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A. MONTORI M.D. F.A.C.S. PROFESSOR OF SURGERY UNIVERSITY OF ROME “LA SAPIENZA”

MSO-MTCC PG TRIPOLI October 1 ST 2010. HOW TO AVOID MAJOR SURGERY IN RECTAL CANCER. A. MONTORI M.D. F.A.C.S. PROFESSOR OF SURGERY UNIVERSITY OF ROME “LA SAPIENZA” President of EAcSS. LOCAL EXCISION FOR RECTAL NEOPLASMS.

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A. MONTORI M.D. F.A.C.S. PROFESSOR OF SURGERY UNIVERSITY OF ROME “LA SAPIENZA”

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  1. MSO-MTCC PG TRIPOLI October 1ST 2010 HOW TO AVOID MAJOR SURGERY IN RECTAL CANCER A. MONTORI M.D. F.A.C.S. PROFESSOR OF SURGERY UNIVERSITY OF ROME “LA SAPIENZA” President of EAcSS

  2. LOCAL EXCISION FOR RECTAL NEOPLASMS THE LOCAL EXCISION OF RECTAL NEOPLASMS STILL REPRESENTS A VERY CONTROVERSIAL ISSUE: • The nature of the lesion (benign or malignant) • The location (distance from anal verge) • The metodology to be used • The progress of technology • The different approach (Surgical or Endoscopic) • The results obtained • The radicality of the intervention (Long-Term survival - QoL)

  3. LOCAL EXCISION FOR RECTAL CANCER LOCAL EXCISION OF RECTAL CANCER IN LOW-RISK PATIENTS IS APPEALING BUT IT PROVIDES LIMITED CONTROL OF THE DISEASE (LACK OF “N” STAGING). NEVERTHELESS IN THE RECENT YEARS IT IS POSSIBLE TO ACHIEVE A CORRECT PREOPERATIVE TUMOR AND NODE STAGING DUE TO THE SIGNIFICANT IMPROVEMENT OF THE TRANSANAL ULTRASOUND, MRI, LYNPHOSCINTIGRAFY, ELICOIDAL CT SCAN IMAGING.

  4. TRANSRECTAL US NORMAL ( FIVE LAYERS ) T 1 T 3 N 1

  5. LOCAL EXCISION FOR RECTAL CANCER

  6. VIRTUAL ENDOSCOPY

  7. RIGID FLEXIBLE (colonoscopy) LOCAL EXCISION FOR RECTAL CANCER • DIGIT EXPLORATION • TUMOR MARKERS • RETTOSIGMOIDOSCOPY • (BIOPSY: microbiopsies for grading - TATOO: defining the excisional line) • ENDOSCOPIC LYMPHOSCINTIGRAPHY • TRANSRECTAL US (T-n) • TC SCAN (Spiral TC Scan and Virtual Endoscopy (T-n) • MRI (T-n) • BONESCAN

  8. ENDOSCOPY: 10-15 mm normal mucosa • biopsies & tatoo Macrobiopsies for grading • Defined excinal line on • hystol. ass normal mucosa • Eval. post RxTerapy response • Follow up

  9. ENDOSCOPIC LYNPHOSCINTIGRAFY 1.0 ml colloidal rhenium sulfide marked with 99mTC

  10. TRANSRECTAL US (N 1 )

  11. LOCAL EXCISION FOR RECTAL CANCER SURGICAL APPROACH • TRANSANAL APPROACH: • PAPILLON: Parachute Technique • PARKS • MAEDA 2004: Minimally Invasive Transanal Surgery - MITAS) • INTERSPHINTERIC EXCISION (MASON) • TRANS-SACRAL APPROACH (KRASKE) • TRANSANAL ENDOSCOPIC MICROSURGERY TEM (BUESS 1984) • (ENDOSCOPIC MUCOSAL RESECTION AND SUBMUCOSAL DISSECTION FOR ADENOMA) ENDOSCOPIC APPROACH

  12. LOCAL EXCISION FOR RECTAL CANCER TRANSANAL APPROACH (PAPILLON: Parachute Technique)

  13. LOCAL EXCISION FOR RECTAL CANCER • TRANSANAL APPROACH (PARKS)

  14. LOCAL EXCISION FOR RECTAL CANCER Minimally Invasive Transanal Surgery - MITAS MAEDA et al. 2004

  15. LOCAL EXCISION FOR RECTAL CANCER INTERSPHINTERIC EXCISION (MASON)

  16. LOCAL EXCISION FOR RECTAL CANCER • TRANS-SACRAL APPROACH (KRASKE)

  17. LOCAL EXCISION FOR RECTAL ADENOMA & CANCER G. BUESS TRANSANAL ENDOSCOPIC MICROSURGERY (TEM) - G. BUESS 1984 (ADENOMA) - E.LEZOCHE 1996 (CANCER)

