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Taunton SpR Training Day 7 th December 2012 Early rectal cancer

Taunton SpR Training Day 7 th December 2012 Early rectal cancer. Tom Edwards Consultant Colorectal Surgeon. Introduction. Staging for Rectal Cancer. Staging for Rectal Cancer. More History. CR07: T1 disease 1.8 (2.9)% LR // OS 94%. The early rectal cancer dilemma.

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Taunton SpR Training Day 7 th December 2012 Early rectal cancer

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  1. Taunton SpR Training Day7th December 2012 Early rectal cancer Tom Edwards Consultant Colorectal Surgeon

  2. Introduction

  3. Staging for Rectal Cancer

  4. Staging for Rectal Cancer

  5. More History CR07: T1 disease 1.8 (2.9)% LR // OS 94%

  6. The early rectal cancer dilemma • Stage 1 rectal cancer is a curable disease with radical surgery But…

  7. The cost for cure • Total mesorectal excision associated with • Long hospital stay and convalescence • Death (young 2% : >85 20%) • Leak rate (16%) • Urinary dysfunction • Sexual dysfunction • Defaecatory dysfunction • Permanent stoma rate (10-40%)

  8. Bowel DysfunctionRadical surgery for rectal cancer Temple et al, DCR 2005

  9. Sexual DysfunctionRadical surgery for rectal cancer Activity: Pre Op Post Op Loss Spont Embarrassed APR 91% 55% 53% 44% LAR 94% 74% 27% 24% TART 80% 87% 13% 0% Hendren et al, Ann Surg 2005

  10. ?

  11. So, what about trans anal, full thickness local excision?

  12. Local Excision is Appealing • Low morbidity • Quick recovery • Minimal effect on long term bowel function • Organ sparing technique • Genitourinary dysfunction avoided

  13. BUT………………Lymph nodes!!!! • Blumberg , et al, Dis Colon Rectum 1999 • T 1/2 = 20% +LN • T 3 = 40% +LN

  14. Local Excision: In an Ideal World • We would know that the lymph nodes are clear • Technically a FTLE is possible • the surgery should be curative! • But equally, if there is a recurrence … • Salvage surgery does not worsen the oncological result

  15. Trans Anal Resection of Tumour (TART) Unfortunately . . . the oncologic results have been disappointing

  16. Favorable T1 CancersTrans Anal Excision (TAE) Mellgren (2000) n=TAE 69 OS 30 Paty (2002) n=TAE 74 Nascimbeni (2004) n=TAE 70 OS 74 Madbouly (2005) n=52 Local Recurrence TAE 18% Rsxn 4% (TME) TAE 14% TAE 7% Rsxn 3% (TME) TAE 17% Survival (CSS/Overall) TAE 72%Rsxn80% TAE 92% TAE 89%(72%)Rsxn90% TAE 89%(75%) “Transanal excision equals total mesorectal neglect” - David Rothenberger

  17. Favorable T1 Cancers “Transanal excision equals total mesorectal neglect”

  18. But, don’t worry, we can perform salvage radical surgery!

  19. Salvage Surgery for Recurrence • Recurrent stages (n=29) • Mean time to recurrence = 26 months • 23/29 underwent curative surgery • Mean follow up = 39 months • Friel, et al. Dis Colon Rectum 2002

  20. Salvage Surgery for Recurrence FTLE Patients DFS Overall 29 12(59%) T1 10 7(70%) T2 19 10(53%) Good histol 22 15(68%) Bad histol 7 2(29%) • Friel, et al. Dis Colon Rectum 2002

  21. Salvage Surgery for Recurrence • 49/50 patients underwent curative surgery • 27 (55%) multivisceral resections • 47/49 underwent R0 resection • Weiser, et al. Dis Colon Rectum 2005

  22. Salvage Surgery for Recurrence FTLE 5 year Survival 53% Weiser, et al. Dis Colon Rectum 2005

  23. Why the high local recurrence rates? • Progression of occult lymphatic tumor • Better histologic predictors • ‘Are all polyps made equal?’ • TART technically limiting

  24. Are all polyps equal? NO

  25. Polyp morphology Pedunculated Sessile

  26. 7 Adverse features • Morphology • Differentiation • Mucinous • LV infiltation • Peri neural invaision • Margin • Exophytic vs ulcerating

  27. The Difficult TART: Origins of TEMS Standard transanal excision: • Limited to lesions: • distal rectum • small tumors (<3 cm) • However… • lighting and exposure is poor • surgical field collapses “short reach, poor visibility”

  28. Origins of TEMS Professor Gerhard Buess

  29. Transanal Endoscopic Microsurgery 4 cm x 10-20 cm proctoscope, airtight faceplate, insufflation, telescope, and laparoscopic instruments

  30. Karl Storz (TEO)

  31. Other techniques are available ESD Contact DXT

  32. Operative Techique

  33. pT1 Rectal Cancer: TEM case series • 1991-2003, single surgeon, n=53 (75) • Age 65 y (31-89) (65y) • Average 7 cm (0-13) from verge (7cm) • F/U: 2.8 y • 7.5% (4/53) recurrence (9%) • No cancer related deaths (0%) Floyd and Saclarides DCR 2006 (Abarca and Saclarides ASCRS 2010)

  34. uT1N0 Rectal Cancer: RCT: TEM vs Low Anterior Rsxn Patients: Age (y): Location L/M/U: Follow-up (m): Complications: Local Recur: Survival: TEM 24 63.7 7/12/5 41 20.8% 1 (4%) 96% LAR 26 60.9 8/11/7 46 34.5% 0 96% Winde et al, DCR 1996

  35. uT2N0 Low Rectal Cancer Patients: Local Recur: Distant Recur: Prob of any Recur: DFS: RCT: ChemoXRT followed by TEM vs Laparoscopic TME minimum 5 year follow-up TEM 35 2 (5.7%) 2 (5.7%) 9% 94% LAC-TME 35 1 (2.8%) 2 (5.7%) 6% 94% Lezoche et al Surg Endosc 2007

  36. So how should we manage early rectal cancer?

  37. Clinical Evaluation • History • Family history • Continence history • Evaluation of operative risk • Physical • Abdomen • Digital Rectal Examination • Rigid proctoscopy

  38. Rectal Cancer Work Up • Biopsy • Colonoscopy/ full bowel imaging • CEA • CT Scan Abdomen / Pelvis • Chest imaging (CXR or CT) • Endoscopic Ultrasound /MRI

  39. Bulky lesion MR/USS T1/2 Young fit patient Elderly/ comorbidity Biopsy proven Ca Biopsy benign Biopsy proven Ca Good T1 Op/ Stoma averse Bad T1 T2 TEMS TME/ APER

  40. Thanks For Listening!

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