Radical surgery is the preferable treatment option for

T1-2/N0 low rectal cancer

 

Jose G. Guillem, MD, MPH

Department of Surgery

Memorial Sloan Kettering Cancer Center

Great Debates & Updates in GI Malignancies

March 28-29, 2014

Rectal Cancer Surgical Options

Local Recurrence

T1N0 18% 0%

T2N0 47% 6%

Mellgren et al. Dis Colon Rectum, 2000

Inadequacy of baseline ERUS staging of primary and LN disease

Stage Pooled Sensitivity (%)

Pooled Specificity (%)

T1 87.8 98.3

T2 80.5 95.6

T3 96.4 90.6

T4 95.4 98.3

N+ (overall) 73.2 75.8

N+ (2001-2008) 70.9 78.6

Puli SR et al. Ann Surg Oncol.. 2009

*Meta-analysis N = 2732 cases

Evaluated parameters

Sensitivity (%) Specificity (%) Diagnostic Odds Ratio (%)

T stage 87 75 20.4

MRF involvement 77 94 56.1

LN involvement 77 71 8.3

Inadequacy of baseline MRI staging of primary, MRF, and LN involvement

*Meta-analysisN = 1249 cases

Al-Sukhni E et al. Ann Surg Oncol. 2012

6.4mm 5.7mm

ERUS Identification of N1 Disease

Photomicrograph (x20, H&E) of a lymph node that is 70% replaced by tumor.

Micrometastatic Disease

Photomicrograph (x20, H&E) of a lymph node with a 1mm tumor deposit

ERUS Lymph Node Staging is T

Dependent

Stage n pN+ Median

metastasis size (mm)

ERUS Nodal

Accuracy Specificity

pT1 21 6 (29%) 0.3 48 67

pT2 67 20 30%) 4.1 67 75

pT3 44 20 46%) 5.9 84 83

pT4 2 1 (50%) 3.0 100 100

All 134 7 (35%) 4.9 70 76

Landman, et al Dis Col Rectum (2007)

TAE for T1 Rectal Cancer

1. High risk of ca recurrence vs. RAD.

2. TAE has a lower cancer cure rate.

3. Neither adjuvant therapy nor surgical salvage are reliable.

Paty P et al Ann Surg 2002

Bentran D et al Ann Surg , 2005

Nash, G DCR, 2008

Survival outcome of local excision versus radical resection of colon or rectal carcinoma: a surveillance, epidemiology, and

end results (SEER) population-based study

• N = 13,262 pts with rectal cancer• Surgery

– 3715 (28%) local excision – 9547 (72%) major resection

• Preoperative clinical T staging– 953 (7%) Tis– 6223 (47%) T1– 6086 (46%) T2

Bhangu A et al. Annals of Surg. 2013.

Survival outcome of local excision versus radical resection of colon or rectal carcinoma: a surveillance, epidemiology, and

end results (SEER) population-based study

Bhangu A et al. Annals of Surg. 2013.

LE Major resection

Adjusted HR p value

TisOS

CSS76.%95.1%

79%96.2%

1.050.78

0.7770.494

T1OS

CSS71.8%92.3%

80.6%94.4%

1.291.16

<0.0010.236

T2OS

CSS63.1%85.2%

75.6%91.5%

1.381.71

<0.001<0.001

*Estimated 5y OS and CSS

Local excision in early rectal cancer – outcome worse than expected: a population based study

• N = 3694 consecutive stage I rectal ca pts from Swedish Rectal Cancer Register

• 448 LE vs 3246 radical resection (Hartmann, LAR, APR)

• LE pts – LR 11.2% (vs ~3% for all radical procedures

combined)– Relative survival 0.81 (95% CI 0.75-0.88)

Saraste D et al. Eur J Surg Oncol. 2013.

Multimodality salvage of recurrent disease after local excision for rectal cancer

You YN et al. Dis Colon Rectum. 2012.

5y OS s/p salvage 63%

3y RFS s/p salvage 43%

In salvage surgery R0 resection in 80%, Multivisceral 30%, neoadjuvant 70%

Sphincter preservation in 33%

Salvage resection after local excision for rectal cancer

Study, year Initial surgery

Initial stage Salvage surgery of curative intent, n

Rate of R0 resection, %

Rate of sphincter preservation, %

Long-term (5-y) outcome, %

MD Anderson, 2002

LE T1, T2 29 79 34 DFS 59

MSKCC, 2005

LE T1, T2 50 97 30 DFS 53

The Netherlands, 2010

TEMS protocol

T1 16 94 56 DSS (3-y) 58

Rome, 2012 TEMS protocol

T1, T2, T3 26 88.5 43 OS 62

MD Anderson 2012

LE T1, T2, T3 40 80 32 OS 68; RFS (3-y) 43

Predicting lymph node metastases in early rectal cancer

• N = 677 pts with pT1-2 rectal Ca in the Swedish Rectal Cancer Register

Saraste D et al. Eur J Cancer. 2013.

Multivariate analysis OR

95% CI(Ref 1)

T2 1.97 (1.19-3.25)

Poor differentiation 6.47 (2.71-15.4)

Vascular infiltration 4.34 (2.46-7.65)

Predicting lymph node metastases in early rectal cancer

Saraste D et al. Eur J Cancer. 2013.

Preoperative Considerations if Pursuing a Sphincter Preserving Resection

• Determination is both preop and intraop

• Body habitus, sphincter mass?

• Sphincter tone, squeeze?

• Co-morbidities?

• Patient expectations, enthusiasm?

• Understands the “good news/bad news” post operative scenario.

As in fly fishing…“Match the Hatch”

“Match the Disease”

Should be the governing paradigm in the management of rectal cancer

J Guillem, Ann Surg 2007