Transcript Surgical Approaches

Rectal Cancer Update:
Neoadjuvant vs Adjuvant Therapy and Surgical
Options
Paul A. Lucha Jr., DO, FACOS
Capt (ret), MC, USN
WG Hefner VA Medical Center, Salisbury NC
Introduction
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Preoperative Evaluation
Imaging in rectal cancer
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TRUS
MRI
CT
PET scanning
Introduction
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Surgical Approaches
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transanal excision
Sphinter sparing
TME (circumferential margin)
nerve sparing
Introduction
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Surgical Approaches
– Laparoscopic Surgery
– Endoscopic Surgery
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WALL Stent
Transanal endoscopic microsurgery
Adjuvant therapy
– neoadjuvant vs postoperative
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Quality of life measures
Preoperative Evaluation
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relevant anatomy
Preoperative Evaluation
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relevant anatomy
Preoperative Evaluation
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clinical evaluation (DRE)
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44-83% Accuracy for depth of tumor penetration
Fixed
palpable nodes (60% accurate at best)
accuracy related to examiners experience
smaller tumors often staged inaccurately
Rigid Sigmoidoscopy
– level of tumor above the dentate line
– position of tumor
Preoperative Evaluation
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TRUS
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“gold standard” for preoperative assessment
depth of penetration through bowel wall (81-96% accurate)
perirectal lymph node involvement (60-83% accurate)
operator dependent
Preoperative Evaluation
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TRUS
– T2NxMx
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TRUS
– T1NxMx
Preoperative Evaluation
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Trus
– T2N0M0
– Pathologic Specimen
Preoperative Evaluation
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TRUS
– T3NxMx
– Penetration into
perirectal fat
Preoperative Evaluation
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CT
– better assessment of local regional involvement
– can detect metastatic disease outside the confines
of the rectum
– unable to detect layers of bowel wall
– poor at assessing lymph node status
Preoperative Evaluation
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CT
– initial reports quoted 77-100% accuracy in staging
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mostly advanced stage tumors
– poor at assessing node status (50% accurate at
best)
– Up to 25% may have metastatic disease at the
time of presentation
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CT more useful to assess liver, adrenal, lungs
90% accurate in assessing liver metastasis
Preoperative Evaluation
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CT
T3N0M0
Preoperative Evaluation
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CT
Metastasis
Preoperative Evaluation
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CT
Hamartoma
Preoperative Evaluation
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MRI
Similar in accuracy to TRUS
– If endorectal coil used
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Better than CT for local pelvic spread
Superior to CT for liver metastasis
Preoperative Evaluation
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MRI (endorectal coil)
– can distinguish 3 rectal wall layers
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Inner layer (mucosa and submucosa)
– Intermediate signal on T1
– High signal on T2
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Middle layer (Muscularis propria)
– low signal on T1 and T2
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Outter layer (subserosa, serosa, perirectal fat)
– High signal on T1 and T2
Preoperative Evaluation
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MRI (endorectal coil)
– T stage sensitivities
between 70-92%
– Lymph node status about
40% in some series
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Better for recurrent
rectal tumors
T3N0M0
Preoperative Evaluation
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PET
– F-18-labeled -2-deoxyglucose
(FDG)
– Tumors with increased glucose
utilization
– Inflammation may cause false
positivity
– little role in primary diagnosis
and evaluation
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understages small lesions
(<1cm)
necrotic neoplasms
peritumoral inflammatory
granulomas
Surgical Approaches
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Local treatment to avoid colostomy or major
resection
Key to success is patient selection (3-5% of
all rectal tumors)
– small exophytic tumor
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<3 cm diameter
< 25% of rectal circumference
uT1NxMx by TRUS
Surgical Approaches
– mobile on exam
– well differentiated pathology
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not mucinous
not colloid
no lymphovascular invasion
Surgical Approaches
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Risk of lymph node metastasis
– by T stage
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pT1 is 12%
pT2 is 22%
– by tumor grade
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0% for grade 1 histology
22% for grade 2 histology
50% for grade 3 histology
– by lymphovascular invasion
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17% non invasive
31% invasive
Surgical Approaches
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Transanal Excision
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uT1
1 cm margins
defect left open or closed
full thickness excision
Transanal Endoscopic Microsurgery
– operating resectoscope
– ? Improved exposure
– higher rectal lesions accessible
Surgical Approaches
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TAE or TEM
– adjuvant therapy if final pathology
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positive margins
pT2 or pT3 and patient refused resection
Surgical Approaches
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Endoscopic Surgery
– Wall Stent
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palliative treatment for obstructing cancer
preoperative treatment of obstructing cancer
– avoidance of stoma
– allows bowel prep
– preoperative neoadjuvant therapy to downstage tumor (or
improve resectability)
Surgical Approaches
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Nerve Sparring
– most are injured during blunt dissection
– wide lateral dissection damages the remainder
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Total Mesorectal Excision (TME)
– Local recurrence rates of 4-8% without adjuvant
therapy
– initial studies included patients who had had XRT
preoperatively and chemotherapy postoperatively
– Dutch Colorectal Cancer Group TME trial
– Randomized Dutch trial examined the role of
adjuvant therapy in patients undergoing TME
Surgical Approaches
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TME
– Heald 1992 (Basingstoke Experience)
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2.6% local recurrence rate at 5 years
– Enker 1995 (Memorial Experience)
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7.3 % local recurrence rate at 5 years
– anastomotic leak rate higher (17%)
– proximal diversion recommended
– lower rates of sexual and urinary tract dysfunction
Surgical Approaches
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Colonic J pouch- randomized studies show
– Decreased mean stool frequency (<2/24 hours)
– Improved continence
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less rectal urgency
– increased maximum volume and compliance by
manometry
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benefits persist for up to two years
– Fewer anastomotic leaks
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? Better blood supply
– Diverting stoma recommended
Surgical Approaches
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Laparoscopic surgery
– Adequacy of resection
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length of specimen andlength of margin
number of lymph nodes harvested
– Short term
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length of operating time and hospital stay
postoperative pain and ileus
cytokine response
– Long term
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return to “work”
cancer survival
Surgical Approaches
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Laparoscopic surgery
– port site/ extraction site recurrences
– long term cancer free survival
– Randomize prospective trial results
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COST Trial
Longer operative times
Shorter hospital stay
– Offsets operative costs
Surgical Approaches
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Endocavitary Irradiation (Papillon tx)
– no pathologic staging
– criteria the same as for TEM or TAE
– often used in those with high surgical risk
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? High rectal tumors not amenable to TAE
Electrofulgeration
– similar limitations and requirements to
endocavitary irradiation
– morbidity rates higher (21%)
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postoperative bleeding
postoperative stricture
Adjuvant Therapy
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NCI Concensus Conference 1990
– Combined modality therapy for T3 and/or N1-2
disease
– XRT and 5FU
– decreases local recurrence rates to about 10%
– Increased 5-year survival by 10-15%
– significant acute toxicity
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25-50%
Adjuvant Therapy
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Neoadjuvant therapy Advantages
– decreased tumor seeding?
– Less toxicity
– increased radiosensitivity
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increased oxygen
– enhanced sphincter preservation
Adjuvant Therapy
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Neoadjuvant therapy disadvantages
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? Overtreatment
? Downstaging tumor (retrospective data)
? Sphincter dysfunction
? Increased risk for incontinence
Adjuvant Therapy
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Neoadjuvant therapy (45-50Gy in 4-5 weeks)
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complete response rate 10%
local recurrence rate 3-10%
acute toxicity rate 15-25%
Swedish Rectal Cancer Trial (25Gy in one week)
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improved survival
short course therapy
– No other trials show improved survival
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Meta analysis, subset analysis, etc
Adjuvant Therapy
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Preoperative downstaging (sphincter
preservation)
– 4-5 week course of 50 Gy
– 4-6 weeks wait until surgical treatment
– interim analysis of NSABP R-03
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27% increase in sphincter preservation
Improved survival
– short course therapy?
Quality of Life measures
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Traditional measures of cancer treatment
– Disease free survival
– Overall survival
– Tumor response rates
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Quality of life difficult to measure
– subjective
– validated questionaires
– must be cancer/ surgery specific
Quality of Life measures
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Incontinence
Impotence (retrograde ejaculation)
Bladder dysfunction
Rectal urgency
Pain
Frequency of Bowel movements
Psychosocial dysfunction
– stoma related
– cancer related
Quality of Life measures
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Chemotherapy or Radiation treatment related
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nausea
diarrhea
vomiting
weakness
Xerostomia
Insomnia
Weight Loss
Few Studies in the English Literature address
this topic
Controversies
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Distal Margin of resection
– 5 cm margin
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studies show that intramural spread of tumor less that 1
cm
2 cm margin acceptable
No difference in long term survival 2 cm vs 5 cm
Some will accept 1 cm margin for exophytic lesions
– measurement of margins
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Weese (1986)
– 5 cm margin fresh pinned specimen
– 2.4 cm margin in the fixed state
Controversies
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Distal rectal washout
– tumorcidal agent
– rectum must be occluded below tumor
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Neoadjuvant therapy vs postoperative
therapy
Preoperative staging
– MRI (endorectal coil)
– TRUS
Controversies
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High vs Low ligation of IMA
– no good evidence that ligation proximal to the left
colic artery improves survival
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TME
– adjuvant therapy?
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Colonic J pouch
Laparoscopic Resection
Introduction
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Low Anterior Resection
– Distal to the peritoneal reflection (5-8 cm)
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Historically
– Oncologic outcomes of surgical treatment
were most important
– Functional outcomes rarely considered
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QOL research and functional assessment have
become more important
Introduction
– Adjunctive treatments changed
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Radiation therapy
– Preoperative or Postoperative
– Compromised rectal function with postoperative XRT
• Reduced compliance of reservoir
– Sphincter dysfunction after XRT (pre and post
operative)
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Chemotherapy
Introduction
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Surgical Management Options
– Local Options
Transanal Endoscopic Microsurgery
 Transanal Excision
 Endocavitary Irradiation (Papillon tx)
 Fulgeration
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Introduction
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Surgical Management Options
– Resection
Abdominal Perineal Resection
 Total Mesorectal Excision
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Straight end to end coloanal anastomosis
Coloplasty
Side to end coloanal anastomosis (Baker)
Colonic J pouch
Pullthrough (Harry E. Bacon MD)
Surgical Approaches- Local
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Transanal Excision
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uT1
1 cm margins
defect left open or closed
full thickness excision
Transanal Endoscopic Microsurgery
– operating resectoscope
– ? Improved exposure
– higher rectal lesions accessible
Surgical Approaches- Local
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Endocavitary Irradiation (Papillon tx)
– no pathologic staging
– criteria the same as for TEM or TAE
– often used in those with high surgical risk
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? High rectal tumors not amenable to TAE
Electrofulgeration
– similar limitations and requirements to
endocavitary irradiation
– morbidity rates higher (21%)
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postoperative bleeding
postoperative stricture
Surgical Approaches- Local
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Functional outcomes
– Since these are local procedures,
functional outcome is primarily related to
stage of disease
– When applied with curative intent, minimal
changes are noted in QOL or functional
outcomes measured
Surgical Approaches- Resection
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Abdominal Perineal Resection
– Traditionally used for low rectal cancer
– Permanent Colostomy
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Efforts to later recreate a sphincter popularized
in Europe (Spain)
– Sphincter reconstruction not attempted in
US
– Functional Outcome self evident
Surgical ApproachesResection
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Total Mesorectal Excision (TME)
– Local recurrence rates of 4-8% without adjuvant
therapy
– initial studies included patients who had had XRT
preoperatively and chemotherapy postoperatively
– Dutch Colorectal Cancer Group TME trial
– Randomized Dutch trial examined the role of
adjuvant therapy in patients undergoing TME
Surgical ApproachesResection
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Straight coloanal
anastomosis
– Most have 1-2 BM/
day
– About 33% will have
>3 BM/ day
– Rectal Urgency with
urgency related
incontinence can
occur
Surgical Approaches- Resection
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Coloplasty
– Described in 1999 by
Z’graggen and Mauer
– May not require as much
mobilization
– Ideally suited for narrow
pelvis
– Performed 4 cm above
cut end of proximal
segment
– 7 cm longitudinal incision
in taenia on
antimesenteric side
Coloplasty
Surgical Approaches- Resection
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Side to end coloanal
anastomosis
– Described in 1950 by
JW Baker
– Revived and more
popular in Europe
– Functionally similar
to J pouch at 6
months
Surgical ApproachesResection
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Colonic J pouch- randomized studies
show
– Decreased mean stool frequency
(<2/24 hours)
– Improved continence
 less rectal urgency
– increased maximum volume and
compliance by manometry
 benefits persist for up to two
years
– Fewer anastomotic leaks
 ? Better blood supply
– Diverting stoma recommended
Surgical Approaches- Resection
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Colonic J Pouch
– 6-7 cm long pouch
– 15 cm pouch with poor function and
evacuation
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Similar to straight coloanal anastomosis
Surgical Approaches- Resection
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Pullthrough
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Popularized in US by Harry E. Bacon
Intersphincteric dissection
No anastomosis therefore no leak
Vascular supply to segment
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Compromise with ischemia and necrosis
– Segment of left colon is brought through the anus
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Anoplasty is accomplished at POD#7
– Poor functional outcome
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Poor evacuation
Daily enema to evacuate
Functional Outcomes
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Colonic J pouch with fewer BM/ day
– Average 3
– Better compliance and evacuation on scintography
and manometry
– Less urgency
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Coloplasty
– Similar outcomes to J-pouch (manometry/
scintography)
– Fewer randomized trials
– Higher leak rates than J-pouch
– QOL scores (SF 36) similar to J- pouch
Functional Outcomes
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Baker type reconstruction
– Similar leak rate to J-pouch
– Poorer function at 3 months
– Similar evacuation function at 6 months
References
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A meta-analysis comparing functional outcome following straight coloanal anastomosis
versus a colonic J pouch. Temple LK and McLeod RS. Sem Colon Rectal Surg 2002, 18:
62-66.
Meta-analysis of colonic reservoirs versus straight coloanal anastomosis after anterior
resection. Heriot AG, Tekkis PP, Constantinides V. Paraskevas P, Nicholls RJ, Darzi A,
Fazio VW. Br J Surg 2006, 93: 19-32.
Evacuation of neorectal reservoirs after TME. Koninger JS, Butters M, Redecke JD,
Z’graggen K. Recent Results Cancer Res. 2005, 165: 180-190.
The transverse coloplasty pouch. Ulrich A, Z’graggen K, Schmitz-Winnenthal H, Weitz J,
Buchler MW. Langenbecks Arch Surg 2005, 390: 355-360.
Techniques for restoring bowel continuity and function after rectal cancer surgery. Yik-Hong
Ho. World J Gastroenterology 2006, 12: 6252-6260.
Comparison of J-pouch and coloplasty pouch for low rectal cancers: A randomized,
controlled trial investigating functional results and comparative anastomotic leak rates. Ho
YH, Brown S, Heah SM, Tsang C, Seow-Choen F, Eu KW, Tang CL. Ann Surg 2002, 1: 4955.
Similar outcome after colonic pouch and side-to end anastomosis in low anterior resection
for rectal cancer: A prospective randomized trial. Machado M, Nygren J, Goldman S,
Ljungqvist O. Ann Surg 2003, 2: 214-220.
A new surgical concept for rectal replacement after low anterior resection: The transverse
coloplasty pouch. Z”graggen K, Maurer C, Birrer S, Giachino D, Kern B, Buchler M. Ann
Surg 2001, 6: 780-787.
Transverse coloplasty pouch: A novel neorectal reservoir. Z’graggen K, Maurer CA,
Buchler MW. Digestive Surgery 1999: 363-366.