Peritoneal spread risk in Gastric , Pancreatic and Colon cancers
www.slideshare.net/GinaBrown3
Understanding patterns of failure
• Improvements in surgical technique• Identification of subgroups benefiting from
preoperative therapy• Refine radiotherapy Rx volumes• Primary endpoint of rectal cancer trials
Predictable patterns of recurrence
• Tumour spillage• CRM involvement• Peritoneal perforation• Distal margin involvement• Residual disease
Space of Retzius
Bladder
mesorectum
rectum
peritoneal
peritoneum
Mesorectal fascia
Post surgical pelvis
Post TME pelvis
Marginal pattern of recurrence
Starling, Scott-Mackie, Brown et al 2005
CRM involvement and later recurrence
Marginal recurrence
Anastomosis
Anastomotic recurrences
Tumour spillage
Perineal recurrence
Perineal
Hydronephrosis = strong likelihood of local recurrence
Brown et al Clinical Radiology 2003
75 patients, new hydronephrosis is a predictor for peritoneal recurrence (90% of patients).
Peritoneal perforation
Distal margin involvement
Nodal recurrence
Nodal recurrence
Krukenberg Tumours
Relapse Pattern No of Patients n=70
(a) Marginal (around the margins of the surgical bed)
43.9%
(b) Lymph node (internal or external iliac groups)
24.3%
(c) Pelvic peritoneal 22.0%
(d) Perineal 14.6%
(e) Anastomotic 12.2%
(f) Krukenberg 2.4%
• MDT 2007-09• 296 sigmoid cancers • 104 for palliative care
• Curable sigmoid cancers: n=192• No FU data at all: n=42• With FU: n=150• FU 36 months (range 1-76, median 38)
• Recurrence: 62/192 (32%) • Local recurrence: 19 (11%)
Recurrence sigmoid cancer
High risk features
• Tumour involving non peritonealised fascial margin
• Tumour penetration of adjacent organs• 4 or more involved nodes• Extramural venous invasion• Depth of extramural spread >5mm
Eur J Surg Oncol. 2005 Oct;31(8):845-53.
Improved survival
Are we able to preoperatively identify poor prognostic features in colon cancer?
Burton 2006 Int. J. Radiation Oncology Biol. Phys
• Primary surgery n=57
• 16 at/above peritoneal reflection
• 19 rectosigmoid• 22 sigmoid
• Neoadj CRTx + surgery n=18
• 9 at/above peritoneal reflection
• 5 rectosigmoid • 4 sigmoid
Burton 2006 Int. J. Radiation Oncology Biol. Phys
MRI predicted prognosis with final histological prognosis in 57 patients undergoing primary surgery
Final histological prognosis
Good Poor TotalMRI Good 31 6 37
PredictedPrognosis Poor 10 11 21
Totals 41 17 5884% (CI =72.6-92.7%) accuracy for MRI prediction of prognosisKappa = 0.63Sensitivity = 90%Specificity = 72%Positive predictive value = 88%Negative predictive value = 76%
Burton 2006 Int. J. Radiation Oncology Biol. Phys
Diagnostic dilemmas – is it recurrent disease or not?
• Mass - ? Significance• Scar vs recurrence• PET-ve• Inflammatory collection vs recurrence
New Mass
Examples of reporting criteria
Importance of baseline review
2004 2000
Peritoneal pelvic recurrence
Scar vs Recurrence
Collection vs Recurrence
PET-ve
Anatomical information – to plan resection/resectability
• Which compartment?• Which sacral level?• Multifocal vs unifocal – High res MRI
essential• Distant metastases, review of both contrast
enhanced MDCT and CT-PET helpful• Trial of chemotherapy/RT prior to radical
surgery – response assessment
Operation likely? – yes/ probably no
• Yes:– Central compartment– Anterior compartment
below peritoneal reflection
– Posterior compartment below S2
– Perineal
• Probably no:– Lateral compartment– Sciatic nerve infiltration
(coronal imaging)– S1/S2 sacral infiltration– Peritoneal perforation
Post TME pelvis
Central compartment
Post Chemo
Lateral compartment
Key messages
• Know patterns of recurrence• Familiarity with post surgical pelvis• FDG PET-CT helpful tool • Growing mass on CT/MRI with elevated CEA =
diagnostic of recurrence
Conclusions
• GI Radiologists now play a key role in the MDT for detecting and selecting patients with recurrent disease for radical treatment– Aggressive imaging based follow up of high risk
patients results in earlier detection increases survival
– Anatomic delineation and characterisation of lesions using both MDCT/MRI with contrast
– Careful use of multimodality imaging in assessing extent of disease (PET/MRI/CT)
Gastric cancer risk factors
• Published evidence – clinico pathological risk features
• Imaging assessment of gastric cancer• Delineation of the primary tumour• Nodal disease versus extranodal disease and
its depiction on CT
Pancreatic cancer
• T4 and transperitoneal seeding– Known Mechanisms of transperitoneal spread in
pancreatic cancer and rates of PC– Lymphatic– Vascular– Implantation and seeding
For the group to develop in future:
• More work in determining imaging features at baseline for peritoneal relapse T category is too broad and crude a tool
• Improve documentation of tumours at baseline and compare against outcomes
• Patterns of spread are key• Proforma reporting and consistent
documentation at diagnosis and at relapse is essential