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 T 1 N 0 18%0% T 2 N 0 47%6% Mellgren et al. Dis Colon Rectum, 2000

Inadequacy of baseline ERUS staging of primary and LN disease StagePooled Sensitivity (%) Pooled Specificity (%) T T T T N+ (overall) N+ ( ) Puli SR et al. Ann Surg Oncol *Meta-analysis N = 2732 cases

Evaluated parameters Sensitivity (%)Specificity (%)Diagnostic Odds Ratio (%) T stage MRF involvement LN involvement Inadequacy of baseline MRI staging of primary, MRF, and LN involvement *Meta-analysis N = 1249 cases Al-Sukhni E et al. Ann Surg Oncol. 2012

6.4mm5.7mm 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 StagenpN+ Median metastasis size (mm) ERUS Nodal Accuracy Specificity pT1216 (29%) pT %) pT %) pT421 (50%) All1347 (35%) 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

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 LEMajor resection Adjusted HRp value Tis OS CSS 76.% 95.1% 79% 96.2% T1 OS CSS 71.8% 92.3% 80.6% 94.4% < T2 OS CSS 63.1% 85.2% 75.6% 91.5% <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 ) Saraste D et al. Eur J Surg Oncol

Multimodality salvage of recurrent disease after local excision for rectal cancer You YN et al. Dis Colon Rectum y 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, yearInitial surgery Initial stageSalvage surgery of curative intent, n Rate of R0 resection, % Rate of sphincter preservatio n, % Long-term (5-y) outcome, % MD Anderson, 2002 LET1, T DFS 59 MSKCC, 2005 LET1, T DFS 53 The Netherlands, 2010 TEMS protocol T DSS (3-y) 58 Rome, 2012TEMS protocol T1, T2, T OS 62 MD Anderson 2012 LET1, T2, T 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 Multivariate analysis OR 95% CI (Ref 1) T21.97( ) Poor differentiation6.47( ) Vascular infiltration4.34( )

Predicting lymph node metastases in early rectal cancer Saraste D et al. Eur J Cancer

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