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The Particular Problem of Low Rectal Cancer

The Particular Problem of Low Rectal Cancer. Brendan Moran Basingstoke 4 th East-West Colorectal Days Hungary 2008. The Particular Problem of Low Rectal Cancer. Tumours within 6cm of anal verge. Issues. Difficulties with reconstruction Problems with APE

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The Particular Problem of Low Rectal Cancer

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  1. The Particular Problem of Low Rectal Cancer Brendan Moran Basingstoke 4th East-West Colorectal Days Hungary 2008

  2. The Particular Problem of Low Rectal Cancer Tumours within 6cm of anal verge

  3. Issues • Difficulties with reconstruction • Problems with APE • Embryology/anatomy of the low rectum/anal canal • Lower tumour – higher risk of lateral pelvic nodal involvement • Pathology different – more poorly diff and increased risk nodal disease

  4. Dutch Rectal Cancer Study n=656 Nagtegaal et al Am J Surg Path, 2002; 26:350-7

  5. MercuryStudy Data n=307

  6. TME Hypothesis • TME provides optimal block dissection of the lymphatic drainage of the rectum. • Does this work for low rectal cancer ??.

  7. Methods • All rectal cancers 1978-2002 in Basingstoke • Anterior resections • Analyzed impact of tumour height on local and systemic recurrence

  8. Surgical Technique

  9. Procedures Performed For Rectal Cancer 41 (6%) 57 (8%) 585 (86%) (Curative 480)

  10. 12-15cm 20%(n=102) 7-11cm 24%(n=190) Systemic Recurrence by tumour height 0-6cm 27%(n=188) Overall 24%(n=480)

  11. 12-15cm <1% (n=102) 7-11cm 2%(n=190) Overall 4%(n=480) Local Recurrence by tumour height 0-6cm 7%(n=188)

  12. Summary • Tumour height of < 6cm predictive for a higher rate of local failure following curative TME • Why is this??

  13. Why ?? • Technical challenges • Anatomy / embryology • Tumour behaviour

  14. What about APE ???

  15. Shihab, Moran, Mercury study Group Presented ASCRS 2008 Patients with low rectal cancer treated by abdomino-perineal excision have worse tumours and higher involved margin rates compared with those treated by anterior resection.

  16. Patients and methods MERCURY (Magnetic Resonance Imaging in Rectal Cancer European Equivalence Study) Prospective, multi-centre (2003-2005) 408 patients with rectal cancer High-resolution MRI TME surgery Standardised pathology

  17. 408 patients 250 > 6 cm from anal verge 158 ≤ 6cm from Anal verge 4 Hartmann’s 1PPC+I 153 patients 81 LAR 72 APE

  18. Patients and methods APE compared to AR for: Median tumour height % undergoing neoadjuvant therapy Involved CRM (CRM+) T-stage

  19. Results 153 patients p < 0.001

  20. Results p = 0.007

  21. Results p = 0.01

  22. Results p = 0.006

  23. ConclusionTumours < 6cm APE group had higher CRM + rates. APE group significantly lower tumours and higher pT stage despite higher proportion undergoing neoadjuvant therapy.

  24. Low Rectal Cancer “mrT4” “PR – Tumour Mobile sitting on levators in coronal view”

  25. Surgical DilemmaSix Main Management Options • Abdomino Perineal Excision (APE) • Anterior Resection (AR) • 5 Gy x 5 days (5x5) and APE • 5x5 and AR • Chemoradiotherapy (CRT) and APE • CRT and AR

  26. Multiple choice 1 APE 2 AR 3 SCRT +APE 4 SCRT + AR 5 CRT +APE 6 CRT +AR

  27. Holm et al. (Karolinska Hospital, Stockholm) BJS 94: 232-238, 2007

  28. Conclusion Low rectal cancer difficulties in optimal staging neoadjuvant therapy surgical treatment.

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