Transcript 投影片 1 - Introduction

Management of Locally Advanced
Rectal Cancer
Joint Hospital Surgical Grand Round
Pamela Youde Nethersole Eastern Hospital
Dr. YH Ling
19 May 2007
Colorectal Cancer
Primary modality of treatment:
Surgical Resection
Rectal Cancer

Middle and lower
rectum
– Located in the confined
pelvis
– Close relationship with
• urogenital tracts
• anal sphincters
Goal of treatment

Achieve oncological cure
– Radical resection
• Negative distal and circumferential
margin
Goal of treatment

Preserve
– Urinary function
– Sphincter function
– Sexual function

Maintain the quality of life
Radical
resection
Pelvic
organ
functions
Locally advanced rectal cancer

Tumour and/or regional nodes have
invaded the adjacent organs
– Bladder, ureters
– seminal vesicles, prostate
– vagina
– sacrum
Pre-op
imaging and
staging
Chemotherapy
Surgery
Radiotherapy
Better
local disease control
Improved overall survival
Greater sphincter preservation rate
Treatment of locally advanced
rectal cancer
Multidisciplinary cancer
management
Surgeons
Oncologists
Diagnostic radiologists
Locally advanced rectal cancer
 Pre-op staging
 Neoadjuvant chemoradiation therapy

Locally advanced rectal cancer
Locally advanced rectal cancer

Tumour and/or regional nodes have
invaded the adjacent organs
– T3-4 or N+
– 6-10% of rectal cancer
Stage
T
N
M
Dukes
MAC
0
I
IIA
IIB
Tis
T1
T2
T3
T4
N0
N0
N0
N0
N0
M0
M0
M0
M0
M0
-A
A
B
B
-A
B1
B2
B3
IIIA
IIIB
IIIC
IV
T1-T2
T3-T4
Any T
Any T
N1
N1
N2
Any N
M0
M0
M0
M1
C
C
C
--
C1
C2/C3
C1/C2/C3
D
CRM ≤ 2mm distinguishes the TNM stage III
patients with high risk of local recurrence
(21.4%) from patients with lower risk of
local recurrence (12%), p = 0.03
Locally advanced rectal cancer
Tumour growing < 2mm from the
mesorectal fascia (fascia proper)
 Beyond mesorectal fascia
 With major lymph node involvement

Pre-operative staging
Imaging modalities
CT scan
 MRI

– With or without endorectal coil

Endorectal ultrasound
CT scan
Widely used to stage colorectal
cancer
 Not good for local staging

– Cannot delineate
• layers of bowel wall
• microinvasion of perirectal fat
– Cannot detect
• small lymph node metastases (<1cm)
• lymph nodes close to the tumour
Endorectal ultrasound (ERUS)

Accuracy
– T staging: 83%
– N staging: 65-83%
• Kim NK, et al. Ann Surg Oncol 2000;7:732–7
• Savides TJ, et al. Endosc2002;56(S4):S12–8.
Endorectal ultrasound (ERUS)

Limitations:
– Bowel wall penetration (T):
• Inflammatory peritumoral changes mimic
deeper invasion
 Overstage T2 tumour
– Nodal status (N):
• Difficult to differentiate inflammatory and
metastatic nodes
• Difficult to detect small or distant lymph
nodes
Endorectal ultrasound (ERUS)

Limitations:
– Stenotic lesion
• Difficult to pass the transducer
– Operator dependent
– “Sampling error” for large tumour
MRI

Advantage:
– Visualize the
distance between
the tumor and the
rectal fascia proper
MRI

Limitation:
– Inability to distinguish tumour extension
from inflammatory changes
–  overstage T2 lesions
•
•
•
•
Brown G, et al.Br J Surg 2003;90:355–64
Vliegen RFA, et al.Imaging 2003;10–6
Williamson PR, et al. Dis Colon Rectum 1996;39:45–9
Fleshman JW, et al. Dis ColonRectum 1992;35:823–9
Preoperative staging of rectal cancer
H. Kwok, LP Bissett, GL Hill et al
Int J Colorectal Dis (2000) 15:9-20
Systemic review
 83 studies from 78 papers
 4897 patients

Bowel wall penetration
Nodal status
Acc (%) Sen (%) Spe (%) Acc (%)
Sen (%) Spe (%)
CT
73
78
63
66
52
78
ERUS
87
93
78
74
71
76
MRI
82
86
77
74
65
80
MRI
84
89
79
82
82
83
with endorectal coil
MRI with endorectal coil

Most useful technique for
preoperative staging of rectal cancer
Limited availability
Limits its routine use


Limited use in stenotic lesions
Neoadjuvant chemoradiation
therapy
Potential Advantages

Reduction in tumour size
– improve resectability
– increase sphincter preservation

Decrease risk of local failure
– Improve tumour response in the preoperative setting
Potential Advantages

Decrease risk of toxicity
– Small bowel more readily excluded from
the radiation field in preoperative
setting

Less bowel dysfunction
– Colon used for reconstruction is not in
the radiation field

No delay of therapy in patients with
operative morbidity
Disadvantage:

Over-treat patient with pre-op
overstaged disease
Preoperative staging of rectal cancer
H. Kwok, LP Bissett, GL Hill et al
Int J Colorectal Dis (2000) 15:9-20
Staging
modality
CT
Accuracy OverUnder(%)
staged (%) staged (%)
80
13
7
ERUS
84
11
5
MRI
74
13
13
MRI with
81
12
6
endorectal coil
Prospective randomized clinical trials that
analyzed neoadjuvant therapy for rectal cancer
Study
Year N
Main results
Swedish
rectal cancer
trial
1997
908
High-dose pre-op radiation therapy
reduced local recurrence and improved
survival
Dutch
colorectal
cancer group
2001
1805 Pre-op radiation therapy decreased local
recurrence following total mesorectal
excision
German rectal 2004
cancer study
group
823
Pre-op chemoradiation therapy
improved local control but did not
improve overall survival compared to
post-op chemoradiatoin therapy
Rectal cancer
T3 or T4 or N +
n = 415
n = 384
Long course radiation
+
Infusional 5-FU
TME
6 weeks
TME
Radiation therapy
+
Infusional 5-FU

5-year cumulative risk of local
failure:
– Pre-op chemoradiation group:
– Post-op chemoradiation group:
• P = 0.006

Survival:
– No difference in two groups
6%
13%

Improved sphincter preservation rates in
pre-op chemoradiation therapy group

20% of patients randomized to the postop chemoradiotherapy group actually
have stage I disease on evaluation of
resection specimen

These patients will be over-treated if
they were treated preoperatively
Chemotherapy with preoperative
radiotherapy in rectal cancer
N Engl J Med 2006;355(11):1114-23
Bosset JF, Collette L, Calais G, et al
Preoperative radiotherapy with or
without concurrent fluorouracil and
leucovorin in T3-4 rectal cancers:
results of FFCD 9203
J ClinOncol 2006;24(28):4620-5
Gerard JP, Conroy T, Bonnetain F, et al

1011 patients with clinical stage T3 or T4
resectable rectal cancer
Randomized to 4 groups:

1
2
3
4
Pre-op
Post-op
RT
Chemo-RT
RT
Chemo-RT
chemotherapy
chemotherapy
The cumulative incidences
of local recurrences as a
first event at 5 years
Pre-op
1
2
3
4
Post-op
RT
Chemo-RT
RT
chemotherapy
Chemo-RT chemotherapy
Cummulative
incidence of local
recurrence (%)
17.1
8.7
9.6
7.6
p=0.002 for the comparison between the group
receiving preoperative radiotherapy alone and
the other three groups
733 patients with T3-4 Nx M0 rectal
cancer
 Randomized to 2 groups

– Pre-op radiotherapy group
– Pre-op chemoradiotherapy group

The 5-year incidence of local
recurrence
– Pre-op radiotherapy
– Pre-op chemoradiotherapy
• p < 0.05

Overall 5-year survival:
– No difference
16.5%
8.1%
Neoadjuvant therapy with combined
chemoradiation is becoming
standard of care in locally advanced
rectal cancer
Surgical resection
Resection of the primary tumour
 With en bloc resection of adjacent
involved structures
 Obtain negative margins

Neoadjuvant therapy cannot
compensate for irradical resection
Conclusions

Locally advanced rectal cancer
– TNM staging: T3-T4 or N+
– Circumferential resection margin:
• Tumour < 2mm from the mesorectal fascia
• Tumour beyond mesorectal fascia
• Tumour with major lymph node involvement
Conclusions

MRI with endorectal coil is the best
diagnostic tool but not widely
available

Endorectal ultrasound (ERUS) is
widely used with good accuracy

Neoadjuvant therapy:
– Pre-op radiation therapy combined with
chemotherapy
–  better local control
– No survival benefits shown
Conclusions

Management of locally advanced
rectal cancer is a multidisciplinary
cancer management involving
diagnostic radiologists, oncologists
and surgeons
Thank You