datum/vortragsthema local resection of rectum tumors peter m. markus elisabeth hospital essen...
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Local resection of Rectum tumorsLocal resection of Rectum tumors
Peter M. Markus
Elisabeth Hospital Essen Germany
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Which tumorsWhich tumors Size, Localisation, HistologySize, Localisation, Histology
local vs anterior resectionlocal vs anterior resection
How do I remove How do I remove
peranal (mucosectomy, full thicknessperanal (mucosectomy, full thickness),), TEM TEM
Rectum tumorsRectum tumorsLocal resectionLocal resection
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Lower thirdLower third peranal peranal
Middle andMiddle and TEM TEM
Upper thirdUpper third anterior wall up to 12 cm anterior wall up to 12 cm
post. wall up to 15 cm, 1/3 circumferencepost. wall up to 15 cm, 1/3 circumference
Rektal tumors Rektal tumors - How to threat -- How to threat -
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Indication for local resectionIndication for local resection- histology -- histology -
Ln-involvementLn-involvement
1.1. adenoma, high grade dysplasiaadenoma, high grade dysplasia 0 0
2.2. T1 Ca low grade (G1, G2, -pL1, -pV1.) T1 Ca low grade (G1, G2, -pL1, -pV1.) ~3% ~3%
local recurrence rate ~ 6 % (0-28%)local recurrence rate ~ 6 % (0-28%)
Matzel et al. Chirurg 2003Matzel et al. Chirurg 2003
Nascimbeni et al. Dis Colon Rectum 2004Nascimbeni et al. Dis Colon Rectum 2004
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17 studies, 1984-2002, 1379 patients17 studies, 1984-2002, 1379 patients
+Ln %+Ln %
T1 high riskT1 high risk > 10 (2,2-35,7)> 10 (2,2-35,7)
T 2 CaT 2 Ca >12>12
ant. resectionant. resection
radio-chemo-therapyradio-chemo-therapy
Deinlein P, Reulbach U, Stolte M, Pathologe 2003Deinlein P, Reulbach U, Stolte M, Pathologe 2003
Indication for local resectionIndication for local resection
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Incidence for lymph node metastasesIncidence for lymph node metastases
LocalisationLocalisation nn + Ln+ Ln
lowerlower 2929 3434
middlemiddle 5454 1111
upperupper 3636 8 8
Nascimbeni et al. Dis Colon Rectum 2002Nascimbeni et al. Dis Colon Rectum 2002
T 1 rectum carcinomaT 1 rectum carcinoma
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lncidence of lymph node metastaseslncidence of lymph node metastases
Lymphatic invasionLymphatic invasion nn + Ln + Ln
pL0pL0 324324 11% 11%
pL1pL1 2828 32% 32%
Nascimbeni et al. Dis Colon Rectum 2002Nascimbeni et al. Dis Colon Rectum 2002
T 1 rectum carcinomaT 1 rectum carcinoma
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Rectum carcinomaRectum carcinomaSubmucosa infiltrationSubmucosa infiltration
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Sm1Sm1 Sm2 Sm2 Sm3 Sm3
N = 70N = 70 120 120 154 154 Ln-Met. = 3Ln-Met. = 3 8 8 23 23
Rectum carcinomaRectum carcinomaSubmucosa infiltrationSubmucosa infiltration
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Grading vs depth of invasionGrading vs depth of invasion
GradingGrading nn Sm1/Sm2Sm1/Sm2 Sm3Sm3
1 + 21 + 2 227227 67%67% 33%33%
3 + 43 + 4 117117 32%32% 68%68%
Nascimbeni et al. Dis Colon Rectum 2002Nascimbeni et al. Dis Colon Rectum 2002
T 1 Rectum carcinomaT 1 Rectum carcinoma
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n= 105, local resectionn= 105, local resection
T1 low riskT1 low risk R1/RX/high gradeR1/RX/high grade
recurrencerecurrence 6%6% 39%39%
Borschitz et al., Dis Colon Rectum 2006Borschitz et al., Dis Colon Rectum 2006
Rectum carcinomaRectum carcinoma- Risk of Recurrence -- Risk of Recurrence -
