1. Beyond TME : why do an exenteration?
Gina Brown
Department of Radiology
Royal Marsden Hospital
Imperial College, London

2. Beyond TME
In a significant proportion of patients (15-20%), tumour extends beyond the achievable TME planes and requires more extensive surgery to achieve clear margins.

3. Exenterative surgery
Radical resection can achieve complete tumor clearance. Reported R0 rates range from 22%-67%.
Can significantly increase survival, enhancing the prospects for long term cure.
High rate of post-operative adverse effects/morbidity.
A.G. Heriot. Colorectal Dis,2006;8(9):

5. Beyond TME Collaborative Trial : Multicentre open observational study
To demonstrate that a validated staging system can be employed,
Establish scale and scope of pelvic exenterative surgery in advanced rectal cancer beyond TME
Assess quality of life and outcomes
Develop prognostic classification to assist in counselling patients

6. Beyond TME trial
Eligibility: Any rectal tumour extending beyond TME plane (primary or recurrent)
Participating sites:
Royal Marsden
St Marks
Oxford
Southampton
Swansea
Edinburgh (tbc)
Pls contact:
if you wish to recruit your patients to this study

7. Anatomic compartments beyond TME : the exenterative compartments
Lateral
Central
Posterior
Central
Posterior
Anterior
Infra-levator

8. Reporting Proforma Advanced Tumour Requiring Surgery Beyond TME
Primary tumour
The primary tumour is demonstrated as an [ Annular | Semi-annular | Ulcerating | | Polypoidal | Mucinous] mass with a [nodular / smooth] infiltrating border.
The distal edge of the luminal tumour arises at a height of [ ] mm from anal verge:
The distal edge of the tumour lies [ ]mm [Above,at, below] the top of the puborectalis sling
The tumour extends craniocaudally over a distance of [ ] mm
The proximal edge of tumour lies [above at below] the peritoneal reflection
Invading edge of tumour extends from [ to ] O’clock
Tumour is [confined to] [extends through] the muscularis propria:
Extramural spread is [ ] mm
mrT stage: [T1 ] [ T2 ] [ T3a] [ T3b ] [ T3c] [ T3d ] [T4visceral ] [T4 peritoneal]  
Lymph node assessment
Only benign reactive and no suspicious nodes shown [N0]
[ ] mixed signal/irregular border nodes [N1/N2]
Extramural venous invasion: [ No evidence ] [ Evidence]
[ ] Small [ ]Medium [ ]Large vein invasion is present
Peritoneal deposits: [ No evidence] [ Evidence]
Pelvic side wall lymph nodes: [ None] [ Benign] [ Malignant mixed signal/irreg border]
Location: [Obturator fossa • R •L ] . [External Iliac Nodes • R •L] .[internal iliac • R •L ]

9. Pelvic fascia are free of disease
Laterally
Pelvic fascia are free of disease
Pelvic sidewall compartment are free of disease
Internal/external iliac arterial /venous branches are free of disease
Sacrotuberous/sacrospinous
Piriformis/Obturator
Infralevator compartment
Levator muscles are free of disease
Sphincter complex are free of disease
Anterior urogenital triangle/Perineum
Vaginal introitus/urethra : free of disease
Retropubic space: : free of disease
Summary:
MRI Overall stage: T N M , [ EMVI positive] [EMVI negative],[PSW positive ] [PSW negative], Total number of compartments, Closest potential surgical margins are located, Resection would require:
Disease affects central compartment
Above the peritoneal reflection within the pelvis
Disease is present/ absent
Ureters are free of disease
Below the Peritoneum anteriorly
Bladder /Uterus/Vagina/Ovaries Prostate/Seminal vesicles/Urethra are free of disease
Posteriorly
The bony cortex/periosteum from S1-S2 is / is not involved by disease
The bony cortex/periosteum from S3-S5 /coccyx is/ is not involved by disease
Presacral fascia (S1/S2/S3/S4/S5) is not involved by disease
Sciatic nerve/ S1/S2 nerve roots
No disease
Disease is present

