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Rectal Cancer. TME SPHINCTER - SAVING SURGERY AFTER CHRT. ENDPOINT: SURVIVAL ● Lower edge of resection: less than 1 cm ● Full-thickness local excision in complete or near complete responders? N+ risk? Relapsing rate?. Rectal Cancer.

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TME SPHINCTER - SAVING SURGERY AFTER CHRT

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Tme sphincter saving surgery after chrt

Rectal Cancer

TME SPHINCTER - SAVING SURGERY

AFTER CHRT

ENDPOINT: SURVIVAL

● Lower edge of resection: less than 1 cm

● Full-thickness local excision in complete or near complete responders?

N+ risk? Relapsing rate?


Prediction of mesorectal n after preop ch rt

Rectal Cancer

PREDICTION OF MESORECTAL N+AFTER PREOP. (CH)RT

RTCHRT

pT (147) (138)

0 0/11/21

1 0/31/12 6%

2 15/53 13*/50

3-4 54/85 28/51

*few cancer foci in 5 pts.

Bujko, Radioth. Oncol. 2005


Tme sphincter saving surgery after chrt

Rectal Cancer

CLINICAL COMPLETE RESPONSE TO NEOADJUV. CHRT

(488 pts. clinically staged T 3-4 or N+ before CHRT)

 cCR is a poor predictor of pCR

 Incidence of occult node-positive disease is relatively high

 Small but deep tumor cells are characteristic of cCR patients: viable tumor?

 A longer waiting period after completion of neoadjuvant therapy can alter the pCR rate

HIGHER RISK FOR LOCAL SURGERY?

MSKCC, J. Am. Coll. Surg. 2002


Tme sphincter saving surgery after chrt

Rectal Cancer

LOCAL EXCISION AFTER CHRT

Median %

No.

All the patients

1,175

Local Excision*

(8-35)

12.7

(3.5-100)

135

* Median age 60.5 yrs. (48-63)

* Median FU 38 mos. (19-48)

Kim 2001, Shell 2002, Lezoche 2002, Ruo 2002, Crane 2003, Bonnen 2004, Osti 2004, Caricato 2006


Tme sphincter saving surgery after chrt

Rectal Cancer

LOCAL EXCISION AFTER CHRT (cT3)

LOCAL RELAPSES IN 546 PTS

No.

%

27/490

5.5

Radical surgery (TME)

M.D.Anderson Hosp, IJROBP 2008

SELECTION CRITERIA?

Local excision

8/56 14.3


Tme sphincter saving surgery after chrt

THE REGINA ELENA NATIONAL CANCER INSTITUTE

Rome, Italy


Tme sphincter saving surgery after chrt

Rectal Cancer

PERSONAL EXPERIENCE

No.

%

All the pts. undergone CHRT and Surg.

220 (cT3-4 before CHRT)

63

Median age (yrs)

Median F.U. (mos.)

42 (24-280)

TME Sphincter-saving surgery

172 89.1

TME Abdominoperineal excision

24 10.9

Local excision 24 10.9

Median age (yrs.) 68

Median FU (mos.) 40 (24-280)


Tme sphincter saving surgery after chrt

Rectal Cancer

5-Yr Survival after CHRT and Surgery

82.2 %

70.0 %

%

12

24

36

48

60

months


Tme surgery after chrt

Rectal Cancer

TME SURGERY AFTER CHRT

No. %

Pts. 196

pT0-1 42 21.4

N+ 2/42 4.7


Tme surgery after chrt 196 pts

Rectal Cancer

TME SURGERY AFTER CHRT (196 pts.)

Relapses 39 19.8

Local 12 6.1

Distant 27 13.7

Second primary 5 2.5

Median Range

TTP (mos.) 15 (2-77)

Follow-up (mos.) 40


Tme sphincter saving surgery after chrt

Rectal Cancer

SURGERY AFTER HIGH-DOSE PELVIC XRT AND CONCURRENT I.V. CH.

5-Yr. DFS by lower edge of resection (min. f.u. 2 yrs.)

63.8 %

61.7 %

%

p = n.s.

12

24

36

48

60

months


Tumor regression grade mandard 1994

TUMOR REGRESSION GRADE(Mandard 1994)

TRG4

TRG2

  • TRG1: absence of residual tumor cells

  • TRG2: rare residual cancer cells scattered through fibrosis

  • TRG3: increased number of residual cancer cells but fibrosis still predominant

  • TRG4: residual cancer cells outgrowing fibrosis

  • TRG5: absence of regressive changes


Tme sphincter saving surgery after chrt

Rectal Cancer

A PROGNOSTIC ROLE FOR TRG ?

(111 pts. with minimum f.u. of 36 mos.)

TRGResp. No Resp.

1-270.829.2

3-536.763.3

p=.01


Uni and multivariate analysis of overall and disease free survival

Uni- and multivariate analysis of Overall and Disease-Free Survival

TRG 1


Tme sphincter saving surgery after chrt

Rectal Cancer

5-Yr DFS by TRG (143 pts.)

72.2 %

58.2 %

%

p=.04

12

24

36

48

60

months


Local excision after chrt

Liver Cancer

LOCAL EXCISION AFTER CHRT

TRG Classification

1

1

3

No. of Pts. 24

10

5


Local excision after chr 24 pts no

Rectal Cancer

LOCAL EXCISION AFTER CHR (24 Pts)No.

%

Relapses 6 25

Local 5*

Distant 1

*1 mesorectal, 4 local radical surgery NED

1 mucin lakes

MedianRange

TTP (mos) 8 (2-28)


5 yr surv after chrt and tme surgery

Rectal Cancer

5-Yr Surv. after CHRT and TME Surgery

5-Yr Survival after CHRT and LE

95.0 %

72.0 %

80.6 %

69.7 %

12

24

36

48

60


Tme sphincter saving surgery after chrt

Rectal Cancer

SPHINCTER-SAVING SURGERY AFTER CHRT

CONCLUSIONS

Lower edge of resection < 1 cm is not correlated with higher risk of local relapse

 Local excision could be adequate for well selected complete responders


Tme sphincter saving surgery after chrt

Colorectal Cancer

THE COLORECTAL DISEASE

MANAGEMENT TEAM

Coordinator: M. Cosimelli

Surgery

Med. Onc.

Biology

Radiotherapy

Surgery

Med. Onc.

Biology

Radiotherapy

F. Ambesi

Impiombato

R. Mancini

F.Graziano

M. Mottolese

C. Garufi

F.Graziano

C.Garufi

F.Guadagni

G. Piaggio

M. Fanciulli

G. Paoletti

F.Carboni

G.Paoletti

M.Mottolese

Impiombato

M. Zeuli

R.Mancini

M.Zeuli

Pathology

M. G. Diodoro

G.Piperno

Radiology

Radiology

Psycho-oncology

Biostatist. Unit

Endoscopy

M.Caterino

M. Caterino

P. Pugliese

D. Giannarelli

V. Stigliano

D. Assisi

S.Giunta

S. Giunta

I. Sperduti


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