Local resection of Rectum tumors

Local resection of Rectum tumors Peter M. Markus Elisabeth Hospital Essen Germany

Rectum tumorsLocal resection Which tumors Size, Localisation, Histology local vs anterior resection How do I remove peranal (mucosectomy, full thickness), TEM

Rektal tumors - How to threat - Lower third peranal Middle and TEM Upper third anterior wall up to 12 cm post. wall up to 15 cm, 1/3 circumference

Indication for local resection- histology - • Ln-involvement • adenoma, high grade dysplasia 0 • T1 Ca low grade (G1, G2, -pL1, -pV1.) ~3% • local recurrence rate ~ 6 % (0-28%) • Matzel et al. Chirurg 2003 • Nascimbeni et al. Dis Colon Rectum 2004

Indication for local resection 17 studies, 1984-2002, 1379 patients +Ln % T1 high risk > 10 (2,2-35,7) T 2 Ca >12 ant. resection radio-chemo-therapy Deinlein P, Reulbach U, Stolte M, Pathologe 2003

T 1 rectum carcinoma Incidence for lymph node metastases Localisation n + Ln lower 29 34 middle 54 11 upper 36 8 Nascimbeni et al. Dis Colon Rectum 2002

T 1 rectum carcinoma lncidence of lymph node metastases Lymphatic invasion n + Ln pL0 324 11% pL1 28 32% Nascimbeni et al. Dis Colon Rectum 2002

Rectum carcinomaSubmucosa infiltration

Rectum carcinomaSubmucosa infiltration Sm1 Sm2 Sm3 N = 70 120 154 Ln-Met. = 3 8 23

T 1 Rectum carcinoma Grading vs depth of invasion Grading n Sm1/Sm2 Sm3 1 + 2 227 67% 33% 3 + 4 117 32% 68% Nascimbeni et al. Dis Colon Rectum 2002

Rectum carcinoma- Risk of Recurrence - n= 105, local resection T1 low risk R1/RX/high grade recurrence 6% 39% Borschitz et al., Dis Colon Rectum 2006

Transanal Endoscopic Microsurgery

TEM Technique of resection

TEM

Specimen after full thickness resection

Resection of benign Rectum tumorsand early Carcinomas n= 182 OP, n= 162 pt., 1995-2001, follow up Ø 34 months histology n OP technique n Adenoma 118 (deep) ant. R. 27 T1 Ca 59 transanale R. 76 others 5 TEM 79 Langer C, Liersch T, Markus PM et al., Int J Colorectal Dis 2003

rectum tumorslocal resection –n = 182, follow up Ø 34 months Langer C, Liersch T, Markus PM et al, Int J Colorectal Dis 2003

Rectum tumors - Complications - Langer C, Liersch T, Markus PM et al, Int J Colorectal Dis 2003

Rectum tumors- Recurrence - Langer C, Liersch T, Markus PM et al, Int J Colorectal Dis 2003

Summary Adenoma T1 Ca G1, G2, (low risk) - pL1, -pV1, Sm 1, Sm 2 local resection TEM (Ultracision) high risk T1 Ca G3, G4, +pL1, Sm 3 anterior resection with TME

Local resection of rectum tumors What to to when histology localisation third therapy R0, high risk middle/upper radical resect. lower RCH R1, low riskmiddle/upper radical resect. lower local re-resect. R1, high risk radical resect.

local recurrence after local resection meta-analysis 22 studies 958 patients + RadioChemo T Lokal-R % Lokal-R% T1 9,7 (0-24) 9,5 (0-50) T2 25 (0-50) 13,6 (0-24) T3 38 (0-100) 13,8 (0-50) Sengupta S et al Dis Colon Rectum 2001)

rectum tumor- endoscopic excision - n = 186, massive polyp >3cm - 19 invasive Ca - 167 adenoma 29 tubular 118 tubulovillous 20 villous 49x high grade dysplasia Doniec JM, Dis Colon Rectum 2003

rectum carcinoma - effect of lateral resection margin - lateral margin. n lokal-Rec. 5 y survival rate TU + 35 32 24% TU - 106 11 74% Adam et al., Lancet 1994

Local resection of Rectum tumors