1. Henry H L Wu Year 4 Medical Student University of Manchester
Local excision of Early Rectal Cancers by Transanal Endoscopic Microsurgery (TEM)
Henry H L Wu
Year 4 Medical Student
University of Manchester

2. What do you mean by “Early Rectal Cancer”

3. The Micro-Anatomy of the Rectal Wall

4. Staging of Rectal Carcinoma

5. Risk of Lymph node Involvement
Superficial T1 5%
Deep T %
T %
T %
Risk increased with
Poor differentiation
Vascular Invasion
Tumour budding

6. Staging MR v TRUS
MR Scan
Trans-rectal Ultrasound

7. Conventional Rectal Surgery

8. Conventional Rectal Surgery Advantages
Complete removal of Mesorectum with all lymph nodes
Wide Excision of Tumour
Low risk of Local Recurrence

9. Conventional Rectal Surgery Disadvantages
Major physiological insult
Long recovery period
Risk of mortality approaching 5%
Stoma
Temporary in anterior resection but with risk of being permanent
Permanent in AP resection
Perineal wound and Pelvic floor disruption in AP resection
Risk of pelvic nerve dysfunction
Erectile impotence
Urinary retention / incontinence
Poor rectal function with frequency in low anterior resection
Doesn’t necessary lower risk of distant metastases

10. AP Resection

11. Transanal Endoscopic Microsurgery (TEM)
Allows much better view than traditional trans-anal resection (TART)
Much lower risk of +ve margins
Developed in 1980s by Gerhard Beuss
Employs modified laparoscope, gas insufflator and laparoscopic instruments
Tumours up to cm diameter
Low lower limit on distance from anus
Upper limit dictated by scope reach and peritoneal reflection (to avoid entering peritoneal cavity)

12. The Peritoneal Reflection

13. Transanal Endoscopic Microsurgery (TEM)
Patient positioned on table with tumour downwards (supine lateral or prone)
Scope inserted and HD camera attached
Resection margin marked out
Rectal wall incised into mesorectal fat
Tumour excised with margin or mesorectum
Rectum washed
Defect sutured via TEM scope

14. Marking Out and Cutting Round

15. Full Thickness Dissection

16. Bulky Polypoid Tumour

17. Good Partial Response T2 Tumour

18. Closing the defect

19. Multi-modality therapy
Radiotherapy ± Chemotherapy can reduce size of primary tumour and eliminate tumour from mesorectal lymph nodes
Conservable variations in results from small trials but probably reduces risk of recurrence from involved lymph nodes to about 5% in T1 tumours and about 10% in T2 tumours
Other poor histological factors need to be considered

20. Pre or Post OP Adjuvant therapy
Pre OP Short Course RT with Delay
Basis of TREC Trial
5 fraction of RT on consecutive days then surgery after 6-8 weeks
Post OP CRT
Long course CRT with 2 fractions of Papillon Boost (contact RT)

21. Pre or Post op Adjuvant therapy
Pre op
Post op
Based on radiotherapy trials eg CRO7
Can cause delayed healing of TEM wounds
Effects of adjuvant therapy can be assessed on histology and guide decision on radical resection
But these may not be applicable to local resection
Adjuvant therapy not delayed by surgery.
Adjuvant regime can be based on histology

