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Management of Rectal Cancer Jacques Heppell, MD Mayo Clinic Scottsdale, Arizona

Management of Rectal Cancer Jacques Heppell, MD Mayo Clinic Scottsdale, Arizona. JH012804. RECTAL CANCER. 42,000 patients are diagnosed each year in the US 8,500 patients die of this disease. JH012804. The Prevention of Invasive Cancer of the Rectum. ‘

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Management of Rectal Cancer Jacques Heppell, MD Mayo Clinic Scottsdale, Arizona

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  1. Management of Rectal CancerJacques Heppell, MDMayo ClinicScottsdale, Arizona JH012804

  2. RECTAL CANCER • 42,000 patients are diagnosed each year in the US • 8,500 patients die of this disease

  3. JH012804

  4. The Prevention of Invasive Cancer of the Rectum • ‘ • The results of the 25+ year Cancer Detection Center study, including 20,000 participants and 100,000+ patient-years experience, demonstrate the obviation of appearance of most lower bowel cancers associated with a program of annual proctosigmoidoscopy and adenomatous polyp removal. • Cancer 41:1137-1139,1978 .

  5. Screening

  6. Incidence per 100,000

  7. AJCC STGE OF COLORECTAL NEOPLASMS: ARIZONA, ALL AGES

  8. Japanese Scientists train Dogs to detect Colorectal Cancer ( Gut, 2011)

  9. JH012804

  10. Who should take care of patients with rectal cancer? JH012804

  11. Designated Center of Excellence ! • SUCCESSFUL IMPLEMENTATION OF A COMMUNITIES OF PRACTICE (COP) MODEL TO FACILITATE QUALITY IMPROVEMENT INITIATIVES IN COLORECTAL CANCER SURGERY • LJ Williams et al. Department of Surgery and Regional Cancer Program, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Can

  12. Team Approach • Expert surgeon (TME,autonomic nerve and sphincter preservation) • Medical oncologist • Radiation oncologist • Nursing • Nutritionist • Psychologist

  13. SURGERY FOR RECTAL CANCER • Cure • Local control • Sphincter preservation • Preservation of sexual and urinary function Goals

  14. TECHNIQUE: “ Old Style” • Blunt dissection commonly used • 30% local failure (worldwide) • 60% distant metastasis • High rates of impotence and urinary dysfunction

  15. PRIMARY GOAL OF SURGERY • Complete excision of all mesorectal disease, enveloped within intact visceral layer of pelvic fascia, together with negative lateral or circumferential margin

  16. TOTAL MESORECTAL EXCISION

  17. TME ALONE Local recurrence 5-8% Distant metastasis 25% "High Risk Patients" T3, N0, M0 or any T, N1-2, M0

  18. Norwegian Rectal Cancer Group • 29% local recurrence rate among 250 surgeons performing 1-14 resections for rectal cancer in 2 years • Establishment of a system for preceptorships to teach TME on a national level and Pathologists trained to evaluate quality of the specimens • Voluntary reduction of the number of surgeons operating on rectal carcinoma (250 to 50)

  19. Norwegian Rectal Cancer Group • TME performed • In 1994 : 78% of cases • In 1998: 98% of cases • Local recurrence rate reduced to 8 %!

  20. NIH Consensus on Adjuvant Therapy for Patients with Rectal Cancer 1990 JH012804

  21. WAS THE NIH CONSENSUS RIGHT? • Quality of life • Bowel function • Most important treatment variable (the surgeon)

  22. Chemoradiation: The Functional Cost JH012804

  23. SUMMARY OF BOWEL FUNCTION IN THE 2 GROUPS Non-Radiation Chemoradiotherapy (59 Patients) (41 Patients) p Value No. of bowel movements/day Medican (range) 2 (1-7) 7 (1-20) <0.001 4 83% 22% – Clustering 3% 42% – 5 14% 37% – Awoken at night for movement 14% 46% <0.001 Incontinence – – <0.001 None 93% 44% – Occasional 7% 39% – Frequent 0% 17% – Wear a pad 10% 41% <0.001 Perianal skin irritation 12% 41% <0.001 Regularly use Lomotil ± Imodium 5% 58% <0.001 Unable to differentiate stool from gas 15% 39% 0.009 Liquid consistency (sometimes or always) 5% 29% 0.001 Unable to defer defecation >15 min 19% 78% <0.001 Need to defecate again within 30 min 37% 88% <0.001 Bowel function different to preoperative 61% 93% 0.001 JH012804

  24. R.J. Nicholls Br J Surg,1996 Apart from the occasional tumor, which is suitable for local excision, most low rectal cancers are best treated by anterior resection with complete removal of the rectum; the construction of the coloanal reservoir should allow routine sphincter saving. This surgery may be carried out independently of adjuvant radiotherapy by which, if given, should be administered before operation

  25. Pre-op vs Post-opChemoradiation • Sauer R. et al. NEJM 2004 • Randomized 421 patients pre-op and 402 patients post-op • 5 year survival 76% vs 74% (p=0.8) • Toxicity: 27 % vs 40% ( p=0.001) • Local control • Increased sphincter saving rate

  26. DOWNSTAGING • Reduce volume of primary tumor • Decrease rectal wall invasion • Sterilize metastatic lymph nodes

  27. JH012804

  28. RECTAL CANCER • Addition of chemotherapyto preoperative radiation therapy increases down-staging and resectability rates for fixed and tethered lesions Locally Advanced Unresectable

  29. PREOPERATIVE CHEMOTHERAPY • No delay in starting systemic therapy • Toxicity rates may be lower • Radiosensitizing effect of 5-FU • Downstaging may allow sphincter-saving procedure Theoretical Benefits

  30. IORT

  31. First report of APR technique at Mayo

  32. Dr. Claude F. Dixon1939 First anterior resection JH012804

  33. Rectosigmoid 15 cm Upper third 11 cm Middle third 7 cm Lower third Anal canal JH012804

  34. Roticulator A B C D E Knight and Griffen, 1980 JH012804

  35. SURGERY: Apples and oranges: the low and mid versus the upper rectum • Martin Weiser & Leonard Saltz  

  36. JH012804

  37. COLONIC-POUCH ANAL ANASTOMOSIS Rolland Parc • 341 cases • 1984-97 • 28% of all rectal cancer • Improved function • 20% emptying difficulty

  38. JH012804

  39. JH012804

  40. Splenic vein Inferiormesentericvein Duodenum Inferiormesentericartery JH012804

  41. JH012804

  42. JH012804

  43. Hand assisted vs Laparoscopic assisted • Larson DW et al Tech Coloproctol 2010 • Same oncologic results at 3 years but length of stay, time to soft diet, incision length, pain score better with laparoscopic assisted

  44. ACOSOG Z6051

  45. Endo anal vs Stapled anastomosis • Better function with stapler but preferable to do endo- anal anastomosis : • Intersphincteric dissection • Very narrow pelvis • Enlarged prostate • Prior radiation for prostate cancer • Short margin !

  46. Colo-anal anastomosis anastomosis

  47. Indications for APR • Inadequate sphincter : low Hartmann? • Sphincter invasion • Inadequate margin • Patient wishes !

  48. MRI or Endorectal US • Better selection of high-risk lesions amenable to downstaging by preoperative chemo-radiation while reserving early-stage disease for surgery alone

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