10. MDT choices and making best use of high resolution MRI
Local excision
MINSTREL and STARTREC
MRI T1/T2 Nx
MRI based
Selection
of patients
For range
treatments
MRI T3a/T3b N any
Low rectal stage 1/2
Canadian “Quicksilver” and German “OCUM” trials
MRI T3c/T3d N any
EMVI positive CRM safe
European RAPIDO trial, TRIGGER
Chemoradiotherapy
Restage – poor TRG
Mercury II and
BeyondTME trials
potential CRM unsafe
MRI advanced
rectal cancer
Post CRT
yMRI TRG 1-2
TRIGGER Deferral of surgery

11. Reporting Minimum Standards

12. Reporting Template Post Treatment

13. Assessment of Rectal Cancer: how good quality MR imaging can help surgeons
Is it malignant or not?
What is the depth of invasion?
Are lymph nodes involved? is there EMVI?
Is the proposed excision plane safe?
Early Rectal Cancers
EMR/ESD:
TEM
Rectal Cancer Staging for primary TME vs preop CRT TME
Low Rectal Cancer
TME plane APE
Beyond TME ELAPE
Locally Advanced Rectal Cancer
Beyond TME/Exenteration
ESR/EMD/TEM: 5 slides
TME – 5 slides
TME plane APE and ELAPE: 5 slides
Beyond TME - 5

14. >1mm submucosa free of tumour 1mm submucosa margin
Local Excision Plane
>1mm submucosa free of tumour
1mm submucosa margin
Early Rectal Cancers

15. TEM plane
>1mm muscularis free of tumour
1mm deep muscle margin

16. TME Mesorectal plane
For coloanal anastomosis/ intersphincteric APE
>1mm of intersphincteric plane clear

17. Beyond TME ELAPE plane
<1mm intersphincteric plane clear

18. Beyond TME exenterative planes

19. Evidence base for MRI as a gold standard
CRM involvement on MRI prognostic predictor for recurrence
Depth of extramural spread >5mm risk factor for poor DFS
Presence of MRI detected venous invasion – risk factor for local and distant recurrence and seen more frequently than path EMVI
MRI detected mucinous tumours
Tumour spread into or beyond the intersphincteric plane: risk of local recurrence
MRI TRG status: independent prognostic predictor for overall survival and disease free survival and seen more frequently than the pathologic gold standard of pCR

20. Acknowledgements: Pelican Cancer Foundation
European Mercury Study Group: Prof Bill Heald, Brendan Moran, Phil Quirke, I Swift, P Tekkis, S Stelzner, G Branagan, M Gudgeon, J Strassburg, S Laurberg, T Holm
Radiologists in MERCURY I and II: Nicola Bees, Helena Blake, Rob Bleehan, Lennart Blomqvist, Alan Chalmers, Mike Creagh, Hanne-Linne Emblemsvaag, Sarah Evans, Ashley Guthrie, Chris George, Knut Håkon Hole, Nick Hughes, Shaun McGee, Petra Knuth, Delia Peppercorn, Clemens Schubert, Andrew Thrower, Turid Vertrus
Research fellows: Sarah Burton, Neil Smith, Gisella Salerno, Fiona Taylor, Shwetal Dighe, Oliver Shihab, Peter How, Uday Patel, Jessica Evans, Chris Hunter, Panagiotis Georgiou, Vera Tudyka, Rafay Siddiqui, Jemma Bhoday, James Read, Manish Chand, Anita Wale, Alistair Slesser, Nick Battersby, Svetlana Balyasnikova , Anisha Patel and Mit Dattani 20

21. 10th – 11th March 2016, London Intensive Hands On 2 Day Workshop
To receive further details
10th – 11th March 2016, London
Intensive Hands On 2 Day Workshop
How to perform Rectal MRI staging and restaging accurately and consistently
HANDS ON Workstation PRACTICE Cases
Case Discussions
Tips and tricks for : Reporting and MDT based working