1. Brendan Moran Basingstoke OCTOBER 2008
How Imaging Has Improved Outcome In Rectal Cancer 4th East- West Colorectal Days Hungary
Brendan Moran
Basingstoke
OCTOBER 2008

3. “ A picture is worth a thousand words”
Image and Imaging
“ A picture is worth a thousand words”
Chinese Proverb

4. What does this illustrate ?
Attempt to describe a “revolutionary” theory
Heald, Husband, Ryall BJS 1982

5. But ? Inaccurate Drawing Not applicable to upper rectal cancer
Only 5 patients
Nevertheless most quoted paper ever in rectal cancer
Heald et al BJS 1982

6. “The mesorectum in rectal cancer surgery -the clue to pelvic recurrence”
Heald et al BJS 1982

9. TME Evolution
Heald RJ Journal Royal Soc Med 1988

10. Pre-operative RT –Sweden Pathology -Quirke
Rectal Cancer 80’s and 90’s
Surgery- TME
Pre-operative RT –Sweden
Pathology -Quirke

11. The Circumferential Resection Margin Quirke et al 1986
In that same year Professor Quirke described the relationship of involvement of the circumferential resection margin - the mesorectal fascia, and the effect on local recurrence.

12. TME and Radiotherapy
Both aim at the circumferential margin
Both reduce the CRM involvement

13. The rationale for TME
Havenga, Eur J Surg Oncol 1999

14. Long Term Follow up Swedish Radiotherapy Study
The benefits are long lasting – at median follow-up 13 years [3–15]
Local recurrence rate 26% versus 9%
Folkesson et al JCO Aug 2005

15. Dutch TME Trial Local Recurrence patients with macroscopically complete local resection (n=1789)
TME alone
5.8% vs 11.4%
p < 0.001
RT + TME
Van de Velde et al. Update at 5 yrs follow up

16. Should we irradiate this patient ?

17. Lange M M, et al, Br J Surg Vol
Lange M M, et al, Br J Surg Vol. 94, 10 Pages: Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd
Figure 1. Percentage of patients with faecal incontinence after rectal cancer surgery with or without preoperative radiotherapy. Dashed portion of curves is based on only one questionnaire for each patient, obtained between 3·3 and 7·4 years after LAR

18. Late bowel obstruction treated surgically
Cumulative proportion without late bowel obstruction, treated surgically
Time after randomization (years)
Br J Surg 2008; 95:

19. Basingstoke Viewpoint BJS 2003
Simunovic et al. BJS 2003;90:

20. Selective pre-operative radiotherapy
Definitely for an involved margin
Consider for a “threatened” margin – very low or very large tumour

21. Basingstoke Viewpoint
Simunovic et al. BJS 2003;90:

22. Problems with this paper
Subjective
Based on large experience with focus on optimal surgery
Not reproducible

23. New methods of staging
Imaging techniques

24. Purpose of Imaging in Colorectal Cancer
Staging
Stage dictates outcome but especially for rectal cancer today – Stage dictates management

26. Management of Rectal Cancer Today
No treatment
Palliative therapy
Local excision/TEM
Radiotherapy alone
Neoadjuvant therapy +Surgery
Surgery alone
Chemotherapy +/- some or all

27. Staging Rectal Cancer
Local staging – local extension of the tumour and particularly the margin (CRM)
Staging for systemic disease

28. Staging Colorectal Cancer “Gold Standard” Pathology
Dukes Staging
TNM

30. Dukes Staging – Post –op pathology
TNM – Increasingly being “estimated” pre -op

31. Published article online: 10-May-2007
Clarifying the TNM staging of rectal cancer in the context of modern imaging and neo-adjuvant treatment: ‘y’‘u’ and ‘p’ need ‘mr’ and ‘ct’
B. Moran, G. Brown, D. Cunningham, I. Daniels, R. Heald, P. Quirke, D. Sebag-Montefiore
Colorectal Disease, OnlineEarly Articles
Published article online: 10-May-2007
doi: /j x

32. Staging – Moran et al Colorectal Disease 2008
“TNM is pathology”
“Imaging not equivalent”
“c” – clinical
“u” – ultrasound
“ct” – CT
“mr” - MRI
“p” – pathology
“y” – after pre-op treatment

