chriscunningham … colorectal! abriefhistoryofrectalcancersurgery 0 20 40 60 80 100 120 1845 1910...

Oxford Colorectal

New approaches in managing rectal cancer

Chris Cunningham Oxford University Hospitals NHS Founda>on Trust

Oxford Colorectal

Areas of change in rectal cancer

Organ preserva>on in early stage disease

More effec>ve minimally invasive surgery

for advanced disease

Oxford Colorectal

Oxford Colorectal

A brief history of rectal cancer surgery

0

20

40

60

80

100

120

1845 1910 1950 1975 2000 2012

Recurrence

mortality Buess%

1984%

Lisfranc%

1822%

Billroth%

1860%

Kocher,%Kraske%

1874%

Miles%

1908%

Dixon%

1948%

Parks%

1982%

Heald,%Quirke%

1986%

TME%and%preop%RT%

2001%

Lloyd%Davies%

1939%

Bosset%and%Gerard%

2006%

Holms%

2008%

1984%

Miles Lisfranc Lloyd-‐Davies Parks Heald Holm Bilroth

Mortality Local recurrence

Oxford Colorectal


0

20

40

60

80

100

120

1845 1910 1950 1975 2000 2012

Cancer rel death Recurrence

mortality

Stoma Buess%

1984%

Lisfranc%

1822%

Billroth%

1860%

Kocher,%Kraske%

1874%

Miles%

1908%

Dixon%

1948%

Parks%

1982%

Heald,%Quirke%

1986%

TME%and%preop%RT%

2001%

Lloyd%Davies%

1939%

Bosset%and%Gerard%

2006%

Holms%

2008%

1984%



Death at 5 Years Stoma

Oxford Colorectal


0

20

40

60

80

100

120

1845 1910 1950 1975 2000 2012

Morbidity

Cancer rel death Recurrence

mortality

Stoma Buess%

1984%

Lisfranc%

1822%

Billroth%

1860%

Kocher,%Kraske%

1874%

Miles%

1908%

Dixon%

1948%

Parks%

1982%

Heald,%Quirke%

1986%

TME%and%preop%RT%

2001%

Lloyd%Davies%

1939%

Bosset%and%Gerard%

2006%

Holms%

2008%

1984%



Death at 5 Years Stoma

Major morbidity

Oxford Colorectal

Radical surgery for T1 cancer Radical surgery

Opera>ve Mortality 2-‐4%

Stoma rate 40%

Major morbidity 30%

Local recurrence

<5%

Death from LR <2.5%

Metasta>c disease 5-‐10%

Overall survival 85-‐90%

Oxford Colorectal

Is there an no alterna>ve to a big opera>on?

Oxford Colorectal

ERC defined as T1 (possibly T2 invasion) Absence of lymph node spread Risk of nodal disease in T1 cancers varies from 3-‐25%

size and depth of invasion lympha>c invasion differen>a>on vascular invasion tumour budding

Cure can be achieved by local excision

Early Rectal Cancer

Oxford Colorectal

Local excision for early rectal cancer

Oxford Colorectal

Transanal endoscopic microsurgery Local excision by TEM offers precise par>al or full thickness excision of the extra-‐peritoneal rectum

Oxford Colorectal

Transanal endoscopic microsurgery

•  GA, inpa>ent 1-‐2 days •  Complica>on rate 5-‐15% •  Good func>onal

recovery 70

72

74

76

78

80

82

84

86

88

90

pre-‐opera>ve 6 weeks 3 month 6 month

VAS

Oxford Colorectal

Oxford Colorectal Bach et al BJS, 2009

Oxford Colorectal

Local excision cures early rectal cancer

•  pT1 •  Tumour <3cm diameter •  Complete excision (R0) •  G1/2 •  No lympha>c or vascular invasion

Oxford Colorectal

What if the post TEM pathology is unfavourable?

How do we manage these risks of recurrence?

What risk of recurrence is acceptable?

Oxford Colorectal

Assessing risk of recurrence

22mm cancer pT1, sm3, Ly1, R0

Oxford Colorectal

Bach et al BJS, 2009



Oxford Colorectal

Bach et al BJS, 2009

25 %



Oxford Colorectal Solomon M, Pager C, Keshava A, Findlay M, Butow P, Salkeld G, et al. What Do Pa>ents Want? Diseases of the Colon & Rectum. 2003;46(10):1351-‐7.

Oxford Colorectal

How can we mi>gate recurrence?

•  Offer comple>on radical surgery if poor post LE pathology?

•  Close surveillance

•  Offer radiotherapy ajer LE

Oxford Colorectal

Diseases of the colon and rectum. 2005; 48: 429-‐37

Oxford Colorectal

“In T1 and T2 tumours excised by TEM and subsequently treated by TME no recurrence was noted… excision biopsy followed by radical reopera>on is reasonable for early tumours” BJS, 2009

TEM then TME TEM then TME

TEM alone TEM alone

Oxford Colorectal





Oxford Colorectal

3-‐36 months 42 months

45 months 48 months

MRI surveillance

Oxford Colorectal

Final pathology

Oxford Colorectal





Oxford Colorectal

Systema>c review and meta-‐analysis of oncological outcome ajer local excision of pT1-‐2 rectal cancer with adjuvant (chemo)radiotherapy

compared to comple>on TME surgery

Borstlap WAA, et al, BJS 2016

Local recurrence according to post TEM treatment

Stage LE then CRT LE then TME

T1 10% 6%

T2 16% 10%

Oxford Colorectal

Systema>c review and meta-‐analysis of oncological outcome ajer local excision of pT1-‐2 rectal cancer with adjuvant (chemo)radiotherapy

compared to comple>on TME surgery

Local recurrence according to post TEM treatment

Stage LE then CRT LE then TME LE alone

T1 10% 6% 15-‐20%

T2 16% 10% 30-‐40%

Borstlap WAA, et al, BJS 2016

Oxford Colorectal

What can be done to extend the use of local excision?

Where is the evidence for

effec>ve use of LE ajer CRT?

Oxford Colorectal Surg Endosc. 2008

DFS 96% 96%

Oxford Colorectal

Oxford Colorectal Bujko K,et al, Radiotherapy and Oncology. 2013.

Oxford Colorectal Bujko K,et al, Radiotherapy and Oncology. 2013.

“…..acceptable local recurrence rate ajer preopera>ve radiotherapy and local excision of small, radiosensi>ve tumours in elderly pa>ents”

Oxford Colorectal

UK TREC Trial: Tes>ng the role for neo-‐adjuvant SCRT

Oxford Colorectal

STARTREC – Study design Phase II/III clinical trial

TME

W&W TEM

Poor/inadequate response

Liole or no residual disease

Good response: residual disease

high risk conversion TME

evalua>on TME

Organ preserva>on

5x5 Gy CRT

cT1-‐3b N0

Radical Surgery Organ preserva>on

week 11-‐13 – central review

week 1-‐5

CCR Not CCR week 16-‐20 – central review

Oxford Colorectal

EMR or TEM treatment of >3cm adenomas

Polypectomy

EMR/ESD

TEM

TME

chriscunningham … colorectal! abriefhistoryofrectalcancersurgery 0 20 40 60 80 100 120 1845 1910...

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