Brendan Moran Basingstoke OCTOBER 2008 How Imaging Has Improved Outcome In Rectal Cancer 4th East- West Colorectal Days Hungary Brendan Moran Basingstoke OCTOBER 2008

“ A picture is worth a thousand words” Image and Imaging “ A picture is worth a thousand words” Chinese Proverb

What does this illustrate ? Attempt to describe a “revolutionary” theory Heald, Husband, Ryall BJS 1982

But ? Inaccurate Drawing Not applicable to upper rectal cancer Only 5 patients Nevertheless most quoted paper ever in rectal cancer Heald et al BJS 1982

“The mesorectum in rectal cancer surgery -the clue to pelvic recurrence” Heald et al BJS 1982

TME Evolution Heald RJ Journal Royal Soc Med 1988

Pre-operative RT –Sweden Pathology -Quirke Rectal Cancer 80’s and 90’s Surgery- TME Pre-operative RT –Sweden Pathology -Quirke

The Circumferential Resection Margin Quirke et al 1986 In that same year Professor Quirke described the relationship of involvement of the circumferential resection margin - the mesorectal fascia, and the effect on local recurrence.

TME and Radiotherapy Both aim at the circumferential margin Both reduce the CRM involvement

The rationale for TME Havenga, Eur J Surg Oncol 1999

Long Term Follow up Swedish Radiotherapy Study The benefits are long lasting – at median follow-up 13 years [3–15] Local recurrence rate 26% versus 9% Folkesson et al JCO Aug 2005

Dutch TME Trial Local Recurrence patients with macroscopically complete local resection (n=1789) TME alone 5.8% vs 11.4% p < 0.001 RT + TME Van de Velde et al. Update at 5 yrs follow up

Should we irradiate this patient ?

Lange M M, et al, Br J Surg Vol Lange M M, et al, Br J Surg Vol. 94, 10 Pages: 1278-1284 Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd Figure 1. Percentage of patients with faecal incontinence after rectal cancer surgery with or without preoperative radiotherapy. Dashed portion of curves is based on only one questionnaire for each patient, obtained between 3·3 and 7·4 years after LAR

Late bowel obstruction treated surgically Cumulative proportion without late bowel obstruction, treated surgically Time after randomization (years) Br J Surg 2008; 95: 206-213

Basingstoke Viewpoint BJS 2003 Simunovic et al. BJS 2003;90:999-1003

Selective pre-operative radiotherapy Definitely for an involved margin Consider for a “threatened” margin – very low or very large tumour

Basingstoke Viewpoint Simunovic et al. BJS 2003;90:999-1003

Problems with this paper Subjective Based on large experience with focus on optimal surgery Not reproducible

New methods of staging Imaging techniques

Purpose of Imaging in Colorectal Cancer Staging Stage dictates outcome but especially for rectal cancer today – Stage dictates management

Management of Rectal Cancer Today No treatment Palliative therapy Local excision/TEM Radiotherapy alone Neoadjuvant therapy +Surgery Surgery alone Chemotherapy +/- some or all

Staging Rectal Cancer Local staging – local extension of the tumour and particularly the margin (CRM) Staging for systemic disease

Staging Colorectal Cancer “Gold Standard” Pathology Dukes Staging TNM

Dukes Staging – Post –op pathology TNM – Increasingly being “estimated” pre -op

Published article online: 10-May-2007 Clarifying the TNM staging of rectal cancer in the context of modern imaging and neo-adjuvant treatment: ‘y’‘u’ and ‘p’ need ‘mr’ and ‘ct’ B. Moran, G. Brown, D. Cunningham, I. Daniels, R. Heald, P. Quirke, D. Sebag-Montefiore Colorectal Disease, OnlineEarly Articles Published article online: 10-May-2007 doi: 10.1111/j.1463-1318.2007.01260.x

