1. Taunton SpR Training Day 7th December 2012 Early rectal cancer
Tom Edwards
Consultant Colorectal Surgeon

2. Introduction Emergency/ complication Symptomatic presentation
Screening for asymptomatic disease

3. Staging for Rectal Cancer

4. Staging for Rectal Cancer

5. More History
APER AR
TME
DXT
CR07: T1 disease 1.8 (2.9)% LR // OS 94%

6. The early rectal cancer dilemma
Stage 1 rectal cancer is a curable disease with radical surgery
But…

7. The cost for cure Total mesorectal excision associated with
Long hospital stay and convalescence
Death (young 2% : >85 20%)
Leak rate (16%)
Urinary dysfunction
Sexual dysfunction
Defaecatory dysfunction
Permanent stoma rate (10-40%)

8. Bowel Dysfunction Radical surgery for rectal cancer
Temple et al, DCR 2005

9. Sexual Dysfunction Radical surgery for rectal cancer
Activity: Pre Op Post Op Loss Spont Embarrassed
APR
91%
55%
53%
44%
LAR
94%
74%
27%
24%
TART
80%
87%
13% 0%
Hendren et al, Ann Surg 2005

10. ?

11. So, what about trans anal, full thickness local excision?

12. Local Excision is Appealing
Low morbidity
Quick recovery
Minimal effect on long term bowel function
Organ sparing technique
Genitourinary dysfunction avoided

13. BUT………………Lymph nodes!!!! Blumberg , et al, Dis Colon Rectum 1999
T 1/2 = 20% +LN
T 3 = 40% +LN
Blumberg , et al, Dis Colon Rectum 1999

14. Local Excision: In an Ideal World
We would know that the lymph nodes are clear
Technically a FTLE is possible
the surgery should be curative!
But equally, if there is a recurrence …
Salvage surgery does not worsen the oncological result

15. Trans Anal Resection of Tumour (TART)
Unfortunately . . .
the oncologic results have been disappointing

16. Favorable T1 Cancers Trans Anal Excision (TAE)
Mellgren (2000)
n=TAE 69 OS 30
Paty (2002)
n=TAE 74
Nascimbeni (2004)
n=TAE 70 OS 74
Madbouly (2005)
n=52
Local Recurrence
TAE 18% Rsxn 4%
(TME)
TAE 14%
TAE 7% Rsxn 3%
TAE 17%
Survival (CSS/Overall)
TAE 72% Rsxn 80%
TAE 92%
TAE 89% (72%) Rsxn 90%
TAE 89% (75%)
“Transanal excision equals total mesorectal neglect”
- David Rothenberger

17. Favorable T1 Cancers
Local Recurrence
Survival (CSS/Overall)
Mellgren (2000)
n=TAE 69 OS 30
TART 18% %(TME)
TART 72% 80%(TME)
Paty (2002)
n=TAE 74
TART 14%
TART 92%
Nascimbeni (2004)
n=TAE 70 OS 74
TART 7% %(TME)
TART 89% (72%)
90%(TME)
Madbouly (2005)
n=52
TAE 17%
TAE 89% (75%)
“Transanal excision equals total mesorectal neglect”

18. But, don’t worry, we can perform salvage radical surgery!

19. Salvage Surgery for Recurrence
Recurrent stages (n=29)
Mean time to recurrence = 26 months
23/29 underwent curative surgery
Mean follow up = 39 months
Friel, et al. Dis Colon Rectum 2002

20. Salvage Surgery for Recurrence FTLE
Patients DFS Overall 29 12(59%) T1 10 7(70%) T (53%) Good histol 22 15(68%) Bad histol 7 2(29%)
Friel, et al. Dis Colon Rectum 2002

21. Salvage Surgery for Recurrence
49/50 patients underwent curative surgery
27 (55%) multivisceral resections
47/49 underwent R0 resection
Weiser, et al. Dis Colon Rectum 2005

22. Salvage Surgery for Recurrence FTLE
5 year
Survival
53%
Weiser, et al. Dis Colon Rectum 2005

23. Why the high local recurrence rates?
Progression of occult lymphatic tumor
Better histologic predictors
‘Are all polyps made equal?’
TART technically limiting

24. Are all polyps equal? NO

25. Polyp morphology
Pedunculated
Sessile

26. 7 Adverse features Morphology Differentiation Mucinous LV infiltation
Peri neural invaision
Margin
Exophytic vs ulcerating

27. The Difficult TART: Origins of TEMS
Standard transanal excision:
Limited to lesions:
distal rectum
small tumors (<3 cm)
However…
lighting and exposure is poor
surgical field collapses
“short reach, poor visibility”

28. Origins of TEMS
Professor Gerhard Buess

29. Transanal Endoscopic Microsurgery
4 cm x cm proctoscope, airtight faceplate, insufflation, telescope, and laparoscopic instruments

30. Karl Storz (TEO)

31. Other techniques are available
ESD
Contact DXT

32. Operative Techique

33. pT1 Rectal Cancer: TEM case series
, single surgeon, n=53 (75)
Age 65 y (31-89) (65y)
Average 7 cm (0-13) from verge (7cm)
F/U: 2.8 y
7.5% (4/53) recurrence (9%)
No cancer related deaths (0%)
Floyd and Saclarides DCR 2006
(Abarca and Saclarides ASCRS 2010)

34. uT1N0 Rectal Cancer: RCT: TEM vs Low Anterior Rsxn
Patients:
Age (y):
Location L/M/U:
Follow-up (m):
Complications:
Local Recur:
Survival:
TEM 24
63.7
7/12/5 41
20.8%
1 (4%)
96%
LAR 26
60.9
8/11/7 46
34.5%
96%
Winde et al, DCR 1996

35. uT2N0 Low Rectal Cancer TEM 35 2 (5.7%) 9% 94% LAC-TME 35 1 (2.8%)
RCT: ChemoXRT followed by
TEM vs Laparoscopic TME
minimum 5 year follow-up
TEM 35
2 (5.7%) 9%
94%
LAC-TME 35
1 (2.8%)
2 (5.7%) 6%
94%
Patients:
Local Recur:
Distant Recur:
Prob of any Recur:
DFS:
Lezoche et al Surg Endosc 2007

36. So how should we manage early rectal cancer?

37. Clinical Evaluation History Physical Family history Continence history
Evaluation of operative risk
Physical
Abdomen
Digital Rectal Examination
Rigid proctoscopy

38. Rectal Cancer Work Up Biopsy Colonoscopy/ full bowel imaging CEA
CT Scan Abdomen / Pelvis
Chest imaging (CXR or CT)
Endoscopic Ultrasound /MRI

39. Bulky lesion
MR/USS T1/2
Young fit patient
Elderly/ comorbidity
Biopsy proven Ca
Biopsy benign
Biopsy proven Ca
Good T1
Op/ Stoma averse
Bad T1 T2
TEMS
TME/ APER

40. Thanks For Listening!