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Preoperative Evaluation of the Patient with Rectal Cancer: Staging and Strategy
Introduction
The aims of the preoperative evaluation of a patient with rectal cancer are to assess both the patient and the tumor and offer a tailored treatment plan that optimizes both cure and sphincter preservation. Accurate staging of rectal cancer is the foundation upon which the choice of the best therapeutic strategy rests. Locoregional staging assists in selecting patients who can benefit from neoadjuvant chemoradiation treatment and in determining the extent of surgery. Early-stage rectal cancer can be treated by local excision or radical resection alone, but T3 cancers with a threatened circumferential resection margin (CRM) may be best managed by neoadjuvant chemoradiation followed by surgery. This approach, when combined with skillfully performed surgery, is associated with the lowest recurrence rates.
In this chapter we discuss our approach to preoperative evaluation of rectal cancer, including clinical assessment, endoscopic evaluation and biopsy, locoregional staging with endoscopic rectal ultrasound and/or magnetic resonance imaging (MRI), and investigation for distant metastases with computed tomography (CT) and other modalities. Finally, we discuss the role and importance of the multidisciplinary team in preoperative evaluation.
Clinical Assessment
History
A detailed cancer-specific history is an important initial step to elicit symptoms that may indicate the location and degree of disease. An asymptomatic patient may have an early, localized tumor, whereas a change in bowel habits and rectal bleeding may be symptoms of a more advanced tumor. Furthermore, tenesmus, anal pain, and incontinence are characteristics of an advanced distal lesion that is impinging on the anal sphincter. Constitutional symptoms including weight loss, anorexia, and fever may be indicators of systemic disease.
Obtaining a complete family history is important to screen for hereditary cancer syndromes and at times to refer the patient for genetic counseling. Any patient with rectal cancer who is younger than 50 years should be referred, along with patients who have at least one affected first-degree relative.
Finally, the history should elucidate prediagnosis bowel habits and fecal continence, as well as risk factors for postoperative fecal incontinence. Risk factors include previous anorectal surgery or trauma, vaginal deliveries with or without episiotomies or tears, and relevant neurologic disorders.
Physical Examination
Precise preoperative assessment of a rectal cancer by the operating surgeon through use of digital rectal examination and rigid proctosigmoidoscopy is critical. Digital rectal examination should include assessment of the distance between the lower border of the tumor and the anorectal ring, its fixation to the sphincters and to any adjacent structures (e.g., vagina, prostate, sacrum), the position of the tumor (anterior, posterior, or lateral), and the patient’s sphincter tone and integrity ( Table 28-1 ). After this examination, the surgeon can often determine whether the patient is a candidate for sphincter-saving surgery (i.e., low anterior resection or intersphincteric resection with colorectal or coloanal anastomosis) or will need an abdominoperineal resection.
TABLE 28-1
Tumor Characteristics upon Digital Rectal Examination and Rigid Sigmoidoscopy That Are Important to Assess and Document Preoperatively
| Distance from the anorectal ring |
| Position of the tumor Anterior Posterior Lateral |
| Degree of circumferential involvement |
| Mobility Mobile Tethered Fixed |
| Fixation to the sphincters |
| Fixation or invasion to adjacent structure Vagina/prostate Sacrum Pelvic side wall |
| Sphincter Resting and squeeze tone Defect |
Abdominal examination should include inspection for prior incisions and evaluation for abdominal distention when an obstruction is suspected. Furthermore, for patients in whom a stoma is anticipated, the right and/or left lower quadrant stoma site should be marked. Ideally, this marking is performed by enterostomal therapists at a site that will minimize postoperative stoma complications.
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