![Page 1: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/1.jpg)
TorbjörnHolm
KarolinskaUniversityHospital
Stockholm,Sweden
WherearewenowwithELAPE?
![Page 2: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/2.jpg)
LocallyrecurrentrectalcancerWemustnotforgetthehistory!
![Page 3: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/3.jpg)
RT+ RT- Total
AR 26/22412% 59/24624% 85/47018%
APE 51/32916% 94/33528% 145/66422%
• LocalrecurrencerateswerenotsignificantlyrelatedtotypeofsurgerybeforeTME
• APEwasperformedin59%ofthepatients(664/1134)
![Page 4: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/4.jpg)
• 136patients,tumours<5cm(1978-1995)• 23%APE• Localrecurrencerateatsixyears
Curative Noncurative Total
AR 1/85 3/20 4/105(4%)
APE 4/15 5/16 9/31(29%)
Dis ColonRectum1997;40:747-751
![Page 5: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/5.jpg)
![Page 6: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/6.jpg)
ProblemsassociatedwithconventionalAPE
• InadvertentbowelperforationsignificantlymorecommonafterAPE
AR APE
Norway 4% 15%
Sweden 3% 14%
Holland 3% 14%
![Page 7: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/7.jpg)
NorwegianRectalCancerGroupBrJSurg2004;91:210-16
![Page 8: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/8.jpg)
ProblemsassociatedwithconventionalAPE
• TumourinvolvedcircumferentialresectionmarginsignificantlymorecommonafterAPE(CRM+ve)
AR APE
• DutchTMETrial 12% 29%
• MERCURYTrial 12% 33%
![Page 9: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/9.jpg)
JClinOncol2005;23:9257-9264
LocalrecurrenceandsurvivalafterAPE,inrelationtoCRMstatus
![Page 10: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/10.jpg)
ProblemsassociatedwithconventionalAPE
• SynchronouscombinedAPEisnotastandardisedoperation
• Resultsarevariableandsuboptimal
• Resultspoorerthanafteranteriorresection– Perforations– Involvedmargins
![Page 11: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/11.jpg)
AbdominoperinealResectionConventionalAPE
![Page 12: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/12.jpg)
AchangingconceptofAPE
• Inordertoimprovesurgeryinlowrectalcancer,anattemptwasmadetodefinethesurgicalplanesoftheperineumandthepelvicfloorandtodescribetheAPEprocedureanatomically.
![Page 13: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/13.jpg)
DefiningthesurgicalplanesonMRIimprovessurgeryforcancerofthelowrectum
OliverCShihab,RichardJHeald,EricRullier,GinaBrown,Torbjorn Holm,PhilipQuirke,BrendanJMoranLancetOncology2009
![Page 14: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/14.jpg)
WhyELAPE?
• ELAPEwasdescribedin
ordertoreduceratesof
perforationand
involvedCRMforlow,
advancedtumours
![Page 15: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/15.jpg)
Patientswithcancerinfiltratingtheinter-sphinctericplaneorthreateningthelevator
needsamoreorlessradicalELAPE
ThreatenedCRM
![Page 16: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/16.jpg)
Indicationsforextra-levator APEinrectalcancer
• Low,advancedtumoursthreateningCRM
– LowMRF,levator orexternalsphincter
![Page 17: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/17.jpg)
ExtralevatorAPE
![Page 18: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/18.jpg)
Lowerratesof:• Bowelperforation• CRMinvolvement• Localrecurrence
Increasedriskof:• Perinealwoundcomplications
AnnSurgOncol(2015)22:2997–3006
![Page 19: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/19.jpg)
BJS2014;101:874–882
APE1981
Excluded72
APE1909
ConventionalAPE1429 ELAPE480
Propensityscorematching
Followedupfor2years 447 448
ConventionalAPEmatchedtoELAPEby:
• Sex• ASA• Neoadjuvanttreatment• Tumourlevel(0–6cm)• PathologicalTNMstage• Typeofresection(R0,CRM)• Qualityofmesorectal
excision
ConventionalAPE ELAPE
1429 480
Excluded 982(69%) 32(3%)
447 448
![Page 20: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/20.jpg)
Conclusion:ELAPEdoesnotimproveratesofCRMinvolvement,intraoperativetumourperforation,localrecurrenceormortality
Comment:HighproportionofexcludedpatientsintheconventionalAPEgroupResultsnotsurprisingwithmatchingforqualityofsurgery
![Page 21: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/21.jpg)
ELAPE ConventionalAPE(n=301) (n=253) p
NeoadjuvantChemo-radiation 211(70%) 114(45%) <0.001Tumourlevel<5cm 267(90%) 159(64%) <0.001ColorectalSurgeon 283(94%) 164(65%) <0.001Tumourperforation 14(5%) 9(4%) 0.28R0resection 253(84%) 233(93%) 0.006
Conclusion:ResectionoflowrectalcancersbyELAPEdidnotimproveshorttermoncologicalresultscomparedwithconventionalAPE
Comment:MoreadvancedandlowtumoursinELAPEgroupNospecimenqualitycontrol
(AnnSurg 2015;261:933–938)
![Page 22: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/22.jpg)
APE ELAPE Undeterminedn=209(16%) n=518(39%) n=592(45%)
<5cmfromanalverge 58(28%) 386(75%) 353(61%)NeoadjuvantRT 144(69%) 456(88%) 472(80%)CRM+ 58(28%) 152(29%) 238(40%)
Conclusion:ELAPEresultsinasignificantlyincreased3-yearlocalrecurrencerateascomparedwithstandardAPE;OR=4.10(95%CI1.19–14.08)
Comment:NodataonrateofLRorperforationsHigher,smalltumourscomparedtolowmoreadvancedtumoursNospecimenqualitycontrolandhighCRM+rateinbothgroups
(AnnSurg 2015Apr21.[Epub])
![Page 23: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/23.jpg)
ComparisonsELAPEvs.”standard”or“conventional”APE
“Theadjective‘standard’begantobeappliedtoAPE,
butithadnomeaningbecauseitwasnotpossibleto
describeitanatomically”
ProfessorJohnNichollsColorectalDisease201315,1329–1330
![Page 24: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/24.jpg)
Whatisa“standard”APE?
