal anastomosis. The choice depends on the location of the neoplasm.

Not only the primary tumor is removed, but also the lymph nodes. This is carried out simultaneously for diagnostic and therapeutic purposes. Removed lymph nodes are examined for cancer to ensure there are no metastases. Their presence or absence affects the treatment tactics. In addition, lymphadenectomy allows the doctors to remove potential sources of regional recurrence if there are still metastases of rectal cancer in the lymph nodes.

Sometimes chemotherapy and radiation therapy may reduce the size of a rectal tumor so that a doctor can perform a transanal resection. This is a minimally invasive endoscopic surgery. The patient can avoid the placement of a colostomy while fully preserving the function of the lower intestine. However, there is a minus; lymph nodes are not removed or examined during this operation. Recurrences in these patients are more common, so they need accurate postoperative monitoring.

Surgery is followed by chemotherapy. Usually, it includes 6 cycles. Different regimens are used: FOLFOX, CAPEOX, and sometimes chemotherapy is performed with only one drug. The choice depends on which treatment is best suited to the patient, taking into account the state of his health.

Stage 3. Metastases appear in the lymph nodes. Patients with rectal cancer usually receive chemotherapy, radiation therapy, and then surgery. In terms of human health, it is safer to perform radiation therapy before surgery than after it. Operations are carried out in the same way as in stage 2 of the disease. However, in some patients, the rectal tumor has already spread to surrounding organs. In such cases, pelvic exenteration is performed. Doctors remove part of the intestine with the surrounding tissues and nearby pelvic organs involved in the tumor process. After surgery, patients with rectal cancer undergo 6 cycles of chemotherapy.

Stage 4. Treatment of rectal cancer depends on the characteristics of the primary tumor, its local extension, the number of distant metastases, and the state of human health. If rectal cancer metastases are rare, the doctor may try to treat the disease. He removes the rectum. At the same time, resection of single metastatic foci is performed, for example, in the liver or lung.

Treatment options for advanced rectal cancer are:

• Surgery followed by chemotherapy
• Chemotherapy, surgery, and then chemoradiotherapy
• Chemotherapy, chemoradiotherapy, surgery, and chemotherapy again
• Chemoradiotherapy, surgery, and then chemotherapy

In advanced stages of rectal cancer, targeted immunotherapy is often used. For local control of metastases, radiation, ablation, and chemoembolization are carried out.

Drug therapy

Systemic treatment methods come to the fore when the tumor extends to distant lymph nodes and organs. In addition, if there are single metastases, doctors may try to remove them, destroy them with radiation, or control them in other ways.

Systemic treatment methods for rectal cancer include:

• Chemotherapy
• Targeted therapy
• Immunotherapy

Drugs are administered intravenously or the patient takes them orally in the form of pills. They enter the systemic circulation, which means that they can affect all tumor foci, regardless of their location. The drugs destroy small metastatic tumors and reduce or stop large neoplastic growth.

For targeted therapy of rectal cancer, the following drugs are used abroad:

• VEGF inhibitors to suppress the formation of new vessels that supply the tumor
• EGFR inhibitors, which prevent the rapid division of cancer cells
• BRAF inhibitors are used in 10% of patients with mutations in the corresponding gene
• Kinase inhibitors as a last-line therapy when other methods fail

Immunotherapy for rectal cancer is carried out with immune checkpoint inhibitors. These advanced drugs are used if tumor samples show high levels of microsatellite instability (MSI-H) or changes in one of the DNA mismatch repair (MMR) genes. Doctors use PD-1 and CTLA-4 inhibitors. They reduce the ability of the tumor to evade the immune response. Since checkpoint inhibitors do not have a direct toxic effect on either the tumor or normal cells of the body, the treatment is well tolerated by patients and in most of them, is safe for health.

Targeted therapy for metastases

Stage 4 is usually considered incurable, and doctors rarely perform surgery on such patients. However, some of them have a small number of distant metastases. Therefore, in a good response to systemic therapy and a satisfactory state of health in general, these people can undergo surgical treatment. During the advanced combined surgeries, doctors remove not only the primary tumor in the intestine but also distant metastatic foci in another organ.

Distant metastases most often appear in the liver. They cannot always be removed during surgery. However, alternative treatment options ensure the total destruction of the tumor. They are resorted to if there are contraindications to the operation, including the patient's weakened health.