  18. SHAPE OF THE SPECIMEN IS LIKE A TRUNCATED PYRAMID • FULL THIKNESS + “local perirectal fat “ EXCISION”

  19. WE START TO THINK THAT RECTAL CANCER COULD BE TREATED WITH LOCAL EXCISION NEARLY 25 YEARS AGO! Int J Colorect Dis (1986) 1:208-211 Surg Endosc (1987) 1:113-117

  20. LOCAL EXCISION FOR RECTAL CANCER NEED FOR ADJUVANT THERAPY • RADIOTHERAPY (Full Dose: 5,040 cGy - 4 weeks) • CHEMOTHERAPY (5 fu cont. infusion 200mg/m2/day for 2 weeks) • (IMMUNOTHERAPY)

  21. LOCAL EXCISION FOR RECTAL CANCER OUR EXPERIENCE 1987-1992: XRT (FULL DOSE) (26 Pts) PRE POST T0 3 T1 5 T1 14 T2 12 DOWNSTAGING LOCAL EXCISION T2 7 T3 9 T3 2 LOCAL RECURRENCES 3 Pts (mean follow up 30 months)

  22. LOCAL EXCISION FOR RECTAL CANCER OUR EXPERIENCE 1992 - 2001: XRT+CHT (11 Pts) PRE POST T0 5 T1 4 T1 4 T2 4 DOWNSTAGING LOCAL EXCISION T2 2 T3 3 T3 0 LOCAL RECURRENCES 1 Pts (mean follow up 30 months)

  23. LOCAL EXCISION FOR RECTAL CANCER WE CAN CONCLUDE THAT IN OUR EXPERIENCE, NEOADJUVANT XRT+CHT GIVE A BETTER RESPONSE AS FAR AS LOCAL EXCISION FOR RECTAL CANCER IS CONCERNED. ACCORDING TO A.HABR-GAMA 30.5% OF Pts WITH DOWNSTAGING (T0) DO NOT NEED SURGERY. Angelita Habr-Gama Dis Colon Rectum 1998

  24. LOCAL EXCISION FOR RECTAL CANCER LOCAL EXCISION FOR RECTAL CANCERS IS ASSOCIATED WITH A LOW MORBIDITY AND PROVIDES SATISFACTORY LOCAL CONTROL AND DISEASE-FREE SURVIVAL RATES FOR T1 RECTAL CANCER. THERE WAS, HOWEVER, A NEED FOR A RANDOMIZED, CONTROLLED TRIAL FOR T2 CANCERS, COMPARING LOCAL EXCISION (FULL THICKNESS ABLATION WITH RDT-CHT) TO RADICAL RESECTION.

  25. TEM VS LAPAROSCOPIC RESECTION INCLUSION CRITERIA • Patients staged as T2N0 G1-2 : • tumour diameter lower than 3 cm • within 6 cm from the anal verge Lezoche & coll. Surg. Endoscopy 2005

  26. TEM VS LAPAROSCOPIC RESECTION AIM OF THE STUDY To compare the results of two minimally invasive procedure (TEM vsLaparoscopic Low Anterior Resection or Laparoscopic Abdominal Perineal Resection) in the treatment of low rectal cancer. INFACT IT IS WELL KNOWN THAT LAP COLORECTAL RESECTION IS LESS IMMUNOSUPPRESIVE THAN THE OPEN APPROACH

  27. TEM VS LAPAROSCOPIC RESECTION • Evidence of local or distance metastases • Other malignancies in history EXCLUSION CRITERIA • Exclusion criteria for radiotherapy: • severe diverticular disease or previusly radiotherapy • Exclusion criteria for chemotherapy: • patients older than 70 years and/or with compromised general • conditions Lezoche & coll. Surg. Endoscopy 2005

  28. TEM VS LAPAROSCOPIC RESECTION • 40 patients T2N0 G1-2 • with 3 year follow-up were randomized to: • 20 patients to TEM20 patients to Lap. Resect. • (arm A)(arm B) Prospective randomized trial

