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Organ Sparing Treatments for Early Rectal Cancer The Oregon Gut Club

Organ Sparing Treatments for Early Rectal Cancer The Oregon Gut Club. Mark H. Whiteford, MD, FACS, FASCRS Director, Colon and Rectal Surgery | Providence Cancer Center Clinical Associate Professor | Oregon Health & Science University

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Organ Sparing Treatments for Early Rectal Cancer The Oregon Gut Club

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  1. Organ Sparing Treatments for EarlyRectal Cancer The Oregon Gut Club Mark H. Whiteford, MD, FACS, FASCRS Director, Colon and Rectal Surgery | Providence Cancer Center Clinical Associate Professor | Oregon Health & Science University Gastrointestinal and Minimally Invasive Surgery Division | The Oregon Clinic, PC

  2. Disclosure • Richard Wolf Medical Instruments • Research funding • Consultant

  3. Rectal Cancer • Colorectal Cancer is second most common cause of cancer related death in the US • Rectal cancer accounts for 40% of these • 36,400 new cases (56% male) • 8,600 deaths (55% male)

  4. Advancements in Rectal Cancer Treatment • Improved tumor imaging: • Endoscopic ultrasound • Rectal MRI

  5. Advancements in Rectal Cancer Treatment • Improved tumor imaging: • Endoscopic ultrasound • Rectal MRI • Advantages of neoadjuvantchemoradiation • Stage 2 and 3

  6. Advancements in Rectal Cancer Treatment • Improved tumor imaging: • Endoscopic ultrasound • Rectal MRI • Advantages of neoadjuvantchemoradiation • Stage 2 and 3 • Better understanding of surgical technique: • 1-2 cm distal margin = Sphincter sparing techniques • Total mesorectal excision

  7. Total Mesorectal Excision • Established gold standard for radical excision of rectal cancer • Nerve sparing technique • Lower local recurrence rates • Improved survival

  8. What is a rectum? • Anus to … • 15 cm? • Upper rectal fold? • “Rectosigmoid junction”? • Peritoneal reflection? • Top of S3?

  9. Gordon PH, 2nd Ed, 1999 The Anatomic Rectum 15 cm Anal Verge

  10. Gordon PH, 2nd Ed, 1999 The Oncologic Rectum 15 cm 12 cm Anal Verge NCI Guidelines 2000 for Colon and Rectal Cancer Surgery, JNCI 2001

  11. Clinical Evaluation • History • Family history • Continence history • Evaluation of operative risk • Physical • Abdomen • Digital Rectal Examination • Rigid proctoscopy

  12. Rectal Cancer Work Up • Clearing colonoscopy • CBC • CMP • CEA • CT Scan Abdomen / Pelvis • Chest imaging (CXR or CT) • Endoscopic Ultrasound (MRI)

  13. Clinical Stage

  14. The early rectal cancer dilemma • Stage 1 rectal cancer is a curable disease with radical surgery But…

  15. The early rectal cancer dilemmaThe cost for cure • Total mesorectal excision associated with • Long hospital stay and convalescence • Infectious complications • Urinary dysfunction • Sexual dysfunction • Defecatory dysfunction • Some need permanent ostomy

  16. Bowel DysfunctionRadical surgery for rectal cancer Temple et al, DCR 2005

  17. Sexual DysfunctionRadical surgery for rectal cancer Activity: Pre Op Post Op Loss Spont Embarrassed APR 91% 55% 53% 44% LAR 94% 74% 27% 24% TAE 80% 87% 13% 0% Hendren et al, Ann Surg 2005

  18. So, what about transanal, full thickness local excision?

  19. Full Thickness Local Excision • “Total Biopsy” • Thorough histologic evaluation • Polyp vs Cancer? • Tumor differentiation • Depth of invasion • Completeness of excision

  20. Local Excision is Appealing • Low morbidity • Quick recovery • Minimal effect on long term bowel function • Organ sparing technique

  21. Local Excision: In an Ideal World • If … • we know that there is no tumor in the lymph nodes • and technically a FTLE can be done, • the surgery should be curative! • And if there is a recurrence … • we can always perform salvage surgery!

