Taunton SpR Training Day 7th December 2012 Early rectal cancer Tom Edwards Consultant Colorectal Surgeon

Introduction Emergency/ complication Symptomatic presentation Screening for asymptomatic disease

Staging for Rectal Cancer

Staging for Rectal Cancer

More History APER AR TME DXT CR07: T1 disease 1.8 (2.9)% LR // OS 94%

The early rectal cancer dilemma Stage 1 rectal cancer is a curable disease with radical surgery But…

The cost for cure Total mesorectal excision associated with Long hospital stay and convalescence Death (young 2% : >85 20%) Leak rate (16%) Urinary dysfunction Sexual dysfunction Defaecatory dysfunction Permanent stoma rate (10-40%)

Bowel Dysfunction Radical surgery for rectal cancer Temple et al, DCR 2005

Sexual Dysfunction Radical surgery for rectal cancer Activity: Pre Op Post Op Loss Spont Embarrassed APR 91% 55% 53% 44% LAR 94% 74% 27% 24% TART 80% 87% 13% 0% Hendren et al, Ann Surg 2005

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So, what about trans anal, full thickness local excision?

Local Excision is Appealing Low morbidity Quick recovery Minimal effect on long term bowel function Organ sparing technique Genitourinary dysfunction avoided

BUT………………Lymph nodes!!!! Blumberg , et al, Dis Colon Rectum 1999 T 1/2 = 20% +LN T 3 = 40% +LN Blumberg , et al, Dis Colon Rectum 1999

Local Excision: In an Ideal World We would know that the lymph nodes are clear Technically a FTLE is possible the surgery should be curative! But equally, if there is a recurrence … Salvage surgery does not worsen the oncological result

Trans Anal Resection of Tumour (TART) Unfortunately . . . the oncologic results have been disappointing

Favorable T1 Cancers Trans Anal Excision (TAE) Mellgren (2000) n=TAE 69 OS 30 Paty (2002) n=TAE 74 Nascimbeni (2004) n=TAE 70 OS 74 Madbouly (2005) n=52 Local Recurrence TAE 18% Rsxn 4% (TME) TAE 14% TAE 7% Rsxn 3% TAE 17% Survival (CSS/Overall) TAE 72% Rsxn 80% TAE 92% TAE 89% (72%) Rsxn 90% TAE 89% (75%) “Transanal excision equals total mesorectal neglect” - David Rothenberger

Favorable T1 Cancers Local Recurrence Survival (CSS/Overall) Mellgren (2000) n=TAE 69 OS 30 TART 18% 4 %(TME) TART 72% 80%(TME) Paty (2002) n=TAE 74 TART 14% TART 92% Nascimbeni (2004) n=TAE 70 OS 74 TART 7% 3%(TME) TART 89% (72%) 90%(TME) Madbouly (2005) n=52 TAE 17% TAE 89% (75%) “Transanal excision equals total mesorectal neglect”

But, don’t worry, we can perform salvage radical surgery!

Salvage Surgery for Recurrence Recurrent stages (n=29) Mean time to recurrence = 26 months 23/29 underwent curative surgery Mean follow up = 39 months Friel, et al. Dis Colon Rectum 2002

Salvage Surgery for Recurrence FTLE Patients DFS Overall 29 12(59%) T1 10 7(70%) T2 19 10(53%) Good histol 22 15(68%) Bad histol 7 2(29%) Friel, et al. Dis Colon Rectum 2002

Salvage Surgery for Recurrence 49/50 patients underwent curative surgery 27 (55%) multivisceral resections 47/49 underwent R0 resection Weiser, et al. Dis Colon Rectum 2005

Salvage Surgery for Recurrence FTLE 5 year Survival 53% Weiser, et al. Dis Colon Rectum 2005

Why the high local recurrence rates? Progression of occult lymphatic tumor Better histologic predictors ‘Are all polyps made equal?’ TART technically limiting

Are all polyps equal? NO

Polyp morphology Pedunculated Sessile

7 Adverse features Morphology Differentiation Mucinous LV infiltation Peri neural invaision Margin Exophytic vs ulcerating

The Difficult TART: Origins of TEMS Standard transanal excision: Limited to lesions: distal rectum small tumors (<3 cm) However… lighting and exposure is poor surgical field collapses “short reach, poor visibility”

Origins of TEMS Professor Gerhard Buess

Transanal Endoscopic Microsurgery 4 cm x 10-20 cm proctoscope, airtight faceplate, insufflation, telescope, and laparoscopic instruments

Karl Storz (TEO)

Other techniques are available ESD Contact DXT

Operative Techique

pT1 Rectal Cancer: TEM case series 1991-2003, single surgeon, n=53 (75) Age 65 y (31-89) (65y) Average 7 cm (0-13) from verge (7cm) F/U: 2.8 y 7.5% (4/53) recurrence (9%) No cancer related deaths (0%) Floyd and Saclarides DCR 2006 (Abarca and Saclarides ASCRS 2010)

uT1N0 Rectal Cancer: RCT: TEM vs Low Anterior Rsxn Patients: Age (y): Location L/M/U: Follow-up (m): Complications: Local Recur: Survival: TEM 24 63.7 7/12/5 41 20.8% 1 (4%) 96% LAR 26 60.9 8/11/7 46 34.5% 96% Winde et al, DCR 1996

uT2N0 Low Rectal Cancer TEM 35 2 (5.7%) 9% 94% LAC-TME 35 1 (2.8%) RCT: ChemoXRT followed by TEM vs Laparoscopic TME minimum 5 year follow-up TEM 35 2 (5.7%) 9% 94% LAC-TME 35 1 (2.8%) 2 (5.7%) 6% 94% Patients: Local Recur: Distant Recur: Prob of any Recur: DFS: Lezoche et al Surg Endosc 2007

So how should we manage early rectal cancer?

Clinical Evaluation History Physical Family history Continence history Evaluation of operative risk Physical Abdomen Digital Rectal Examination Rigid proctoscopy

Rectal Cancer Work Up Biopsy Colonoscopy/ full bowel imaging CEA CT Scan Abdomen / Pelvis Chest imaging (CXR or CT) Endoscopic Ultrasound /MRI

Bulky lesion MR/USS T1/2 Young fit patient Elderly/ comorbidity Biopsy proven Ca Biopsy benign Biopsy proven Ca Good T1 Op/ Stoma averse Bad T1 T2 TEMS TME/ APER

Thanks For Listening!