1. Basingstoke Colorectal The Particular Problem of Low Rectal Cancer Brendan Moran Basingstoke 4 th East-West Colorectal Days Hungary 2008

2. Basingstoke Colorectal The Particular Problem of Low Rectal Cancer Tumours within 6cm of anal verge

3. Basingstoke Colorectal Issues n Difficulties with reconstruction n Problems with APE n Embryology/anatomy of the low rectum/anal canal n Lower tumour – higher risk of lateral pelvic nodal involvement n Pathology different – more poorly diff and increased risk nodal disease

4. Basingstoke Colorectal Dutch Rectal Cancer Study Nagtegaal et al Am J Surg Path, 2002; 26:350-7 n=656

5. Basingstoke Colorectal Mercury Study Data n=307

6. Basingstoke Colorectal TME Hypothesis n TME provides optimal block dissection of the lymphatic drainage of the rectum. n Does this work for low rectal cancer ??.

8. Basingstoke Colorectal Methods n All rectal cancers 1978-2002 in Basingstoke n Anterior resections n Analyzed impact of tumour height on local and systemic recurrence

9. Basingstoke Colorectal Surgical Technique

10. Basingstoke Colorectal Procedures Performed For Rectal Cancer 585 (86%) (Curative 480) 41 (6%) 57 (8%)

11. Basingstoke Colorectal Systemic Recurrence by tumour height Log Rank for Heterogen eity Trend Chi2 1.6638 1.3767 D.F. 2 1 P0.43520.2407 12-15cm 20%(n=102) 7-11cm 24%(n=190) 0-6cm 27%(n=188) Overall 24%(n=480)

12. Basingstoke Colorectal Log Rank for Heterogen eity Trend Chi2 10.4074 9.5821 D.F. 2 1 P0.00550.0020 Local Recurrence by tumour height 12-15cm <1% (n=102) 7-11cm 2%(n=190) 0-6cm 7%(n=188) Overall 4%(n=480)

13. Basingstoke Colorectal Summary n Tumour height of < 6cm predictive for a higher rate of local failure following curative TME n Why is this??

14. Basingstoke Colorectal Why ?? n Technical challenges n Anatomy / embryology n Tumour behaviour

15. Basingstoke Colorectal What about APE ???

16. Basingstoke Colorectal Shihab, Moran, Mercury study Group Presented ASCRS 2008 Patients with low rectal cancer treated by abdomino-perineal excision have worse tumours and higher involved margin rates compared with those treated by anterior resection.

17. Basingstoke Colorectal Patients and methods n MERCURY (Magnetic Resonance Imaging in Rectal Cancer European Equivalence Study) n Prospective, multi-centre (2003-2005) n 408 patients with rectal cancer n High-resolution MRI n TME surgery n Standardised pathology

18. Basingstoke Colorectal 408 patients 158 ≤ 6cm from Anal verge 250 > 6 cm from anal verge 72 APE 81 LAR 153 patients 4 Hartmann’s 1PPC+I

19. Basingstoke Colorectal Patients and methods APE compared to AR for : n Median tumour height n % undergoing neoadjuvant therapy n Involved CRM (CRM+) n T-stage

20. Basingstoke Colorectal Results 153 patients Operationn Median Tumour Height (range) APE723 (0-6cm) AR815 (1-5cm) p < 0.001

21. Basingstoke Colorectal Results Operationn Neoadjuvant Therapy APE7264% (n=46) AR8141% (n=33) p = 0.007

22. Basingstoke Colorectal Results Operationn CRM +'ve % APE7231.9 (n=23) AR8113.6 (n=11) TOTAL15322.2 p = 0.01

23. Basingstoke Colorectal Results Local Invasion OperationnT0T1T2T3T4 APE7223193810 AR816618510 p = 0.006

24. Basingstoke Colorectal Conclusion Tumours < 6cm n APE group had higher CRM + rates. n APE group significantly lower tumours and higher pT stage despite higher proportion undergoing neoadjuvant therapy.

25. Low Rectal Cancer “ mrT4” “PR – Tumour Mobile sitting on levators in coronal view ”

26. Basingstoke Colorectal Surgical Dilemma Six Main Management Options 1. Abdomino Perineal Excision (APE) 2. Anterior Resection (AR) 3. 5 Gy x 5 days (5x5) and APE 4. 5x5 and AR 5. Chemoradiotherapy (CRT) and APE 6. CRT and AR

27. Multiple choice 1 APE 2 AR 3 SCRT +APE 4 SCRT + AR 5 CRT +APE 6 CRT +AR

28. Holm et al. (Karolinska Hospital, Stockholm) BJS 94: 232-238, 2007

29. Basingstoke Colorectal Conclusion n Low rectal cancer difficulties in n optimal staging n neoadjuvant therapy n surgical treatment.