1. Datum/Vortragsthema Local resection of Rectum tumors Peter M. Markus Elisabeth Hospital Essen Germany

2. Datum/Vortragsthema Which tumorsSize, Localisation, Histology Which tumorsSize, Localisation, Histology local vs anterior resection How do I remove peranal (mucosectomy, full thickness ), TEM Rectum tumors Local resection

3. Datum/Vortragsthema Lower third peranal Middle and TEM Upper third anterior wall up to 12 cm post. wall up to 15 cm, 1/3 circumference post. wall up to 15 cm, 1/3 circumference Rektal tumors - How to threat -

4. Datum/Vortragsthema Indication for local resection - histology - Ln-involvement 1. adenoma, high grade dysplasia 0 2.T1 Ca low grade (G1, G2, -pL1, -pV1.) ~3% local recurrence rate ~ 6 % (0-28%) Matzel et al. Chirurg 2003 Nascimbeni et al. Dis Colon Rectum 2004

5. Datum/Vortragsthema 17 studies, 1984-2002, 1379 patients 17 studies, 1984-2002, 1379 patients +Ln % T1 high risk> 10 (2,2-35,7) T1 high risk> 10 (2,2-35,7) T 2 Ca>12 ant. resection radio-chemo-therapy Deinlein P, Reulbach U, Stolte M, Pathologe 2003 Indication for local resection

6. Datum/Vortragsthema Incidence for lymph node metastases Incidence for lymph node metastases Localisationn+ Ln Localisationn+ Ln lower2934 lower2934 middle5411 middle5411 upper36 8 upper36 8 Nascimbeni et al. Dis Colon Rectum 2002 Nascimbeni et al. Dis Colon Rectum 2002 T 1 rectum carcinoma T 1 rectum carcinoma

7. Datum/Vortragsthema lncidence of lymph node metastases lncidence of lymph node metastases Lymphatic invasionn + Ln Lymphatic invasionn + Ln pL0324 11% pL0324 11% pL1 28 32% pL1 28 32% Nascimbeni et al. Dis Colon Rectum 2002 Nascimbeni et al. Dis Colon Rectum 2002 T 1 rectum carcinoma T 1 rectum carcinoma

8. Datum/Vortragsthema Rectum carcinoma Submucosa infiltration

9. Datum/Vortragsthema Sm1 Sm2 Sm3 Sm1 Sm2 Sm3 N = 70 120 154 N = 70 120 154 Ln-Met. = 3 8 23 Ln-Met. = 3 8 23 Rectum carcinoma Submucosa infiltration

10. Datum/Vortragsthema Grading vs depth of invasion Grading vs depth of invasion GradingnSm1/Sm2Sm3 GradingnSm1/Sm2Sm3 1 + 222767%33% 1 + 222767%33% 3 + 4 11732%68% 3 + 4 11732%68% Nascimbeni et al. Dis Colon Rectum 2002 T 1 Rectum carcinoma T 1 Rectum carcinoma

11. Datum/Vortragsthema n= 105, local resection T1 low riskR1/RX/high grade recurrence6%39% Borschitz et al., Dis Colon Rectum 2006 Rectum carcinoma - Risk of Recurrence -

12. Datum/Vortragsthema Transanal Endoscopic Microsurgery

13. Datum/Vortragsthema TEM Technique of resection

14. Datum/Vortragsthema TEM

15. Specimen after full thickness resection

16. Datum/Vortragsthema n= 182 OP, n= 162 pt., 1995-2001, follow up Ø 34 months histologynOP technique n Adenoma118(deep) ant. R. 27 T1 Ca 59transanale R. 76 others 5TEM 79 Langer C, Liersch T, Markus PM et al., Int J Colorectal Dis 2003 Resection of benign Rectum tumors and early Carcinomas

17. Datum/Vortragsthema Langer C, Liersch T, Markus PM et al, Int J Colorectal Dis 2003 rectum tumors - local resection – n = 182, follow up Ø 34 months

18. Datum/Vortragsthema Langer C, Liersch T, Markus PM et al, Int J Colorectal Dis 2003 Rectum tumors - Complications -

19. Datum/Vortragsthema Langer C, Liersch T, Markus PM et al, Int J Colorectal Dis 2003 Rectum tumors - Recurrence -

20. Datum/Vortragsthema Adenoma Adenoma T1 Ca G1, G2, (low risk) - pL1, -pV1, Sm 1, Sm 2local resection - pL1, -pV1, Sm 1, Sm 2local resection TEM (Ultracision) high risk high risk T1 Ca G3, G4, +pL1, Sm 3anterior resection T1 Ca G3, G4, +pL1, Sm 3anterior resection with TME Summary

21. Datum/Vortragsthema Local resection of rectum tumors What to to when histologylocalisationthirdtherapy R0, high riskmiddle/upper radical resect. lower RCH R1, low riskmiddle/upper radical resect. lower local re-resect. R1, high riskradical resect.

22. Datum/Vortragsthema

24. local recurrence after local resection meta-analysis 22 studies 958 patients + RadioChemo + RadioChemo T Lokal-R % Lokal-R% T Lokal-R % Lokal-R% T1 9,7 (0-24) 9,5 (0-50) T1 9,7 (0-24) 9,5 (0-50) T225 (0-50) 13,6 (0-24) T225 (0-50) 13,6 (0-24) T338 (0-100)13,8 (0-50) T338 (0-100)13,8 (0-50) Sengupta S et al Dis Colon Rectum 2001)

25. Datum/Vortragsthema n = 186, massive polyp >3cm n = 186, massive polyp >3cm - 19 invasive Ca - 19 invasive Ca - 167 adenoma29 tubular - 167 adenoma29 tubular 118 tubulovillous 20 villous 49x high grade dysplasia Doniec JM, Dis Colon Rectum 2003 rectum tumor - endoscopic excision -

26. Datum/Vortragsthema lateral margin.n lokal-Rec. 5 y survival rate lateral margin.n lokal-Rec. 5 y survival rate TU +35 3224% TU - 1061174% Adam et al., Lancet 1994 rectum carcinoma - effect of lateral resection margin -