The following options for suppressing liver tumors are used:

• Hepatic artery chemoembolization
• Ablation
• Stereotactic radiation therapy

In small neoplasms located far from large bile ducts and vessels, doctors perform radiofrequency ablation of tumor foci. They insert a probe into the center of a metastatic tumor and heat it up. As a result of exposure to high temperature, a zone of necrosis is formed. This is a minimally invasive percutaneous procedure: a probe is inserted through a skin puncture. Less often, doctors resort to non-traumatic laparoscopic surgery to deliver a probe to the tumor.

Other ablation options can be:

• Alcohol-based (ethanol)
• Microwave
• Cryoablation
• Destruction of the tumor by high-intensity focused ultrasound is an innovative ablation method that is performed without skin incisions and punctures.

In large metastatic tumors, as well as in the case of location near the vessels and bile ducts, hepatic artery chemoembolization is considered the preferred treatment method. The essence of this procedure is the blockage of blood vessels that supply the tumor with drug-saturated microspheres. They not only deprive the cancer cells of the blood supply, but also destroy them within a few weeks with chemotherapeutic agents, which are gradually released from emboli. After this advanced procedure, the metastatic cancerous tumor is reduced in size by several times, and in some patients, it disappears completely.

Sometimes stereotactic radiation therapy is used to suppress a metastatic tumor. Modern linear accelerators deliver radiation precisely to the tumor, from different angles, in high doses, which allows the doctors to reduce the number of sessions to a minimum.

Why you should undergo treatment abroad

If you are undergoing treatment abroad, you can expect better results and minimal health risks. European clinics have modern medical equipment. They employ specialists with high authority in the world of medicine. There are a few reasons for you to undergo treatment abroad:

• Minimally invasive endoscopic surgeries in the initial stages of rectal cancer
• Laparoscopic, robot-assisted interventions
• Doctors strive to preserve the rectal obturator to provide the patient with the possibility of independent defecation, if possible.
• Complex combined operations are performed in the advanced stages, which are effective even in the presence of distant metastases.
• Advanced methods of radiation therapy are used: very accurate, with minimal risk of post-radiation complications.
• The latest drugs are used: not only chemotherapy but also targeted therapy and immunotherapy.
• Modern methods of controlling distant metastases are available, including ablation, chemoembolization, stereotactic radiation therapy, and high-intensity focused ultrasound.

Treatment in Europe with Booking Health

To undergo rectal cancer treatment in one of the European hospitals, you are welcome to use the Booking Health services. On our website, you can find the cost of treatment and compare prices in different clinics to book a medical care program at a favorable price. Treatment in Europe will be easier and faster for you, and the cost of treatment will be decreased. Average costs of certain procedures are as follows:

1. Da Vinci treatment for rectal cancer – 27,400 EUR
2. Surgical treatment of rectal cancer with endoscopic resection – 25,100 EUR
3. Treatment of colorectal cancer with radiation and chemotherapy – 21,500 EUR

The average price of oncological rehabilitation after rectal cancer treatment is 1,190 EUR per day, the minimum price is 1,041 EUR per day, and the maximum price is 1,553 EUR per day. Please leave a request on the Booking Health website. Our specialist will contact you and hold a consultation on treatment in Europe. Booking Health will fully arrange your trip to another country. We will provide you with the following benefits:

• We will select the best European hospital whose doctors specialize in the treatment of rectal cancer.
• We will help you overcome the language barrier and establish contact with the doctor in the European hospital.
• We will reduce the waiting period for the beginning of the medical care program. You will receive treatment on the most suitable dates.
• We will reduce the prices. The cost of treatment in Europe will be reduced due to the lack of overpricing and additional coefficients for foreign patients.
• We will solve any organizational issues: we will prepare the documents, meet you abroad and take you to the hospital, book a hotel, and provide an interpreter.
• We will elaborate on the medical care program and translate medical documents. You will not have to undergo previously performed diagnostic procedures.
• We will help you keep in touch with doctors after treatment in Europe.
• We organize additional examinations and treatment in a European hospital.
• We will buy medicines in another country and forward them to your native country.
• We will buy medicines in another country and forward them to your native country.

The world's leading doctors will take care of your health. The Booking Health specialists will help you reduce the cost of treatment, organize your trip to a European hospital, and you can fully focus on restoring your health.

Authors: 

The article was edited by medical experts, board certified doctors Dr. Vadim Zhiliuk and Dr. Sergey Pashchenko. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!

Our editorial policy, which details our commitment to accuracy and transparency, is available here. Click this link to review our policies.

Sources:

National Cancer Institute

American Society of Colon and Rectal Surgeons

Annals of Oncology