33. Staging – Moran et al Colorectal Disease 2008
Thus a tumour staged by MRI as “T3N1 “should be described as mrT3N1
If given CRT eventual pathology might be
ypT2N0

34. Depth of Tumour (“T” staging) Mesorectal Margin
Local Staging
Depth of Tumour (“T” staging)
Mesorectal Margin

35. Imaging/ Staging Rectal Cancer Now
Finger
X-ray
Endoscopy US CT
MRI
PET

36. Colonoscopy and Cross-sectional imaging
The traditional view of a rectal cancer is luminal, but the key to the successful management is the assessment of the invasion of the disease. Incomplete excision of a locally advances tumour leads to local recurrence and the extremely distressing symptoms of pelvic pain, fistulation and poor bowel and bladder function.

37. Stage Dictates Therapy

38. Local Staging
Finger- Key
EAUS
MRI

39. Superficial Rectal Cancer
Wij kunnen MRI voorspellen. Nu aan de clinici Wat doen we ermee?
Wat kan imaging: T staging eus of endoMRI N1 ?
Alle andere ca MRI CRM+ N
CT redelijk goed CRM ,N minder goed
Wat voor onderzoek je wil hangt af van wat je wel en niet wil doen hoe gedetailleerd je info moet zijn
Dat als je wil voorkomen dat je preop verrast wordt door ca die je anders had willen behandelen dat je pat met rectum ca preop lokaal moet imagen.
EUS
not for evaluation of mesorectal fascia

40. uT1
intact outer hypoechoic layer (muscalaris propria)

41. uT3 uN1

42. Limitations of EAUS Unable to view margins (CRM) Stenotic tumours
Low painfull tumours

43. Phased array coil/ no bowel prep

44. The major advance has been in the development of MRI, by Gina Brown and others in the local staging of rectal cancer.
Here we can see the cancer and the mesorectal fascia and can assess their relationship.
The protocol employed a thin 3mm section turbo spin-echo T2-weighted technique using a surface pelvic phased array coil

47. Accuracy of MRI

48. The M.E.R.C.U.R.Y. Study Magnetic REsonance Imaging and Rectal Cancer
EURopean Equivalence
StudY
The MERCURY Study is the Magnetic……………..

49. Aims of MERCURY

50. British MedicalJournal Volume 33 14th October 2006
Diagnostic Accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer:prospective observational Study
MERCURY Study Group
Accuracy
1 Depth of extramural invasion – 95% to within 0.5mm
2 Prediction of a clear CRM (>1mm)- 91%

51. Imaging Focal Point of MDT to plan treatment

52. Tailored Treatment according to Risk for Local Recurrence
The Good
Surgery
The Bad
Surgery + ? ( SC RT)
The Ugly
Long course CRT
Delayed surgery

53. The Good

54. Extramural vascular invasion
The Bad
Extramural vascular invasion

55. Tumour satellite close to CRM
Nodal disease and EMVI
Heterogenous nodes
Tumour satellite close to CRM

56. The Bad
Now 2 years old
mrT3N1 Cancer at 20 weeks

57. The Ugly
July 06
Feb 06
When you compare the images at the same level, you can clearly see a good response to radiotherapy.
A relatively mild circumferential thickening of the rectum remains to be seen.
Coarse fibrotic band remains on the left side at 3 and 4 o’clock, abutting the thickened mesorectum.
Previously enlarged lymph nodes have largely resolved.

58. “ A picture is worth a thousand words”
Image and Imaging
“ A picture is worth a thousand words”
Chinese Proverb

59. Rectal Cancer Today and 1982

60. Ongoing problems with staging/MRI
MRI is not pathology
Low Rectal Cancer – staging poor- Finger better

61. Low tumours involving sphincter
Combination of PR and MRI
to plan
Neoadjuvant therapy
Subsequent surgery (AR or APE)

62. Holm et al. (Karolinska Hospital, Stockholm) BJS 94: 232-238, 200762

63. Future –Optimal Staging To Select for
TME Surgery alone
Selective neoadjuvant therapy
AR or APE

64. Thank You