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T Staging: Rectal cancer

T1 invades submucosa. T2 invades muscularis propria. T3 invades subserosa or perirectal tissues. T4 invades peritoneum, organs or structures (15% of cases). T Staging: Rectal cancer. T4: Female. T4: Rectal cancer. Prostatic Involvement. T4: Male. Anterior T4 Rectal cancer. APR

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T Staging: Rectal cancer

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  1. T1 invades submucosa T2 invades muscularis propria T3 invades subserosa or perirectal tissues T4 invades peritoneum, organs or structures (15% of cases) T Staging: Rectal cancer

  2. T4: Female

  3. T4: Rectal cancer

  4. Prostatic Involvement

  5. T4: Male

  6. Anterior T4 Rectal cancer APR + Radical prostatectomy

  7. APR + Radical Prostate

  8. T4: Posterior Rectal cancer

  9. T4 Strategy: Staging • EUA, cystoscopy • MR pelvis • CT abdo, thorax • ? PET scan

  10. T4 Strategy: Adjuvant therapy • RTH • Chemo/RTH • Intra op RTH • HIPEC: Hyperthermic Intra Peritoneal CT

  11. Adjuvant Rx for fixed tumours • Pre-operative RTH plays a major role • Only a minority will be cured with RTH alone • Pre-operative CRTH has increased risks • Phase II studies oxaliplatin, irinotecan and capecitabine • What do we do with complete regression?

  12. Current optimum CRT schedule Radiotherapy with 3 or 4 field plan 45 Gy in 25 # over 5 weeks Capecitabine 825mg/m2 bd for 5 weeks

  13. T4 Strategy: Pre-emptive surgery • Stomas • Stenting • Nephrostomies

  14. T4 Strategy: Definitive surgery • Engage the team • Stent the ureters • En bloc resection • ? IP Chemotherapy (peritoneal reflection)

  15. Total Pelvic Clearance Christie NHST 2001 -2005 MDT Assessment Consecutive patients 100 Total Pelvic Clearance 45 Unsuitable for surgery 55

  16. TPC: Surgical candidates • Nutrition • Renal function • Liver function ? Disease confined to pelvis

  17. Outcome of radical surgery • Primary v recurrent disease • Munro v mountain • 30 - 80% 5y survival Lenhert et al 2002, Sanfilippo et al 2001, Law et al 2000

  18. Total Pelvic Clearance n mortality morbidity % % Adachi et al 1999 9 0% 44% Kakuda et al 2003 22 5% 68% Jimenez et al 2003 55 5.5% 40+% Nakafusa et al 2004 53 0% 49% Sharma et al 2005 48 4.2% 75% Sagar et al 2005 18 1.6% na Christie 2006 45 0% 11% op 38% non op

  19. Christie: Total Pelvic Clearance Complications Operative Stoma Revision 2 Perineal wound 2 SBO 1 Non operative Infections 12 PE/DVT 1/1 Bleeding 1 MI 1 CVA 1

  20. Christie: Total Pelvic Clearance Number Age

  21. T4 Tumours: HIPEC • Peritoneal involvement • Complete excision • Intraperitoneal mitomycin C 3 bolus over 90min @ 41- 43°C

  22. Peritoneal metastasis

  23. T4 : Palliative therapies • CRT • Pain relief • Tumour ablation • Tumour resection • Drainage of sepsis • Stenting and stomas

  24. Survival: Cyto + HIPEC

  25. T Staging: Rectal cancer T4 Male Invading adjacent organs

  26. T4: Rectal cancer

  27. Anterior T4 rectal tumour APR + Radical Prostate

  28. CRC complete CRC incomplete Survival: Cytoreduction + HIPEC CRC Peritoneal v liver resections

  29. T4 : Palliative therapies • CRT • Pain relief • Tumour ablation • Tumour resection • Drainage of sepsis • Stenting and stomas

  30. T4: Palliative surgery There you are gentleman,you’ve seen the operation that everyone said was impossible, performed with complete success. But Doctor, the patient’s dead! What of it! She would have died anyway without the operation.

  31. Survival: Cyto + HIPEC

  32. Total Pelvic Clearance

  33. Peritoneal carcinomatosis Sugarbaker

  34. Survival with Colorectal Liver Metastases % years Scheele 1993

  35. Surgical candidates • Nutrition • Renal function • Liver function • Proximal small bowel loops • Disease confined to pelvis, R/LIF +/- omentum

  36. T4 adjuvant IORT Fixed / inoperable tumours RTH + resection N = 248 Local recurrence free survival 11% RTH + resection + IORT N = 78 Local recurrence free survival 2.6% Sadahiro et al Dis Colon Rectum 2001

  37. RTH for fixed rectal tumours 45 - 65%have potentially curable resections after radiotherapy 50% developlocal recurrence Only a minority will be cured with RTH alone (Martenson et al, in Cancer of the colon, rectum and anus 1995)

  38. Pre-operative CRT • Small studies n = 7-64 • 5FU, FA, cisplatin, mmc • RTh 40Gy/20#, 50Gy/30# • Resectability 70 -100% • Pathology T0 4 -72% • DFS 60 -80% (Videtic et al, 1998)

  39. Preoperative RTH + Raltitrexed(tomudex) Fixed / inoperable tumours Christie and Walsgrave N = 36 MR T3: 17 T4: 19 Response: 81% Curative resection: 64% Path T0: 14% ASCO 2003

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