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)

Rectal Cancer: TME

Circumferential resection margins determine outcome

T4 Treatment failure

Poor Judgement

Inadequate skills

Lack of knowledge

Lack of insight/arrogance

Inadequate resources

Common condition

Uncommon variant

Higher order of treatment

T4: Female

T4 Male anterior tumours

T4 Rectovesical peritoneum

T4 Seminal vesicles

T4 Male

Invading adjacent organs

T4 Seminal vesicles

T4 Male

Invading adjacent organs

Anterior T4 prostatic involvement

APR + Radical prostatectomy

APR + Radical Prostate

T4 Bladder involvement

T4: Male anterior tumours

T4: Posterior Rectal cancer

T4 Strategy: Staging

EUA, cystoscopy

MR pelvis

CT abdo, thorax

? PET scan

Pre-operative RTH has a major role

Only a minority will be cured with RTH alone

Pre-operative CRTH has increased risks

Phase II studies oxaliplatin, irinotecan

capecitabine and Mabs

What do we do with complete regression?

Adjuvant Rx for fixed tumours

Current CRT schedule

Radiotherapy with 3 or 4 field plan

45 Gy in 25 # over 5 weeks

Capecitabine 825mg/m2 bd for 5 weeks

CRT for fixed rectal tumours

• 45 - 65% have potentially curable resections after CRT

• When is the right time to operate?

10-12 weeks post DXT

Stomas

Stenting

Nephrostomies

T4 Strategy: Pre-emptive surgery

TPC: Surgical candidates

Nutrition

Renal function

Liver function

? Disease confined to pelvis

Re assess clinically and radiologically after CRT

Total Pelvic Clearance

Christie NHS FT 2001 -2005

MDT Assessment pre and post CRT Consecutive patients 100

Total Pelvic Clearance 45

Unsuitable for surgery 55

Christie: Total Pelvic Clearance

0

2

4

6

8

10

12

14

16

<40 40-50 50-60 60-70 >70

Age

Number

T4 Strategy: Definitive surgery

Engage the team

Stent the ureters

En bloc resection

? IP Chemotherapy (peritoneal reflection)

Outcome of radical surgery

Primary v recurrent

Munro v mountain

30 - 80% 5y survival

Lenhert et al 2002, Sanfilippo et al 2001, Law et al 2000

Advanced disease

Total Pelvic Clearance

n mortality morbidity% %

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 2008 51 0% 11% op

38% non op

Christie: Total Pelvic Clearance

Operative

Stoma Revision 3Perineal wound 2Bleeding 1SBO 1

Complications

Non operative

Infections 12Ileus 10PE/DVT 1/1Bleeding 1MI 1CVA 1

Advanced/Recurrent Pelvic tumours

0

20

40

60

80

100

%

0 12 24 36 48Time (months)

Colorectal

Others

(57%)

(31%)

Cancer-specific survival

CRM +ve 9%

Perineal reconstruction

Gracilis

TRAM Flap

Perineal reconstruction

Tissue interposition Omentum

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

T4 Tumours: HIPEC

Intraperitoneal mitomycin C

3 bolus over 90min @ 41-

43°C

T4 : Palliative therapies

CRT

Pain relief

Tumour ablation

Tumour resection

Drainage of sepsis

Stenting and stomas