Management of Rectal Cancer Jacques Heppell, MD Mayo Clinic Scottsdale, Arizona

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Management of Rectal Cancer Jacques Heppell,
MDMayo ClinicScottsdale, Arizona

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RECTAL CANCER

• 42,000 patients are diagnosed each year in the US
• 8,500 patients die of this disease

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The Prevention of Invasive Cancer of the Rectum

• The results of the 25 year Cancer Detection
  Center study, including 20,000 participants and
  100,000 patient-years experience, demonstrate
  the obviation of appearance of most lower bowel
  cancers associated with a program of annual
  proctosigmoidoscopy and adenomatous polyp
  removal.
• Cancer 411137-1139,1978
• .

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Screening
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Incidence per 100,000
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AJCC STGE OF COLORECTAL NEOPLASMS ARIZONA, ALL
AGES

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Japanese Scientists train Dogs to detect
Colorectal Cancer ( Gut, 2011)
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Who should take care of patients with rectal
cancer?

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Designated Center of Excellence !

• SUCCESSFUL IMPLEMENTATION OF A COMMUNITIES OF
  PRACTICE (COP) MODEL TO FACILITATE QUALITY
  IMPROVEMENT INITIATIVES IN COLORECTAL CANCER
  SURGERY
• LJ Williams et al. Department of Surgery and
  Regional Cancer Program, The Ottawa Hospital,
  University of Ottawa, Ottawa, Ontario, Can

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Team Approach

• Expert surgeon (TME,autonomic nerve and sphincter
  preservation)
• Medical oncologist
• Radiation oncologist
• Nursing
• Nutritionist
• Psychologist

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SURGERY FOR RECTAL CANCER
Goals

• Cure
• Local control
• Sphincter preservation
• Preservation of sexual and urinary function

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TECHNIQUE Old Style

• Blunt dissection commonly used
• 30 local failure (worldwide)
• 60 distant metastasis
• High rates of impotence and
  urinary dysfunction

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PRIMARY GOAL OF SURGERY

• Complete excision of all mesorectal disease,
  enveloped within intact visceral layer of pelvic
  fascia, together with negative lateral or
  circumferential margin

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TOTAL MESORECTAL EXCISION
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TME ALONE
"High Risk Patients" T3, N0, M0 or any T, N1-2,
M0

• Local recurrence 5-8
• Distant metastasis 25

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Norwegian Rectal Cancer Group

• 29 local recurrence rate among 250
  surgeons performing 1-14 resections for rectal
  cancer in 2 years
• Establishment of a system for preceptorships to
  teach TME on a national level and Pathologists
  trained to evaluate quality of the specimens
• Voluntary reduction of the number of surgeons
  operating on rectal carcinoma (250 to 50)

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Norwegian Rectal Cancer Group

• TME performed
• In 1994 78 of cases
• In 1998 98 of cases
• Local recurrence rate reduced to 8 !

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NIH Consensus on Adjuvant Therapy for Patients
with Rectal Cancer 1990

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WAS THE NIH CONSENSUS RIGHT?

• Quality of life
• Bowel function
• Most important treatment variable (the surgeon)

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Chemoradiation The Functional Cost

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SUMMARY OF BOWEL FUNCTION IN THE 2 GROUPS

• Non-Radiation Chemoradiotherapy
  (59 Patients) (41
  Patients) p Value
• No. of bowel movements/day
• Medican (range) 2 (1-7) 7
  (1-20) lt0.001
• ?4 83 22
• Clustering 3 42
• ?5 14 37
• Awoken at night for movement 14 46
  lt0.001
• Incontinence
  lt0.001
• None 93 44
• Occasional 7 39
• Frequent 0 17
• Wear a pad 10 41 lt0.001
  
• Perianal skin irritation 12 41
  lt0.001
• Regularly use Lomotil Imodium 5 58
  lt0.001
• Unable to differentiate stool from
  gas 15 39 0.009
• Liquid consistency (sometimes or
  always) 5 29 0.001
• Unable to defer defecation gt15 min 19
  78 lt0.001
• Need to defecate again within 30
  min 37 88 lt0.001

