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)

T4: Female

T4: Rectal cancer

Prostatic Involvement

T4: Male

Anterior T4 Rectal cancer

APR +

Radical prostatectomy

APR + Radical Prostate

T4: Posterior Rectal cancer

T4 Strategy: Staging

EUA, cystoscopy

MR pelvis

CT abdo, thorax

? PET scan

T4 Strategy: Adjuvant therapy

RTH

Chemo/RTH

Intra op RTH

HIPEC: Hyperthermic Intra Peritoneal CT

Pre-operative RTH plays a major role

Only a minority will be cured with RTH alone

Pre-operative CRTH has increased risks

Phase II studies oxaliplatin, irinotecan and

capecitabine

What do we do with complete regression?

Adjuvant Rx for fixed tumours

Current optimum CRT schedule

Radiotherapy with 3 or 4 field plan

45 Gy in 25 # over 5 weeks

Capecitabine 825mg/m2 bd for 5 weeks

Stomas

Stenting

Nephrostomies

T4 Strategy: Pre-emptive surgery

T4 Strategy: Definitive surgery

Engage the team

Stent the ureters

En bloc resection

? IP Chemotherapy (peritoneal reflection)

Total Pelvic Clearance

Christie NHST 2001 -2005

MDT Assessment Consecutive patients 100

Total Pelvic Clearance 45

Unsuitable for surgery 55

TPC: Surgical candidates

Nutrition

Renal function

Liver function

? Disease confined to pelvis

Outcome of radical surgery

Primary v recurrent disease

Munro v mountain

30 - 80% 5y survival

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

Total Pelvic Clearance

n mortality morbidity% %

Adachi et al 1999 9 0% 44%

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 2006 45 0% 11% op

38% non op

Christie: Total Pelvic Clearance

Operative

Stoma Revision 2Perineal wound 2SBO 1

Complications

Non operative

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

Christie: Total Pelvic Clearance

0

2

4

6

8

10

12

14

16

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

Age

Number

T4 Tumours: HIPEC

Peritoneal involvement

Complete excision

Intraperitoneal mitomycin C

3 bolus over 90min @ 41-

43°C

Peritoneal metastasis

T4 : Palliative therapies

CRT

Pain relief

Tumour ablation

Tumour resection

Drainage of sepsis

Stenting and stomas

Survival: Cyto + HIPEC

0

20

40

60

2y 3y 5y

CRC

PSM

T Staging: Rectal cancer

T4 Male

Invading adjacent organs

T4: Rectal cancer

Anterior T4 rectal tumour

APR + Radical Prostate

Survival: Cytoreduction + HIPEC

CRC Peritoneal v liver resections

CRC complete

CRC incomplete

T4 : Palliative therapies

CRT

Pain relief

Tumour ablation

Tumour resection

Drainage of sepsis

Stenting and stomas

What of it! She would have died anyway without the operation.

There you are gentleman,you’ve seen the operation that everyone said was impossible, performed with complete success.

But Doctor, the patient’s dead!

T4: Palliative surgery

Survival: Cyto + HIPEC

0

20

40

60

2y 3y 5y

CRC

PSM

Liverresection

Total Pelvic Clearance

Peritoneal carcinomatosis

Sugarbaker

Survival with Colorectal Liver MetastasesSurvival with Colorectal Liver Metastases

0

20

40

60

80

100

120

0 1 2 3 4 5 6 7 8 9 10

Resected

Not resected

Unresectable%

years Scheele 1993Scheele 1993

Surgical candidates

Nutrition

Renal function

Liver function

Proximal small bowel loops

Disease confined to pelvis, R/LIF +/- 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

RTH for fixed rectal tumours

• 45 - 65% have potentially curable resections after radiotherapy

• 50% develop local recurrence

• Only a minority will be cured with RTH alone

(Martenson et al, in Cancer of the colon, rectum and anus 1995)

Pre-operative CRT

(Videtic et al, 1998)

Small studies n = 7-64

5FU, FA, cisplatin, mmc

RTh 40Gy/20#, 50Gy/30#

Resectability 70 -100%

Pathology T0 4 -72%

DFS 60 -80%

Preoperative RTH + Raltitrexed(tomudex)

ASCO 2003

Fixed / inoperable tumoursChristie and Walsgrave

N = 36 MR T3: 17 T4: 19

Response: 81%Curative resection: 64%Path T0: 14%

T4 Strategy: Pre-emptive surgery

Stenting

Stomas

Nephrostomies

HIPEC

HIPEC

Vaginal vault recurrence

Abdo/pelvis 20-35%

Liver 40-50%

Lung 16%

Brain 8 %

Bone 4-6%

Metastatic disease

Advanced disease