MCC 2011 - Slide 26

Department of Surgery, University Medical Center Groningen Multidisciplinary treatment of locally advanced rectal cancer Theo Wiggers Cascais, Portugal February 16 th , 2011

Multidisciplinary treatment of locally advanced rectal cancer T3 + T2

Rectal cancer subgroups: “the good”: no radiotherapy “the bad”: short course 5x5 Gray “the ugly”: long course chemoradiation Multidisciplinary treatment of locally advanced rectal cancer ?

This lecture ,[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

Definition ,[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

Definition ( = outcome) ,[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

Definition (=input) ,[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

Goals (neo) adjuvant treatment =strategy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

10 FAQ’s ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

[object Object],Multidisciplinary treatment of locally advanced rectal cancer How to stage locally advanced tumors ?

Are lymph nodes important ? Pathological lymph nodes outside the endopelvic fascia Multidisciplinary treatment of locally advanced rectal cancer Clinical relevance yes! Inclusion in the radiation field Removal if still present on MRI after chemoradiation

What is the optimal radiation dose? ,[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

Postoperative radiotherapy after R1 resection Marijnen et al In J Rad Oncol 2003 Multidisciplinary treatment of locally advanced rectal cancer

Radiotherapy Schedules HART ,[object Object],[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer Coucke, Radiotherapy and Oncology 79,2006

Radiotherapy Extra ,[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer Rau Strahlenther Onkol 1998 Kusters et al Annals of Oncology 21: 1279–1284, 2010 Unfortunately, it is difficult to study the quantitative effect of IORT. But fact is that the 5-year LR rate of 12.0% is very low in this high-risk group of patients. Further, 55% of the patients with positive surgical margins did not develop LR, suggesting that these residual tumor cells were sterilized

Is there a standard chemotherapy regime ? Yes chemoradiation ,[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer Gerard, NEJM 2006

Preoperative chemoradiotherapy (CRT) with Capecitabine and Oxaliplatin, in advanced rectal cancer. A phase I-II multi-centre study of the Dutch Colorectal Cancer Group ,[object Object],[object Object],[object Object],[object Object],Hospers et al Eur J Cancer 2007 Multidisciplinary treatment of locally advanced rectal cancer

Improvement of chemoradiation not likely ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

What is the optimal time interval ? ,[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer Bujko, BJS 2006 Veenhof, Int J Colorectal Dis. 2007

Optimal time interval ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer J Surg Oncol. 2007

Which kind of surgery is necessary? Does chemoradiation and long interval improve sphincter preserving rates? ,[object Object],[object Object],Department of Surgery, University Medical Center Groningen Multidisciplinary treatment of locally advanced rectal cancer

Which kind of surgery is necessary? Multidisciplinary treatment of locally advanced rectal cancer ,[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Surgical options in locally advanced rectal cancer Multidisciplinary treatment of locally advanced rectal cancer

Technical aspects ,[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

Technique ,[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer Stripping of the fascia of the sacrum, Resection of the sacrum (below S3) or os coccyx

Technique ,[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer Resection outside the TME field (sometimes with resection of the vessels)

Vaginal reconstruction Multidisciplinary treatment of locally advanced rectal cancer

Technique ,[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

Technique ,[object Object],[object Object],[object Object],[object Object],[object Object],Exposure to the operative field is better Hydrostatic venous pressure is lower, reducing bleeding Assistance and tutoring is feasible Gravity will pull the perineum downwards, flattening the pelvic floor Multidisciplinary treatment of locally advanced rectal cancer

“ Filling the gap” Multidisciplinary treatment of locally advanced rectal cancer

What to do with synchronous metastases ? ,[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

Synchronous metastases M1 study ,[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

Adjuvant chemotherapy Multidisciplinary treatment of locally advanced rectal cancer ?

Rutten et al 2003 1.0 .9 .8 .7 .6 .5 .4 .3 .2 .1 1 2 3 4 5 6 7 years Locally advanced rectal cancer Overall survival; radiation vs chemoradiation CRT RT p=0.017 start 3 5 rs CRT 100% 67% 57% RT 100% 50% 43% T3 Dutch TME study

Take home ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

Take home ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Multidisciplinary treatment of locally advanced rectal cancer

Next step: ,[object Object],Multidisciplinary treatment of locally advanced rectal cancer R ectal cancer A nd P re-operative I nduction therapy followed by D edicated O peration experimental group : 5 x 5 Gy radiation followed by six cycles of combination chemotherapy (capecitabine and oxaliplatin) and surgery control group : with long course chemoradiotherapy followed by surgery

Next step: ,[object Object],Multidisciplinary treatment of locally advanced rectal cancer Locally advanced tumour fulfilling at least one of the following criteria on pelvic MRI indicating high risk of failing locally and/or systemically (T4a, i.e. overgrowth to an adjacent organ or structure like the prostate, urinary bladder, uterus, sacrum, pelvic floor or side wall (according to TNM version 5), cT4b, i.e. peritoneal involvement, extramural vascular invasion (EMVI+). N2, i.e. four or more lymph nodes in the mesorectum showing morphological signs on MRI indicating metastatic disease. Four or more nodes, whether enlarged or not, with a rounded, homogeneous appearance is thus not sufficient. Positive MRF (previously named CRM), i.e. tumor or lymph node < 1 mm from the mesorectal fascia. Enlarged lateral nodes, > 1 cm (lat LN+).

I like movies Multidisciplinary treatment of locally advanced rectal cancer Thank you for your attention Happy to answer questions

MCC 2011 - Slide 26

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MCC 2011 - Slide 26