TAUNTON SPR TRAINING DAY7TH DECEMBER 2012 EARLY RECTAL CANCERTom Edwards Consultant Colorectal Surgeon

Introduction

Staging for Rectal Cancer

Staging for Rectal Cancer

More History

CR07: T1 disease 1.8 (2.9)% LR // OS 94%

The early rectal cancer dilemma

Stage 1 rectal cancer is a curable disease with radical surgery

But…

The cost for cure

Total mesorectal excision associated with Long hospital stay and convalescence Death (young 2% : >85 20%) Leak rate (16%) Urinary dysfunction Sexual dysfunction Defaecatory dysfunction Permanent stoma rate (10-40%)

Bowel DysfunctionRadical surgery for rectal cancer

Temple et al, DCR 2005

Sexual DysfunctionRadical surgery for rectal cancer

Activity:Pre Op

Post OpLoss Spont

Embarrassed

APR

91%55%53%44%

LAR

94%74%27%24%

TART

80%87%13%0%

Hendren et al, Ann Surg 2005

?

So, what about trans anal, full thickness local excision?

Local Excision is Appealing

Low morbidity Quick recovery Minimal effect on long term bowel function Organ sparing technique Genitourinary dysfunction avoided

BUT………………Lymph nodes!!!!

Blumberg , et al, Dis Colon Rectum 1999

•T 1/2 = 20% +LN•T 3 = 40% +LN

Local Excision: In an Ideal World

We would know that the lymph nodes are clear

Technically a FTLE is possible the surgery should be curative!

But equally, if there is a recurrence … Salvage surgery does not worsen the

oncological result

Trans Anal Resection of Tumour (TART)

Unfortunately . . .the oncologic results have been disappointing

Favorable T1 CancersTrans Anal Excision (TAE)

Mellgren (2000)n=TAE 69 OS 30

Paty (2002)n=TAE 74

Nascimbeni

(2004)n=TAE 70 OS 74

Madbouly (2005)n=52

Local Recurrence

TAE 18% Rsxn

4%

(TME)

TAE 14%

TAE 7% Rsxn

3%

(TME)

TAE 17%

Survival (Survival (CSSCSS//OverallOverall))

TAE TAE 72%72% Rsxn Rsxn 80%80%

TAE TAE 92%92%

TAE TAE 89%89% ((72%72%)) Rsxn Rsxn

90%90%

TAE TAE 89%89% ((75%75%))

“Transanal excision equals total mesorectal neglect”- David Rothenberger

Favorable T1 Cancers

Local Recurrence Survival Survival ((CSSCSS//OverallOverall))

Mellgren (2000)n=TAE 69 OS 30

TART 18% 4 %

(TME)

TART TART 72%72% 80%80%(TME)(TME)

Paty (2002)n=TAE 74

TART 14% TART TART 92%92%

Nascimbeni (2004)n=TAE 70 OS 74

TART 7% 3%

(TME)

TART TART 89%89% ((72%72%))

90%90%(TME)(TME)

Madbouly (2005)n=52

TAE 17% TAE TAE 89%89% ((75%75%))

“Transanal excision equals total mesorectal neglect”

But, don’t worry, we can perform salvage radical surgery!

Salvage Surgery for Recurrence Recurrent stages (n=29) Mean time to recurrence = 26 months 23/29 underwent curative surgery Mean follow up = 39 months

Friel, et al. Dis Colon Rectum 2002

Salvage Surgery for Recurrence FTLE

Patients DFSOverall 29 12(59%)T1 10 7(70%)T2 19 10(53%)

Good histol 22 15(68%)Bad histol 7 2(29%)

Friel, et al. Dis Colon Rectum 2002

Salvage Surgery for Recurrence

Weiser, et al. Dis Colon Rectum 2005

49/50 patients underwent curative surgery

27 (55%) multivisceral resections

47/49 underwent R0 resection

Salvage Surgery for Recurrence FTLE

Weiser, et al. Dis Colon Rectum 2005

5 year Survival

53%

Why the high local recurrence rates?

Progression of occult lymphatic tumor

Better histologic predictors ‘Are all polyps made equal?’

TART technically limiting

Are all polyps equal?

NO

Polyp morphology

Pedunculated

Sessile

7 Adverse features

1. Morphology2. Differentiation3. Mucinous4. LV infiltation5. Peri neural invaision6. Margin7. Exophytic vs ulcerating

The Difficult TART: Origins of TEMS

Standard transanal excision: Limited to lesions:

distal rectum small tumors (<3 cm)

However… lighting and exposure is poor surgical field collapses

“short reach, poor visibility”

Professor Gerhard Buess

Origins of TEMS

Transanal Endoscopic Microsurgery

4 cm x 10-20 cm proctoscope, airtight faceplate, insufflation, telescope, and laparoscopic instruments

Karl Storz (TEO)

Other techniques are available

ESD Contact DXT

Operative Techique

pT1 Rectal Cancer: TEM case series 1991-2003, single surgeon, n=53 (75) Age 65 y (31-89) (65y) Average 7 cm (0-13) from verge (7cm) F/U: 2.8 y

7.5% (4/53) recurrence (9%) No cancer related deaths (0%)

Floyd and Saclarides DCR 2006(Abarca and Saclarides ASCRS 2010)

uT1N0 Rectal Cancer: RCT: TEM vs Low Anterior Rsxn

Patients:Age (y):

Location L/M/U:

Follow-up (m):

Complications:Local Recur:

Survival:

TEM24

63.77/12/5

41

20.8%1 (4%)96%

LAR26

60.98/11/7

46

34.5%0

96%

Winde et al, DCR 1996

Patients:

Local Recur:Distant Recur:

Prob of any Recur:DFS:

TEM35

2 (5.7%)2 (5.7%)

9%94%

LAC-TME35

1 (2.8%)2 (5.7%)

6%94%

Lezoche et al Surg Endosc 2007

uT2N0 Low Rectal Cancer

RCT: ChemoXRT followed byTEM vs Laparoscopic TMEminimum 5 year follow-up

So how should we manage early rectal cancer?

Clinical Evaluation

1. History• Family history• Continence history• Evaluation of operative risk

2. Physical• Abdomen• Digital Rectal Examination• Rigid proctoscopy

Rectal Cancer Work Up

1. Biopsy2. Colonoscopy/ full bowel imaging3. CEA4. CT Scan Abdomen / Pelvis5. Chest imaging (CXR or CT)6. Endoscopic Ultrasound /MRI

Bulky lesion

MR/USS T1/2

Biopsy benign

TEMS

Young fit patient

Biopsy

proven Ca

Bad T1T2

TME/ APER

Good T1Op/ Stoma

averse

Elderly/ comorbidit

y

Biopsy proven Ca

Thanks For Listening!