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Transanal Endoscopic MicrosurgeryTransanal Endoscopic Microsurgery
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TEM Technique of resectionTEM Technique of resection
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TEMTEM
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Specimen after full thickness Specimen after full thickness resectionresection
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n= 182 OP, n= 162 pt., 1995-2001, follow up n= 182 OP, n= 162 pt., 1995-2001, follow up Ø 34 monthsØ 34 months
histologyhistology nn OP techniqueOP technique n n
AdenomaAdenoma 118118 (deep) ant. R. (deep) ant. R. 27 27
T1 CaT1 Ca 59 59 transanale R.transanale R. 76 76
othersothers 5 5 TEMTEM 79 79
Langer C, Liersch T, Markus PM et al., Int J Colorectal Dis 2003Langer C, Liersch T, Markus PM et al., Int J Colorectal Dis 2003
Resection of benign Rectum tumorsResection of benign Rectum tumorsand early Carcinomasand early Carcinomas
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Langer C, Liersch T, Markus PM et al, Int J Colorectal Dis 2003
rectum tumorsrectum tumors- local resection –- local resection –
n = 182, follow up n = 182, follow up Ø Ø 34 months34 months
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Langer C, Liersch T, Markus PM et al, Int J Colorectal Dis 2003
Rectum tumorsRectum tumors - Complications - - Complications -
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Langer C, Liersch T, Markus PM et al, Int J Colorectal Dis 2003
Rectum tumorsRectum tumors- Recurrence -- Recurrence -
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AdenomaAdenoma
T1 Ca G1, G2, (low risk)T1 Ca G1, G2, (low risk)
- pL1, -pV1, Sm 1, Sm 2- pL1, -pV1, Sm 1, Sm 2 local resectionlocal resection
TEM (Ultracision)TEM (Ultracision)
high riskhigh risk
T1 Ca G3, G4, +pL1, Sm 3T1 Ca G3, G4, +pL1, Sm 3 anterior resectionanterior resection
with TMEwith TME
SummarySummary
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Local resection of rectum tumors Local resection of rectum tumors What to to whenWhat to to when
histologyhistology localisationlocalisation thirdthird therapytherapy
R0, high riskR0, high risk middle/upper middle/upper radical resect.radical resect.
lower lower RCHRCH
R1, low riskR1, low risk middle/upper middle/upper radical resect.radical resect.
lower lower local re-resect.local re-resect.
R1, high riskR1, high risk radical resect.radical resect.
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local recurrence after local resectionlocal recurrence after local resection
meta-analysis 22 studies 958 patientsmeta-analysis 22 studies 958 patients
+ RadioChemo+ RadioChemo
TT Lokal-R %Lokal-R % Lokal-R% Lokal-R%
T1T1 9,7 (0-24)9,7 (0-24) 9,5 (0-50)9,5 (0-50)
T2T2 25 (0-50)25 (0-50) 13,6 (0-24)13,6 (0-24)
T3T3 38 (0-100)38 (0-100) 13,8 (0-50)13,8 (0-50)
Sengupta S et al Dis Colon Rectum 2001)Sengupta S et al Dis Colon Rectum 2001)
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n = 186, massive polyp >3cmn = 186, massive polyp >3cm
- 19 invasive Ca- 19 invasive Ca
- 167 adenoma- 167 adenoma 29 tubular29 tubular
118 tubulovillous118 tubulovillous
20 villous20 villous
49x high grade dysplasia49x high grade dysplasia
Doniec JM, Dis Colon Rectum 2003Doniec JM, Dis Colon Rectum 2003
rectum tumorrectum tumor - endoscopic excision -- endoscopic excision -
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lateral margin.lateral margin. nn lokal-Rec. lokal-Rec. 5 y survival rate 5 y survival rate
TU +TU + 35 35 3232 24%24%
TU - TU - 106106 1111 74%74%
Adam et al., Lancet 1994Adam et al., Lancet 1994
rectum carcinoma rectum carcinoma - effect of lateral - effect of lateral resection marginresection margin - -