22. Table 1: patient demographics and operative details
Outcomes of T1sm3 rectal cancer treated by Transanal Endoscopic Microsurgery (TEM) and post-operative chemoradiotherapy with Papillion brachytherapy.
C Slawinski, D Richardson, A Beveridge
Introduction
Methods
Transanal Endoscopic Microsurgery (TEM) represents a minimally invasive alternative to radical resection in early rectal cancer, with reduced morbidity and mortality1.
However, the inherent risks of local recurrence due to potentially involved mesorectal lymph nodes that are left behind, results in a local recurrence rate of 15% in T1sm3 disease with TEM alone2,3.
Adjuvent therapy attempts to reduce this risk4.
We assessed local recurrence in T1sm3 rectal cancers treated by our protocol of multimodal therapy: TEM with post-operative chemoradiotherapy (CRT) and Papillion brachytherapy.
Patients are discussed in the MDT following pre-operative staging with CT chest/abdo/pelvis, MRI abdo/pelvis staging and TRUS.
TEM is offered to patients with likely T1 disease on staging.
Patients with T1sm3 disease on post-op histology are offered CRT/papillion if further surgery is declined.
Post-op follow-up is with 3-monthly MRI and flexible sigmoidoscopy for the first year, then 6-monthly.
We reviewed electronic letters, operation notes and the hospital reporting system for all patients with T1sm3 rectal cancer undergoing TEM between September 2008 and September 2013.
Results
Demographics and operative details for the 11 patients undergoing TEM for T1sm3 rectal cancer are shown in table 1.
Outcomes for patients undergoing TEM resection for T1sm3 disease are summarised in figure 1.
Post-operative histology findings are summarised in table 2.
Demographic
Patients with T1sm3 (n) 11
Mean age (years)
69 (range 51 – 78)
Mean op time (mins)
200 (range )
Mean hospital stay (days)
4.6 (range 2-9)
Complications
4 patients (clavien 2)
90-day mortality 0%
Table 1: patient demographics and operative details
Post-op CRT/Papillion:
TEM Resection:
11 patients T1sm3
No Post-op CRT/Papillion:
2 patients
(prostate cancer; comorbidities)
9 patients
Local recurrence
0 patients
(31.1 months)
Distant Mets
1 patient
(died 38 months)
Disease - Free
(32 months)
1 patient developed a solitary liver metastasis and underwent hemi-hepatectomy and remains disease free at 48months.
1 patient developed local recurrence, underwent chemotherapy and late salvage surgery, and later developed advanced metastatic disease and died 38 months post-operatively.
Histological finding
Well differentiated (n) 2
Moderately differentiated (n) 9
Mean tumour diameter (mm) 27
Vascular invasion 4
Positive margins
Table 2: Post-operative histology findings
Conclusion
CRT/Papillion therapy following TEM resection for T1sm3 tumours affords good local disease control at medium-term follow-up, where patients decline early salvage surgery.
Local control of 94% has been shown possible in early rectal cancer treated with post-operative CRT/Papillion4.
We acknowledge the small patient numbers in this case series and the need for further numbers to assess outcomes of adjuvant CRT/Papillion therapy.
References:
2. Bach SP, Hill J, Monson JR, Simson JN, Lane L, Merrie A, et al. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg 2009, Mar;96(3):
1. Sajid MS, Farag S, Leung P, Sains P, Miles WF, Baig MK. Systematic review and meta-analysis of published trials comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the management of early rectal cancer. Colorectal Dis 2014, Jan;16(1):2-14
3. Morino M, Allaix E. Transanal endoscopic microsurgery: What indications in 2013? Gastroenterology Report 2013, Sep 1;1(2):75-84.
4. Myint AS. Contact radiotherapy for elderly patients with early low rectal cancers. Br J Hosp Med (Lond) 2013, Jul;74(7):391-6

24. Special cases Good Partial Response to Pre-op CRT
Possible therapy if complete radiological response of mesorectal lymph nodes and shrinkage of primary tumour
Results not know but may be attractive option to avoid APR
Endoscopic Removal of Polyp cancers with uncertain margins
Allows definitive histology of rectal wall at tumour site

25. TREC TRIAL (RT+TEM v Radical Surgery)

26. The case for Local Resection
The majority of patients with Early Rectal cancer do not have involved lymph nodes
Patients who develop nodal recurrence may be salvaged by subsequent radical surgery
Almost half of patients with involved nodes may succumb to distant metastatic disease rather than local recurrence
Considerable morbidity and mortality with radical surgery

27. The case against Excellent oncological outcomes with radical resection
Chances if salvage after radical resection probably significantly poorer than with initial radical surgery
TEM resection especially combined with radiotherapy may lead to impaired rectal function
Intensive surveillance with sigmoidoscopy and MR scanning needed after local resection

28. Who should get TEM T1 and T2? cancer Well differentiated histology
For TEM
Against TEM
T1 and T2? cancer
Well differentiated histology
Low rectal cancer where alternative is APR (Bottom 1/3)
Significant co-morbidity
Patient Choice
T2? or above
Poorly differentiated histology
Mid /upper rectal cancer suitable for anterior resection (upper 2/3).
Young fit patients
Patient Choice

29. Patient’s Choice
 They had managed to save my arse. At that stage I had no thoughts about remission, the cancer coming back or other things that may or may not go wrong, I was just over the moon to be still in possession of my arse; my rusty sheriffs badge, my chocolate starfish, my poop shoot was safe and I was a very happy chappy.
Mark Davies

30. Conclusions TEM allows resection of small early rectal cancers
Mesorectal lymph nodes not removed and may lead to local recurrence
Limited application alone in cancer (early cancers up to T2?)
Wider application as part of multimodality treatment with radiotherapy ± chemotherapy
Multidisciplinary Team (MDT) and patient discussion vital at all stages in treatment.