Staging – Moran et al Colorectal Disease 2008 “TNM is pathology” “Imaging not equivalent” “c” – clinical “u” – ultrasound “ct” – CT “mr” - MRI “p” – pathology “y” – after pre-op treatment

Staging – Moran et al Colorectal Disease 2008 Thus a tumour staged by MRI as “T3N1 “should be described as mrT3N1 If given CRT eventual pathology might be ypT2N0

Depth of Tumour (“T” staging) Mesorectal Margin Local Staging Depth of Tumour (“T” staging) Mesorectal Margin

Imaging/ Staging Rectal Cancer Now Finger X-ray Endoscopy US CT MRI PET

Colonoscopy and Cross-sectional imaging The traditional view of a rectal cancer is luminal, but the key to the successful management is the assessment of the invasion of the disease. Incomplete excision of a locally advances tumour leads to local recurrence and the extremely distressing symptoms of pelvic pain, fistulation and poor bowel and bladder function.

Stage Dictates Therapy

Local Staging Finger- Key EAUS MRI

Superficial Rectal Cancer Wij kunnen MRI voorspellen. Nu aan de clinici Wat doen we ermee? Wat kan imaging: T staging eus of endoMRI N1 ? Alle andere ca MRI CRM+ N CT redelijk goed CRM ,N minder goed Wat voor onderzoek je wil hangt af van wat je wel en niet wil doen hoe gedetailleerd je info moet zijn Dat als je wil voorkomen dat je preop verrast wordt door ca die je anders had willen behandelen dat je pat met rectum ca preop lokaal moet imagen. EUS not for evaluation of mesorectal fascia

uT1 intact outer hypoechoic layer (muscalaris propria)

uT3 uN1

Limitations of EAUS Unable to view margins (CRM) Stenotic tumours Low painfull tumours

Phased array coil/ no bowel prep

The major advance has been in the development of MRI, by Gina Brown and others in the local staging of rectal cancer. Here we can see the cancer and the mesorectal fascia and can assess their relationship. The protocol employed a thin 3mm section turbo spin-echo T2-weighted technique using a surface pelvic phased array coil

Accuracy of MRI

The M.E.R.C.U.R.Y. Study Magnetic REsonance Imaging and Rectal Cancer EURopean Equivalence StudY The MERCURY Study is the Magnetic……………..

Aims of MERCURY

British MedicalJournal Volume 33 14th October 2006 Diagnostic Accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer:prospective observational Study MERCURY Study Group Accuracy 1 Depth of extramural invasion – 95% to within 0.5mm 2 Prediction of a clear CRM (>1mm)- 91%

Imaging Focal Point of MDT to plan treatment

Tailored Treatment according to Risk for Local Recurrence The Good Surgery The Bad Surgery + ? ( SC RT) The Ugly Long course CRT Delayed surgery

The Good

Extramural vascular invasion The Bad Extramural vascular invasion

Tumour satellite close to CRM Nodal disease and EMVI Heterogenous nodes Tumour satellite close to CRM

The Bad Now 2 years old mrT3N1 Cancer at 20 weeks

The Ugly July 06 Feb 06 When you compare the images at the same level, you can clearly see a good response to radiotherapy. A relatively mild circumferential thickening of the rectum remains to be seen. Coarse fibrotic band remains on the left side at 3 and 4 o’clock, abutting the thickened mesorectum. Previously enlarged lymph nodes have largely resolved.

“ A picture is worth a thousand words” Image and Imaging “ A picture is worth a thousand words” Chinese Proverb

Rectal Cancer Today and 1982

Ongoing problems with staging/MRI MRI is not pathology Low Rectal Cancer – staging poor- Finger better

Low tumours involving sphincter Combination of PR and MRI to plan Neoadjuvant therapy Subsequent surgery (AR or APE)

Holm et al. (Karolinska Hospital, Stockholm) BJS 94: 232-238, 2007 62

Future –Optimal Staging To Select for TME Surgery alone Selective neoadjuvant therapy AR or APE

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