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Pre-operative evaluation of patients with low rectal carcinoma

  • World Progress In Surgery
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Abstract

Advances in surgical technique and adjuvant therapy have broadened the spectrum of treatment available for patients with low rectal cancer. Combination of careful pre-operative clinical examination with newer, more sophisticated techniques, particularly in the field of imaging, can stage the extent of disease more accurately then previously. Adoption of an extended pre-operative evaluation allows a more rational approach to treatment in the individual, and standardizes criteria for entry into, and interpretation of, future clinical trials.

Résumé

Les progrès enregistrés en matière de technique chirurgicale et de traitement adjuvant ont élargi la panoplie thérapeutique pour les patients ayant un cancer du rectum. La combinaison d'un examen clinique préopératoire soigneux et de techniques plus sophistiquées, telle l'imagerie moderne, conribue à un bilan d'extension plus précis qu'avant. Un tel bilan préopératoire permet une approche rationnelle de chaque patient, et le recueil d'informations importantes pouvant guider la conduite et l'interprétation d'essais thérapeutiques futurs.

Resumen

Los avances en la técnica quirúrgica y en las terapias adyuvantes han ampliado la perspectiva terapéutica en los pacientes con cáncer del recto distal. La combinación de un meticuloso examen clínico preoperatorio con las nuevas y sofisticadas técnicas de diagnóstico, especialmente en el campo de la imagenología, ha logrado realizar la estadificación de la enfermedad en forma más certera. La adopción de una extensa valoración preoperatoria permite un aproche más racional al tratamiento en cada caso individual y la mejor estandarización de criterios para iniciar e interpretar ensayos clínicos futuros. Son cuatro los parámetros de importancia en cuanto a pronóstico en un paciente con carcinoma rectal: el grado de invasión local intrapélvica, el estado de los ganglios locales, el grado de diferenciación tumoral y la presencia de metástasis distantes. Las técnicas imagenológicas más usadas para determinar el grado de extensión intrapélvica son la tomografía computadorizada (TC) y la ultrasonografía endoluminal transanal. La resonancia magnética ha demostrado ser menos precisa. La ultrasonografía endoluminal es más precisa que la TC en cuanto a detectar invasión linfática, y la linfoescintigrafía y linfografía carecen de utilidad. El grado de diferenciación histológica del tumor se logra con la toma de múltiples biopsias mediante el sigmoidoscopio; el estudio de citometría de flujo permite establecer el contenido nuclear de DNA y la ploidia celular; esta técnica puede lograr creciente aceptación en el futuro. La valoración de metástasis distantes se obtiene mediante tres téchnicas principales de imagenología: la ultrasonografía, la escanografía con isótopos y la TC, siendo la TC el método de elección. Niveles elevados de antígeno carcinoembriónico permiten predecir la existencia de enfermedad metastásica.

Entre 2% y 9% de los pacientes con carcinoma rectal distal presentan un segundo carcinoma en el colon, y un porcentaje mucho mayor exhibe pólipos sincrónicos, por lo cual todo paciente con carcinoma rectal debe ser sometido a examen de la totalidad del colon, idealmente mediante colonoscopia.

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  1. The Surgical Unit., The Royal London Hospital, London, United Kingdom

    Paul Durdey M.S. (F.R.C.S.) & Norman S. Williams M.S. (F.R.C.S)

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  2. Norman S. Williams M.S.
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Durdey, P., Williams, N.S. Pre-operative evaluation of patients with low rectal carcinoma. World J. Surg. 16, 430–436 (1992). https://doi.org/10.1007/BF02104443

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