Early colorectal cancer State-of-the-art of surgery for ... · Early colorectal cancer...
Transcript of Early colorectal cancer State-of-the-art of surgery for ... · Early colorectal cancer...
Early colorectal cancer
State-of-the-art of surgery for resectable
primary tumors
(Special focus on rectal cancer surgery)
Stefan Heinrich & Hauke Lang
Department of General, Visceral and Transplantation Surgery
University Hospital of Mainz, Germany
Department of General, Visceral and
Transplantation Surgery
ESMO Clinical Practice Guidelines
Department of General, Visceral and
Transplantation Surgery
Staging and risk assessment for rectal cancer
▪ History & physical examination, CEA
▪ DRE, rigid rectoscopy – biopsy (localization)
▪ Colonoscopy (20% synchronous cancers)
▪ CT scan of thorax & abdomen (metastases)
▪ Endorectal ultrasound (local tumor extension)
▪ MRI (local tumor extension)
▪ MDT – multidisciplinary team discussion
Department of General, Visceral and
Transplantation Surgery
Surgical strategy for primary rectal cancer
TEM
PME upper rectal cancerLocal excision
Open surgery
RECTAL CANCER Rectal resection
TME middle/low rectal cancer
TAMIS
Multivisceral resection
Laparoscopic surgery
Robotic surgery
ISR
taTMEAbdomino-perineal
resection
Neoadjuvant
RT/CRT
Department of General, Visceral and
Transplantation Surgery
Risk adapted surgical strategy for locoregional rectal
cancer
PME / TME
▪ Open Surgery
▪ Laparoscopic Surgery
▪ Robotic Surgery
▪ -- Transanal Approach (taTME and ISR)
cT1 (G3, V1, L1) or cT2-3 N0 or cN1
Department of General, Visceral and
Transplantation Surgery
Total Mesorectal Resection
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Department of General, Visceral and
Transplantation Surgery
In the era of TME - quality of Surgery -
Most important pathologic outcomes 1-5
▪ Negative circumferential resection margin (CRM)
▪ Complete TME
▪ Associated with lower local and distal recurrence rates and
better long-term survival
1 Quirke et al. Lancet 2009; 373: 821828
2 Kusters et al. Eur J Surg Oncol 2010; 36: 470476
3 Nagtegaal et al. J Clin Oncol 2008; 26: 303312
4 Birbeck et al. Ann Surg 2002; 235: 449-457
5 Garcia-Granero Cancer. 2009; 115: 3400-3411 Hugen & al. Nature Reviews 2016; 13: 361-369
Department of General, Visceral and
Transplantation Surgery
Circumferential Resection Margin (CRM)
▪ Cohort of 563 patients with locally advanced rectal cancer
▪ Treated with neoadjuvant CRT and surgery
CRM ≤ 1mm CRM >1mm
5-year local recurrence free survival 66% 98%
Trakarnsanga et al. Ann Surg Oncol 2013; 20: 1179-1184
Department of General, Visceral and
Transplantation Surgery
Completeness of Mesorectal Excision
▪ Cohort of 1156 patients with locally advanced rectal cancer
▪ Treated with neoadjuvant RT or selective postoperative CRT
Complete Nearly
complete
Incomplete
3-year local recurrence free survival 4% 7% 13%
Quirke et al. Lancet 2009; 373: 821828
Department of General, Visceral and
Transplantation Surgery
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Laparoscopic versus open rectal resection
Vennix & al. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD005200
surgical outcome oncological quality
Department of General, Visceral and
Transplantation Surgery
Laparoscopic vs. Open mesorectal excision Pathologic outcome
▪ Meta-analysis - 14 RCTs, 4034 patients
LLR ORR p-value Studies
Positive CRM (≤1 mm) in % 7.9 6.1 0.26 9
M.E.R.C.U.R.Y (≥ 2) in % 13.2 10.4 0.02 5
No significant difference - distal resection margin, lymphnodes retrieved
- distance to distal and radial margins
Martinez-Perez et al. JAMA Surg. 2017; 19:152:e165665.
Department of General, Visceral and
Transplantation Surgery
Laparoscopic vs. Open mesorectal excision Oncologic outcome
COREAN 1 – non-inferiority RCT LLR
(n = 170)
ORR
(n = 170)
3-year disease free survival rate (%) 72.5 79.2
1 Jeong et al. Lancet Oncol 2014; 15: 767-774
2 Bonjer et al. New Engl J Med 2015; 372: 1324-1332
COLOR II 2 – non-inferiority RCT LLR
(n = 699)
ORR
(n = 345)
3-year disease free survival rate (%) 74.8 70.8
Overall survival rate (%) 86.7 83.6
Similar rates
Department of General, Visceral and
Transplantation Surgery
Transanal vs laparoscopic TME
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Laparoscopic
TME
Department of General, Visceral and
Transplantation Surgery
Transanal vs laparoscopic TME
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Transanal
TME
Department of General, Visceral and
Transplantation Surgery
Transanal mesorectal excision
Indications for taTME – transanal Total Mesorectal Excision
Motson et al. Colorectal Dis 2015
▪ Male Gender
▪ Rectal cancer less than 12 cm from anal verge, including very low cancers
▪ Narrow and/or deep pelvis
▪ Visceral obesity and/or BMI>30
▪ Prostatic hypertrophy
▪ Tumordiameter > 4cm
▪ Distorted tissue planes due to neoadjuvant RT
▪ Impalpable, low primary tumour requiring accurate placement of distal resection margin
Department of General, Visceral and
Transplantation Surgery
Penna & al. Ann Surg 2017; 266: 111–117
Department of General, Visceral and
Transplantation Surgery
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Robotic vs. laparoscopic total mesorectal excision
Prete & al. Ann Surg 2017; epub
Department of General, Visceral and
Transplantation Surgery
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Robotic and transanal total mesorectal excision
Two-team approach
with courtesy of Prof. W. Kneist
Department of General, Visceral and
Transplantation Surgery
Transanal vs laparoscopic TME
Positive circumferential
resection margin
Macroscopic
quality of tme
Circumferential
resection margin
Ma et al. BMC Cancer (2016) 16:380
Department of General, Visceral and
Transplantation Surgery
Rectal resection – postoperative function
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Low anterior resection syndrome (LARS)
5 questions regarding bowel function – stool continence
Jeminez-Gomez & al. Colorectal Dis 2017; doi: 10.1111/codi.13901.