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R.J. Nicholls Br J Surg,1996
Apart from the occasional tumor, which is
suitable for local excision, most low rectal
cancers are best treated by anterior resection
with complete removal of the rectum the
construction of the coloanal reservoir should
allow routine sphincter saving. This surgery
may be carried out independently of adjuvant
radiotherapy by which, if given, should be
administered before operation
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Pre-op vs Post-opChemoradiation

• Sauer R. et al. NEJM 2004
• Randomized 421 patients pre-op and 402 patients
  post-op
• 5 year survival 76 vs 74 (p0.8)
• Toxicity 27 vs 40 ( p0.001)
• Local control
• Increased sphincter saving rate

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DOWNSTAGING

• Reduce volume of primary tumor
• Decrease rectal wall invasion
• Sterilize metastatic lymph nodes

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RECTAL CANCER
Locally Advanced Unresectable

• Addition of chemotherapyto preoperative
  radiation therapy increases down-staging and
  resectability rates for fixed and tethered
  lesions

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PREOPERATIVE CHEMOTHERAPY
Theoretical Benefits

• No delay in starting systemic therapy
• Toxicity rates may be lower
• Radiosensitizing effect of 5-FU
• Downstaging may allow sphincter-saving procedure

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IORT
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First report of APR technique at Mayo
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Dr. Claude F. Dixon1939 First anterior resection

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Knight and Griffen, 1980
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• SURGERY Apples and oranges the low and mid
  versus the upper rectum
• Martin Weiser Leonard Saltz  

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COLONIC-POUCH ANAL ANASTOMOSIS
Rolland Parc

• 341 cases
• 1984-97
• 28 of all rectal cancer
• Improved function
• 20 emptying difficulty

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Splenic vein
Inferiormesentericvein
Duodenum
Inferiormesentericartery
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Hand assisted vs Laparoscopic assisted

• Larson DW et al Tech Coloproctol 2010
• Same oncologic results at 3 years but length of
  stay, time to soft diet, incision length, pain
  score better with laparoscopic assisted

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ACOSOG Z6051
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Endo anal vs Stapled anastomosis

• Better function with stapler but preferable to do
  endo- anal anastomosis
• Intersphincteric dissection
• Very narrow pelvis
• Enlarged prostate
• Prior radiation for prostate cancer
• Short margin !

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Colo-anal anastomosis anastomosis
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Indications for APR

• Inadequate sphincter low Hartmann?
• Sphincter invasion
• Inadequate margin
• Patient wishes !

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MRI or Endorectal US

• Better selection of high-risk lesions amenable to
  downstaging by preoperative chemo-radiation while
  reserving early-stage disease for surgery alone

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Isolated Adrenal Metastase
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RECTAL CANCER
Selective Approach Based on Preop Imaging

• Rectal endosonography
• T1, ? local excison
• T2T3 ? radical surgery

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LOCAL EXCISION

• Careful selection (5)
• Endorectal ultrasound essential in assessing
  penetration of rectal wall
• Accessible, small, confined to rectal wall and
  without anaplastic histology

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Local treatment failure

• Low salvage rates after radical surgery argue
  for aggressive additional therapy for patients
  whose initial tumors showed invasion of
  muscularis propria (T2), positive margins, poor
  differentiation,or lymphovascular invasion

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LOCAL EXCISION

• Deep
• Dark
• Difficult

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Trans anal Endoscopic Microsurgery
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PREOPERATIVE CHEMO-RADIATION

• Complete Pathologic No. Response,
• Creighton Univ 20 35
• MSK 32 9
• Duke University 43 27
• MD Anderson 77 29
• NW University 30 20

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RESPONDERS TO NEOADJUVANT THERAPY

• 644 patients with proctectomy after neoadj Rx
  retrospectively (TE Read)
• ypT0 2 positive nodes
• ypT1 4
• ypT2 23
• ypT3 47
• ypT4 48

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This study has very significant implications. It
suggests that patients who respond well to
preoperative chemoradiation may be safely treated
by local excision and spared the morbidity of
radical surgery.
Neil H. Hyman, MD

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ACOSOG Z6041

• Pathologic complete response (pCR) to neoadjuvant
  chemoradiation (CRT) of uT2uN0 rectal cancer (RC)
  treated by local excision (LE) Results of the
  ACOSOG Z6041 trial

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What do you do ?

• Radical Surgery
• Wide local excision
• Wait and see ?

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Future research

• Robotics gt my eye!

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Ernestine Hambrick
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