Basingstoke Colorectal The Particular Problem of Low Rectal Cancer Brendan Moran Basingstoke 4 th East-West Colorectal Days Hungary 2008

Basingstoke Colorectal The Particular Problem of Low Rectal Cancer Tumours within 6cm of anal verge

Basingstoke Colorectal Issues n Difficulties with reconstruction n Problems with APE n Embryology/anatomy of the low rectum/anal canal n Lower tumour – higher risk of lateral pelvic nodal involvement n Pathology different – more poorly diff and increased risk nodal disease

Basingstoke Colorectal Dutch Rectal Cancer Study Nagtegaal et al Am J Surg Path, 2002; 26:350-7 n=656

Basingstoke Colorectal Mercury Study Data n=307

Basingstoke Colorectal TME Hypothesis n TME provides optimal block dissection of the lymphatic drainage of the rectum. n Does this work for low rectal cancer ??.

Basingstoke Colorectal Methods n All rectal cancers in Basingstoke n Anterior resections n Analyzed impact of tumour height on local and systemic recurrence

Basingstoke Colorectal Surgical Technique

Basingstoke Colorectal Procedures Performed For Rectal Cancer 585 (86%) (Curative 480) 41 (6%) 57 (8%)

Basingstoke Colorectal Systemic Recurrence by tumour height Log Rank for Heterogen eity Trend Chi D.F. 2 1 P cm 20%(n=102) 7-11cm 24%(n=190) 0-6cm 27%(n=188) Overall 24%(n=480)

Basingstoke Colorectal Log Rank for Heterogen eity Trend Chi D.F. 2 1 P Local Recurrence by tumour height 12-15cm <1% (n=102) 7-11cm 2%(n=190) 0-6cm 7%(n=188) Overall 4%(n=480)

Basingstoke Colorectal Summary n Tumour height of < 6cm predictive for a higher rate of local failure following curative TME n Why is this??

Basingstoke Colorectal Why ?? n Technical challenges n Anatomy / embryology n Tumour behaviour

Basingstoke Colorectal What about APE ???

Basingstoke Colorectal Shihab, Moran, Mercury study Group Presented ASCRS 2008 Patients with low rectal cancer treated by abdomino-perineal excision have worse tumours and higher involved margin rates compared with those treated by anterior resection.

Basingstoke Colorectal Patients and methods n MERCURY (Magnetic Resonance Imaging in Rectal Cancer European Equivalence Study) n Prospective, multi-centre ( ) n 408 patients with rectal cancer n High-resolution MRI n TME surgery n Standardised pathology

Basingstoke Colorectal 408 patients 158 ≤ 6cm from Anal verge 250 > 6 cm from anal verge 72 APE 81 LAR 153 patients 4 Hartmann’s 1PPC+I

Basingstoke Colorectal Patients and methods APE compared to AR for : n Median tumour height n % undergoing neoadjuvant therapy n Involved CRM (CRM+) n T-stage

Basingstoke Colorectal Results 153 patients Operationn Median Tumour Height (range) APE723 (0-6cm) AR815 (1-5cm) p < 0.001

Basingstoke Colorectal Results Operationn Neoadjuvant Therapy APE7264% (n=46) AR8141% (n=33) p = 0.007

Basingstoke Colorectal Results Operationn CRM +'ve % APE (n=23) AR (n=11) TOTAL p = 0.01

Basingstoke Colorectal Results Local Invasion OperationnT0T1T2T3T4 APE AR p = 0.006

Basingstoke Colorectal Conclusion Tumours < 6cm n APE group had higher CRM + rates. n APE group significantly lower tumours and higher pT stage despite higher proportion undergoing neoadjuvant therapy.

Low Rectal Cancer “ mrT4” “PR – Tumour Mobile sitting on levators in coronal view ”

Basingstoke Colorectal Surgical Dilemma Six Main Management Options 1. Abdomino Perineal Excision (APE) 2. Anterior Resection (AR) 3. 5 Gy x 5 days (5x5) and APE 4. 5x5 and AR 5. Chemoradiotherapy (CRT) and APE 6. CRT and AR

Multiple choice 1 APE 2 AR 3 SCRT +APE 4 SCRT + AR 5 CRT +APE 6 CRT +AR

Holm et al. (Karolinska Hospital, Stockholm) BJS 94: , 2007

Basingstoke Colorectal Conclusion n Low rectal cancer difficulties in n optimal staging n neoadjuvant therapy n surgical treatment.