  29. TEMVSLAPAROSCOPIC RESECTION ANAGRAPHIC DATA TEM n=20 LR n=20 p n.s.* 13(65) Gender, male [n, (%)] 12 (60) 67 (62-68) Age (years) [median, (25th p-75th p)] 68 (64-70) n.s.# 48-78 Range (years) 34-74 Lezoche & coll. Surg. Endoscopy 2005 # Wilcoxon Test * Chi-Square Test

  30. TEM VSLAPAROSCOPIC RESECTION RADIOTHERAPY DOWNSTAGE TEM n=20 LR n=20 p n.s * 7 p T0 4 p T1 Radiotherapy downstage 7 p T0 6 p T1 4 n.s * Reduction > 50% 6 No significative effect 3 3 n.s.* Lezoche & coll. Surg. Endoscopy 2005 * Chi-Square Test

  31. TEM VSLAPAROSCOPIC RESECTION INTRAOPERATIVE COMPLICATIONS TEM n=20 LR n=20 p 0 0 2 2 Conversions: - to open - lap. LAR to lap. APR 0.05 Operative time (minutes) 110 (45-210) 0.001# 196 (150-300)* 172(130-210)** * Laparoscopic low anterior resection **Laparoscopic Miles procedure Blood loss(ml) 45 250(100-700) 0.001 # Transfusions (n. of patients) - 4 0.053 ^ # Wilcoxon Test^Fisher Exact Test

  32. TEM VSLAPAROSCOPIC RESECTION STOMA TEM n=20 LR n=20 p 0.016^ No Stoma 20 (100 %) 12 (60 %) 0 4 (20 %) temporary ileostomy definitive colostomy 0 4 (20 %) ^Fisher Exact Test

  33. TEM VSLAPAROSCOPIC RESECTION INTRAOPERATIVE COMPLICATIONS TEM n=20 LR n=20 p Analgesic (n. of pts) 0.001* 2 20 Hospital Stay (days) 4.5 (3-6) 0.001# 7.5 (6 –10) 17 (85%) 2 (10%) 1(temp. ileostomy) 17 ( 85 %) 2 (10 %) 1 (temp. ileostomy) No p.o. Complicat. Minor Major n.s ^ n.s ^ * Chi-Square Test # Wilcoxon Test ^Fisher Exact Test

  34. TEM VSLAPAROSCOPIC RESECTION FOLLOW-UP 48 months (36-76) TEM n=20 LR n=20 1 (dead) 1 (at 6 mo., APR 15 mo. disease free) Local recurrence 1 (dead) 1 (dead after hepatic resection) Distant metastases Disease free survival rate 80% 85% * Chi-Square Test # Wilcoxon Test ^Fisher Exact Test

  35. TEM VS LAPAROSCOPIC RESECTION CONCLUSIONS 1 • According to the study design in our experience TEM versus LR with preoperative chemoradiotherapy has achieved no significant difference in terms of: • probability of local recurrence or distant metastases (5%) • disease free survival rate (85% in arm A and 80% and B ) • post operative complications

  36. TEM VS LAPAROSCOPIC RESECTION CONCLUSIONS 2 • According to the study design in our experience TEM versus LR with preoperative chemoradiotherapy has achieved significative better results in terms of: • n. of temporary & definitive stoma (p 0.016) • convertion rate (p 0.05) • operative time (p 0.001) • blood loss (p 0.001) and necessity of trasfusions • use of analgesic (p 0.001) • hospital stay (p 0.001)

  37. TEM VS LAPAROSCOPIC RESECTION CONCLUSIONS 3 ADVANTAGES OF TEM • low operative trauma • more rapid return to • - normal respiratory functions • - quick ambulation • - normal activities • better cosmetic results

  38. LOCAL EXCISION FOR RECTAL CANCER CONCLUSION 4 THE LOCAL EXCISION OF THE RECTAL CANCER STILL REPRESENTS TODAY A VERY CONTROVERSIAL ISSUE, HOWEVER THE ROLE OF NEOADJUVANT THERAPY SEEMS TO BE BENEFICIAL. THEREFORE PRIOR TO PROCEEDING FOR EXCISION OF RECTAL CANCER A MULTIDISCIPLINARY APPROACH AMONG SURGEON, ONCOLOGIST, RADIOLOGIST AND PATHOLOGIST IS NEEDED IN ORDER TO SELECT THE Pts AND CONSIDER THE RISK OF LOCAL RECURRENCES.

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