Management of
Rectal Cancer
Jacques Heppell, MD
Mayo Clinic
Scottsdale, Arizona
JH012804
JH012804
RECTAL CANCER
• 42,000 patients are diagnosed each
year in the US
• 8,500 patients die of this disease
JH012804
JH012804
JH012804
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 41:1137-1139,1978
.
JH012804
Screening
JH012804
Incidence per 100,000
JH012804
AJCC STGE OF COLORECTAL
NEOPLASMS: ARIZONA, ALL AGES
JH012804
Japanese Scientists train Dogs to
detect Colorectal Cancer ( Gut, 2011)
JH012804
JH012804
JH012804
Who should take care of
patients with rectal cancer?
JH012804
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
JH012804
Team Approach
• Expert surgeon (TME,autonomic nerve
and sphincter preservation)
• Medical oncologist
• Radiation oncologist
• Nursing
• Nutritionist
• Psychologist
JH012804
SURGERY FOR RECTAL CANCER
Goals
• Cure
• Local control
• Sphincter preservation
• Preservation of sexual
and urinary function
JH012804
TECHNIQUE: “ Old Style”
• Blunt dissection commonly used
• 30% local failure (worldwide)
• 60% distant metastasis
• High rates of impotence and
urinary dysfunction
JH012804
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
JH012804
TOTAL MESORECTAL EXCISION
JH012804
TME ALONE
"High Risk Patients"
T3, N0, M0 or any T, N1-2, M0
Local recurrence
5-8%
Distant metastasis
25%
JH012804
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)
JH012804
Norwegian Rectal Cancer Group
•
•
•
•
TME performed
In 1994 : 78% of cases
In 1998: 98% of cases
Local recurrence rate reduced to 8 %!
JH012804
NIH Consensus on
Adjuvant Therapy for
Patients with
Rectal Cancer
1990
JH012804
WAS THE NIH CONSENSUS RIGHT?
• Quality of life
• Bowel function
• Most important treatment variable
(the surgeon)
JH012804
Chemoradiation:
The Functional Cost
JH012804
SUMMARY OF BOWEL FUNCTION IN THE 2 GROUPS
Non-Radiation
(59 Patients)
No. of bowel movements/day
Medican (range)
4
Clustering
5
Awoken at night for movement
Incontinence
None
Occasional
Frequent
Wear a pad
Perianal skin irritation
Regularly use Lomotil ± Imodium
Unable to differentiate stool from gas
Liquid consistency (sometimes or always)
Unable to defer defecation >15 min
Need to defecate again within 30 min
Bowel function different to preoperative
2 (1-7)
83%
3%
14%
14%
–
93%
7%
0%
10%
12%
5%
15%
5%
19%
37%
61%
Chemoradiotherapy
(41 Patients)
7 (1-20)
22%
42%
37%
46%
–
44%
39%
17%
41%
41%
58%
39%
29%
78%
88%
93%
p Value
<0.001
–
–
–
<0.001
<0.001
–
–
–
<0.001
<0.001
<0.001
0.009
0.001
<0.001
<0.001
JH012804
0.001
JH012804
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
JH012804
Pre-op vs Post-op
Chemoradiation
• Sauer R. et al. NEJM 2004
• Randomized 421 patients pre-op and
402 patients post-op
• 5 year survival 76% vs 74% (p=0.8)
• Toxicity: 27 % vs 40% ( p=0.001)
• Local control
• Increased sphincter saving rate
JH012804
DOWNSTAGING
• Reduce volume of primary tumor
• Decrease rectal wall invasion
• Sterilize metastatic lymph nodes
JH012804
JH012804
JH012804
RECTAL CANCER
Locally Advanced Unresectable
• Addition of chemotherapy
to preoperative radiation therapy
increases down-staging and
resectability rates for fixed and
tethered lesions
JH012804
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
JH012804
JH012804
IORT
JH012804
First report of APR technique at Mayo
JH012804
Dr. Claude F. Dixon
1939 First anterior resection
JH012804
JH012804
Rectosigmoid
15 cm
Upper third
11 cm
Middle third
7 cm
Lower third
Anal canal
JH012804
Knight and Griffen, 1980
Roticulator
A
B
C
D
E
JH012804
• SURGERY: Apples and oranges: the
low and mid versus the upper
rectum
• Martin Weiser & Leonard Saltz
JH012804
JH012804
JH012804
COLONIC-POUCH ANAL ANASTOMOSIS
Rolland Parc
• 341 cases
• 1984-97
• 28% of all rectal cancer
• Improved function
• 20% emptying difficulty
JH012804
JH012804
JH012804
JH012804
JH012804
Splenic vein
Inferior
mesenteric
vein
Duodenum
Inferior
mesenteric
artery
JH012804
JH012804
JH012804
JH012804
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
JH012804
ACOSOG Z6051
JH012804
JH012804
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 !
JH012804
Colo-anal anastomosis anastomosis
JH012804
Indications for APR
•
•
•
•
Inadequate sphincter : low Hartmann?
Sphincter invasion
Inadequate margin
Patient wishes !
JH012804
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
JH012804
JH012804
Isolated Adrenal Metastase
JH012804
RECTAL CANCER
Selective Approach Based
on Preop Imaging
• Rectal endosonography
– T1,  local excison
– T2T3  radical
surgery
JH012804
JH012804
LOCAL EXCISION
• Careful selection (5%)
• Endorectal ultrasound essential in
assessing penetration of rectal wall
• Accessible, small, confined to rectal
wall and without anaplastic histology
JH012804
JH012804
JH012804
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”
JH012804
LOCAL EXCISION
• Deep
• Dark
• Difficult
JH012804
Trans anal Endoscopic Microsurgery
JH012804
JH012804
JH012804
PREOPERATIVE CHEMO-RADIATION
Creighton Univ
MSK
Duke University
MD Anderson
NW University
No.
Complete
Pathologic
Response, %
20
32
43
77
30
35
9
27
29
20
JH012804
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% “
JH012804
“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
JH012804
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
JH012804
What do you do ?
• Radical Surgery
• Wide local excision
• Wait and see ?
JH012804
JH012804
JH012804
JH012804
Future research
• Robotics > my eye!
JH012804
Ernestine Hambrick
JH012804
JH012804