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TME SPHINCTER - SAVING SURGERY AFTER CHRT

Rectal Cancer. TME SPHINCTER - SAVING SURGERY AFTER CHRT. ENDPOINT: SURVIVAL ● Lower edge of resection: less than 1 cm ● Full-thickness local excision in complete or near complete responders? N+ risk? Relapsing rate?. Rectal Cancer.

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TME SPHINCTER - SAVING SURGERY AFTER CHRT

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  1. Rectal Cancer TME SPHINCTER - SAVING SURGERY AFTER CHRT ENDPOINT: SURVIVAL ● Lower edge of resection: less than 1 cm ● Full-thickness local excision in complete or near complete responders? N+ risk? Relapsing rate?

  2. Rectal Cancer PREDICTION OF MESORECTAL N+AFTER PREOP. (CH)RT RT CHRT pT (147) (138) 0 0/1 1/21 1 0/3 1/12 6% 2 15/53 13*/50 3-4 54/85 28/51 *few cancer foci in 5 pts. Bujko, Radioth. Oncol. 2005

  3. Rectal Cancer CLINICAL COMPLETE RESPONSE TO NEOADJUV. CHRT (488 pts. clinically staged T 3-4 or N+ before CHRT)  cCR is a poor predictor of pCR  Incidence of occult node-positive disease is relatively high  Small but deep tumor cells are characteristic of cCR patients: viable tumor?  A longer waiting period after completion of neoadjuvant therapy can alter the pCR rate HIGHER RISK FOR LOCAL SURGERY? MSKCC, J. Am. Coll. Surg. 2002

  4. Rectal Cancer LOCAL EXCISION AFTER CHRT Median % No. All the patients 1,175 Local Excision* (8-35) 12.7 (3.5-100) 135 * Median age 60.5 yrs. (48-63) * Median FU 38 mos. (19-48) Kim 2001, Shell 2002, Lezoche 2002, Ruo 2002, Crane 2003, Bonnen 2004, Osti 2004, Caricato 2006

  5. Rectal Cancer LOCAL EXCISION AFTER CHRT (cT3) LOCAL RELAPSES IN 546 PTS No. % 27/490 5.5 Radical surgery (TME) M.D.Anderson Hosp, IJROBP 2008 SELECTION CRITERIA? Local excision 8/56 14.3

  6. THE REGINA ELENA NATIONAL CANCER INSTITUTE Rome, Italy

  7. Rectal Cancer PERSONAL EXPERIENCE No. % All the pts. undergone CHRT and Surg. 220 (cT3-4 before CHRT) 63 Median age (yrs) Median F.U. (mos.) 42 (24-280) TME Sphincter-saving surgery 172 89.1 TME Abdominoperineal excision 24 10.9 Local excision 24 10.9 Median age (yrs.) 68 Median FU (mos.) 40 (24-280)

  8. Rectal Cancer 5-Yr Survival after CHRT and Surgery 82.2 % 70.0 % % 12 24 36 48 60 months

  9. Rectal Cancer TME SURGERY AFTER CHRT No. % Pts. 196 pT0-1 42 21.4 N+ 2/42 4.7

  10. Rectal Cancer TME SURGERY AFTER CHRT (196 pts.) Relapses 39 19.8 Local 12 6.1 Distant 27 13.7 Second primary 5 2.5 Median Range TTP (mos.) 15 (2-77) Follow-up (mos.) 40

  11. Rectal Cancer SURGERY AFTER HIGH-DOSE PELVIC XRT AND CONCURRENT I.V. CH. 5-Yr. DFS by lower edge of resection (min. f.u. 2 yrs.) 63.8 % 61.7 % % p = n.s. 12 24 36 48 60 months

  12. TUMOR REGRESSION GRADE(Mandard 1994) TRG4 TRG2 • TRG1: absence of residual tumor cells • TRG2: rare residual cancer cells scattered through fibrosis • TRG3: increased number of residual cancer cells but fibrosis still predominant • TRG4: residual cancer cells outgrowing fibrosis • TRG5: absence of regressive changes

  13. Rectal Cancer A PROGNOSTIC ROLE FOR TRG ? (111 pts. with minimum f.u. of 36 mos.) TRG Resp. No Resp. 1-2 70.8 29.2 3-5 36.7 63.3 p=.01

  14. Uni- and multivariate analysis of Overall and Disease-Free Survival TRG 1

  15. Rectal Cancer 5-Yr DFS by TRG (143 pts.) 72.2 % 58.2 % % p=.04 12 24 36 48 60 months

  16. Liver Cancer LOCAL EXCISION AFTER CHRT TRG Classification 1 1 3 No. of Pts. 24 10 5

  17. Rectal Cancer LOCAL EXCISION AFTER CHR (24 Pts)No. % Relapses 6 25 Local 5* Distant 1 *1 mesorectal, 4 local radical surgery NED 1 mucin lakes MedianRange TTP (mos) 8 (2-28)

  18. Rectal Cancer 5-Yr Surv. after CHRT and TME Surgery 5-Yr Survival after CHRT and LE 95.0 % 72.0 % 80.6 % 69.7 % 12 24 36 48 60

  19. Rectal Cancer SPHINCTER-SAVING SURGERY AFTER CHRT CONCLUSIONS Lower edge of resection < 1 cm is not correlated with higher risk of local relapse  Local excision could be adequate for well selected complete responders

  20. Colorectal Cancer THE COLORECTAL DISEASE MANAGEMENT TEAM Coordinator: M. Cosimelli Surgery Med. Onc. Biology Radiotherapy Surgery Med. Onc. Biology Radiotherapy F. Ambesi Impiombato R. Mancini F.Graziano M. Mottolese C. Garufi F.Graziano C.Garufi F.Guadagni G. Piaggio M. Fanciulli G. Paoletti F.Carboni G.Paoletti M.Mottolese Impiombato M. Zeuli R.Mancini M.Zeuli Pathology M. G. Diodoro G.Piperno Radiology Radiology Psycho-oncology Biostatist. Unit Endoscopy M.Caterino M. Caterino P. Pugliese D. Giannarelli V. Stigliano D. