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)

Rectal Cancer: TME Circumferential resection margins determine outcome

T4 Treatment failure Poor Judgement Inadequate skills Lack of knowledge Lack of insight/arrogance Inadequate resources Common condition Uncommon variant Higher order of treatment

T4: Female

T4 Male anterior tumours

T4 Rectovesical peritoneum

T4 Seminal vesicles T4 Male Invading adjacent organs

T4 Seminal vesicles T4 Male Invading adjacent organs

Anterior T4 prostatic involvement APR + Radical prostatectomy

APR + Radical Prostate

T4 Bladder involvement

T4: Male anterior tumours

T4: Posterior Rectal cancer

T4 Strategy: Staging  EUA, cystoscopy  MR pelvis  CT abdo, thorax  ? PET scan

 Pre-operative RTH has a major role  Only a minority will be cured with RTH alone  Pre-operative CRTH has increased risks  Phase II studies oxaliplatin, irinotecan capecitabine and Mabs  What do we do with complete regression? Adjuvant Rx for fixed tumours

Current CRT schedule Radiotherapy with 3 or 4 field plan 45 Gy in 25 # over 5 weeks Capecitabine 825mg/m 2 bd for 5 weeks

CRT for fixed rectal tumours % have potentially curable resections after CRT When is the right time to operate? weeks post DXT

 Stomas  Stenting  Nephrostomies T4 Strategy: Pre-emptive surgery

TPC: Surgical candidates Nutrition Renal function Liver function ? Disease confined to pelvis Re assess clinically and radiologically after CRT

Total Pelvic Clearance Christie NHS FT MDT Assessment pre and post CRT Consecutive patients 100 Total Pelvic Clearance 45 Unsuitable for surgery 55

Christie: Total Pelvic Clearance Age Number

T4 Strategy: Definitive surgery  Engage the team  Stent the ureters  En bloc resection  ? IP Chemotherapy (peritoneal reflection)

Outcome of radical surgery  Primary v recurrent  Munro v mountain  % 5y survival Lenhert et al 2002, Sanfilippo et al 2001, Law et al 2000 Advanced disease

Total Pelvic Clearance n mortality morbidity % % Kakuda et al % 68% Jimenez et al % 40+% Nakafusa et al % 49% Sharma et al % 75% Sagar et al % na Christie % 11% op 38% non op

Christie: Total Pelvic Clearance Operative Stoma Revision3 Perineal wound 2 Bleeding1 SBO1 Complications Non operative Infections12 Ileus10 PE/DVT1/1 Bleeding1 MI1 CVA1

Advanced/Recurrent Pelvic tumours % Time (months) Colorectal Others (57%) (31%) Cancer-specific survival CRM +ve 9%

Perineal reconstruction Gracilis

TRAM Flap Perineal reconstruction

Tissue interposition 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

T4 Tumours: HIPEC Intraperitoneal mitomycin C 3 bolus over °C

T4 : Palliative therapies  CRT  Pain relief  Tumour ablation  Tumour resection  Drainage of sepsis  Stenting and stomas