Taunton SpR Training Day 7 th December 2012 Early rectal cancer
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Transcript of Taunton SpR Training Day 7 th December 2012 Early rectal cancer
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TAUNTON SPR TRAINING DAY7TH DECEMBER 2012 EARLY RECTAL CANCERTom Edwards Consultant Colorectal Surgeon
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Introduction
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Staging for Rectal Cancer
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Staging for Rectal Cancer
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More History
CR07: T1 disease 1.8 (2.9)% LR // OS 94%
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The early rectal cancer dilemma
Stage 1 rectal cancer is a curable disease with radical surgery
But…
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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%)
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Bowel DysfunctionRadical surgery for rectal cancer
Temple et al, DCR 2005
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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
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?
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So, what about trans anal, full thickness local excision?
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Local Excision is Appealing
Low morbidity Quick recovery Minimal effect on long term bowel function Organ sparing technique Genitourinary dysfunction avoided
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BUT………………Lymph nodes!!!!
Blumberg , et al, Dis Colon Rectum 1999
•T 1/2 = 20% +LN•T 3 = 40% +LN
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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
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Trans Anal Resection of Tumour (TART)
Unfortunately . . .the oncologic results have been disappointing
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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
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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”
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But, don’t worry, we can perform salvage radical surgery!
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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
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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
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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
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Salvage Surgery for Recurrence FTLE
Weiser, et al. Dis Colon Rectum 2005
5 year Survival
53%
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Why the high local recurrence rates?
Progression of occult lymphatic tumor
Better histologic predictors ‘Are all polyps made equal?’
TART technically limiting
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Are all polyps equal?
NO
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Polyp morphology
Pedunculated
Sessile
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7 Adverse features
1. Morphology2. Differentiation3. Mucinous4. LV infiltation5. Peri neural invaision6. Margin7. Exophytic vs ulcerating
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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”
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Professor Gerhard Buess
Origins of TEMS
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Transanal Endoscopic Microsurgery
4 cm x 10-20 cm proctoscope, airtight faceplate, insufflation, telescope, and laparoscopic instruments
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Karl Storz (TEO)
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Other techniques are available
ESD Contact DXT
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Operative Techique
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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)
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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
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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
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So how should we manage early rectal cancer?
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Clinical Evaluation
1. History• Family history• Continence history• Evaluation of operative risk
2. Physical• Abdomen• Digital Rectal Examination• Rigid proctoscopy
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Rectal Cancer Work Up
1. Biopsy2. Colonoscopy/ full bowel imaging3. CEA4. CT Scan Abdomen / Pelvis5. Chest imaging (CXR or CT)6. Endoscopic Ultrasound /MRI
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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
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Thanks For Listening!