  22. Predicting success? • How to predict which tumors are confined to the rectal wall ? • What tumor characteristics predict node positivity?

  23. Local Treatment of Rectal CancerT-stage relates to Lymph Node Metastasis Morson BC Proc R Soc Med 1966 Hojo K Am J Surg 1982 Minsky BD Cancer 1989 Huddy SPJ BJS 1993 T1 10.9% 17.9% 0% 11% T2 12.1% 37.8% 28% 23% T3 58.3% >50% 36% ns

  24. Blumberg , et al, Dis Colon Rectum 1999

  25. Favorable Features of Early Rectal Cancers • T1 • Moderate to well differentiated • Negative margins • No LVI • < 4cm greatest dimension • < 40% circumference • < 8-10 cm from anal verge

  26. Case series of FTLE Morson, et al. GUT 1977

  27. CALGB 8984 Trial • Full Thickness Local Excision Steele, et al, Ann Surg Oncol 1999

  28. CALGB 8984 Trial Steele, et al, Ann Surg Oncol 1999

  29. Local Treatments for Rectal Cancer • Transanal excision of rectal neoplasmsbecame standard practice:

  30. Unfortunately . . . the oncologic results have been disappointing

  31. Favorable T1 CancersParks Trans 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 (CSS/Overall) TAE 72%Rsxn80% TAE 92% TAE 89%(72%)Rsxn90% TAE 89%(75%) “Transanal excision equals total mesorectal neglect” - David Rothenberger

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

  33. Salvage Surgery for Recurrence FTLE • Recurrent stages (n=29) • stage 1: 2 • stage 2: 13 • stage 3: 12 • stage 4: 2 • Mean time to recurrence = 26 months • 23/29 underwent curative surgery • Mean follow up = 39 months Friel, et al. Dis Colon Rectum 2002

  34. Salvage Surgery for Recurrence FTLE Patients DFS Overall 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

  35. Salvage Surgery for Recurrence FTLE • 49/50 patients underwent curative surgery • 31 Abdomioperineal • 11 Low anterior • 4 Pelvic exenteration • 1 Transanal excision • 27 (55%) multivisceral resections • 47/49 underwent R0 resection Weiser, et al. Dis Colon Rectum 2005

  36. Salvage Surgery for Recurrence FTLE 5 year Survival 53% Weiser, et al. Dis Colon Rectum 2005

  37. Why the high failure rates? • Progression of occult lymphatic tumor • Implantation of viable tumor cells • Better histologic predictors • Remove deeper en bloc section of mesorectum • More precise instrumentation • Less traumatic tissue handling • Better visualization

  38. Better Histologic Predictors • Routine use of EUS • Submucosal Depth of Invasion Kikuchi Classification: 1-3% 8-10% 23-25% • Eventually: molecular markers

  39. Why the high failure rates? • Progression of occult lymphatic tumor • Implantation of viable tumor cells • Better histologic predictors • Remove deeper en bloc section of mesorectum • More precise instrumentation • Less traumatic tissue handling • Better visualization

  40. Origins of TEM 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”

  41. Origins of TEM Professor Gerhard Buess

  42. Richard Wolf Medical Instruments

  43. Transanal Endoscopic Microsurgery 4 cm x 10-20 cm proctoscope, airtight faceplate, insufflation, telescope, and laparoscopic instruments

  44. TEM Instruments

  45. Karl Storz (TEO)

  46. Other requirements for TEM • Need correct equipment • Need staff familiar with equipment • Need a surgeon skilled in TEM

  47. TEM Equipment Set Up

  48. TEM Set-up

  49. Operative Technique

  50. Where can TEM help? • Progression of occult lymphatic tumor • Implantation of viable tumor cells • Better histologic predictors • Remove deeper en bloc section of mesorectum • More precise instrumentation • Less traumatic tissue handling • Better visualization

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