Prytzetal.IntJColorectalDis(2014)29:981–987
![Page 25: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/25.jpg)
ComparisonsELAPEvs.”standard”or“conventional”APE
• ResultsafteranteriorresectionimprovedwithTMEsurgery
• ConventionalAPEwasnotastandardizedprocedure
• ResultsafterAPEwerestillpoorinpopulationbasedstudies
• ResultsseemedtoimproveafterintroductionofELAPE
• SomecomparisonsfavorELAPEwhileothersshownodifferencebetweenELAPEand“standard”APE
• “Standard”APEhasprobablychangedwithtimeandincreasingknowledge,andisnowamoreorlessextensiveELAPE
![Page 26: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/26.jpg)
ChangingconceptofAPE
• TheAPEprocedureshouldbetailoredtothetumourandtothepatient
• Relatedtodefinedanatomicalstructures
– Inter-sphincteric
– Extra-levator
– Ischio-anal
• Eachprocedureshouldbestandardised
• Indicationsshouldbedefinedforeachprocedure
• Basedonappropriatestaging– MRI,ultrasoundandclinicalexamination
![Page 27: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/27.jpg)
Inter-sphincteric APE
![Page 28: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/28.jpg)
IndicationsforAPEinrectalcancerInter-sphinctericAPE
• PatientunsuitableforbowelreconstructionPreoperativehistoryofincontinence
Highriskofanastomotic leak
Co-morbidity– crucialtopreventleakage+fataloutcome
Patientspreference
– OptionsHartmann’sprocedure
Inter-sphinctericAPE
![Page 29: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/29.jpg)
Tumourperforatingintoischio-analspace
![Page 30: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/30.jpg)
Ischio-anal APE
![Page 31: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/31.jpg)
Indicationsforischio-analAPE
• Locallyadvancedcancerinfiltrating– Levatormuscles– Ischio-analfat– Perianalskin
• Perforatedcancerwithabscessorfistulainischio-analfossa
![Page 32: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/32.jpg)
Supineorproneapproach
• Inter-sphincteric APE: Supine• Extra-levatorAPE: Pronepreferable,Supinepossible• Ischio-analAPE: Prone
![Page 33: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/33.jpg)
Whyproneposition?
• Excellentviewimprovesteaching
• Posteriorvagina,prostateandautonomicnerveseasiertosee
• Bettercontroloftheprocedure
![Page 34: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/34.jpg)
KarolinskaExperienceELAPE2000-2012
• 193patients 81female 112malePreoperativetumourstage(MRI)• T1–T3 67 35%• T4 126 65%
• Radiotherapy 102 48%• Radio-chemotherapy 91 47%• Nopreoperativetreatment 105%
• Pelvicexenteration 25 13%• ExtendedELAPE 56 29%• ELAPEalone 112 58%
![Page 35: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/35.jpg)
KarolinskaExperienceELAPE2000-2012
• Postoperativemortality 6 3%
• Histopathology
T0-T2 69 36%
T3-T4 124 64%
CRM+ 20 10%
Perforations 19 10%
![Page 36: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/36.jpg)
KarolinskaExperienceELAPE2000-2012
FollowupAugust2013 Medianfollowup31months
• Localrecurrence 12/187 6%
• Rectalcancerdeaths 44/187 23%
• Alldeaths 55/187 29%
![Page 37: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/37.jpg)
KarolinskaExperienceELAPE2000-2012Cumulativeincidenceoflocalrecurrence
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0.00
0 1 2 3 4 5Time (Year)
Kaplan-Meier failure estimate
![Page 38: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/38.jpg)
KarolinskaExperienceELAPE2000-2012Survival
0 1 2 3 4 5Survival Time year
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
Cum
ulat
ive
Prop
ortio
n Su
rviv
ing
![Page 39: Where are we now with ELAPE? - ACPGBI · 2017-01-14 · Where are we now with ELAPE? Locally recurrent rectal cancer We must not forget the history! ... No specimen quality control](https://reader034.vdocuments.net/reader034/viewer/2022042103/5e80808e24f45917d253448e/html5/thumbnails/39.jpg)
APEinlowrectalcancerConclusion
• Assesspatientandtumour– Analfunction,co-morbidity,patientpreference– VerylowtumourorthreatenedCRM
• PlanprocedureaccordingtoMRIandclinicalassessment
• IfAPEthecorrectchoice– whattypeofAPE?– Inter-sphincteric– Extra-levator (moreorlessextensive)– Ischio-anal(moreorlessextensive)
• Goodlocalcontrolandsurvivalcanbeachievealsoinlocallyadvancedrectalcancer