Department of General, Visceral and
Transplantation Surgery
Specific considerations- Pelvic autonomic innervation -
Moszkowicz et al. Dis Colon Rectum 2012
Internal anal sphincter Genitalia
Bladder
Kneist & al. Langenbecks Arch Surg 2013
CAAD technique Intraoperative
electrophysiological test
Department of General, Visceral and
Transplantation Surgery
Nerve sparing surgery
Kauff DW, Lang H, Kneist W. Risk factor analysis for newly developed urogenital
dysfunction after total mesorectal excision and impact of pelvic intraoperative
neuromonitoring-a prospective 2-year follow-up study. J Gastrointest Surg 2017
Department of General, Visceral and
Transplantation Surgery
Risk adapted surgical strategy for locoregional
rectal cancer
TEM / TEO
Transanal endoscopic microsurgery
Transanal endoscopic operation
TAMIS
Transanal minimally invasive surgery
Kneist W. Chirurg 2017; 88: 656-663
cT1 N0 M0 (low risk: G1/G2, L0, V0) – Local excision
Department of General, Visceral and
Transplantation Surgery
Minimal Surgery - Local excision TEM
▪ Originally described by Buess et al. 1984 1
Compared to Transanal Excision (TAE) 2
▪ Less Fragmentation
▪ Higher rate of negative resection margins
▪ Lower recurrence rate
1 Buess et al. Chirurg 1984; 55: 677-680
2 Moore et al. Dis Colon Rectum 2008; 51: 1026-1030
Department of General, Visceral and
Transplantation Surgery
Minimal Surgery - Local excision TAMIS
▪ Originally described by Atallah et al. 2010
▪ Hybrid between TEM and single-site laparoscopy
▪ Designed on a readily available platform in most hospitals
Atallah et al. Surg Endosc 2010; 24: 2200-2205
Department of General, Visceral and
Transplantation Surgery
Overview of the quality of the local excision procedures
TAE 1 TEM 1 TAMIS 2
Fragmentation rate (%) 37 0 4
Positive resection margins (%) 22 2 6
Recurrence rate (%) 24 8 2
1 Moore et al. Dis Colon Rectum 2008; 51: 1026-1030,
2 Albert et al. Dis Colon Rectum 2013; 56: 301307
Department of General, Visceral and
Transplantation Surgery
TEM and TAMIS: is one technique superior?
Retrospective analysis 2012 – 2015, Omaha, Nebraska
TEM
(n = 40)
TAMIS
(n = 29)
p value
Complications (%)
(Urinary retention, bleeding, perforation)
13 10 0.55
Re-Operation 8 3 0.44
Positive resection margins (%) 3 10 0.19
Recurrence rate (%) 5 3 0.62
Melin et al. Am J Surg 2016; 212: 1063-1067
Department of General, Visceral and
Transplantation Surgery
Minimal Surgery - Local excision
- Benefits of TAMIS -
Compared to TAE 1
▪ Applications to lesions further away from anal verge
▪ Better oncologic outcome
Compared to TEM 2,3
▪ Reduced cost for equipment
▪ Less post-procedural sphincteric complications
1 Saclarides Clin Colon Rectal Surg 2015; 28: 165175
2 Arezzo A et al. Surg Endosc 2014; 28: 427438,
3 Albert et al. Dis Colon Rectum 2013; 56: 301307
Department of General, Visceral and
Transplantation Surgery
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abdomino-perineal
resection (APR)Inter-spincteric
resection (ISR)
Department of General, Visceral and
Transplantation Surgery
Intersphincteric Resection (ISR) versus
Abdominoperineal resection (APR)
T1-2 T3-4
Local recurrence rate
Tumor depth ISR APR p
T1 0 % 0 % n.s.
T2 4.9% 2.8% n.s.
T3-4 13.2% 3.8% 0.039
Low rectal cancer <5cm
Department of General, Visceral and
Transplantation Surgery
▪ Risk of anastomotic leakage in patients with increased
cardiovascular risk based on medication history
Boström P et al. Colorectal Dis 2015;17:1018-1027
Swedish colorectal cancer registry
n.s.
Specific considerations- High tie vs. low tie -
Department of General, Visceral and
Transplantation Surgery
Specific considerations- High tie vs. low tie -
▪ Impact on function
HIGHLOW - randomized multicenter Trial
Mari G et al. Trials 2015;16:21
212 patients sample size middle/low rectal cancer
Primary end point urogenital function
Secondary end point anastomotic leakage
… but no investigations on anorectal function
Department of General, Visceral and
Transplantation Surgery
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Summary
Standard of care: total mesorectal excision (TME)
- Minimal invasiveness
- Laparoscopic resection
- Robotic surgery
- TaTME/TEM sufficient for early cancer (T1 G1)
Anorectal/urogenital/sexual function
=
Quality of life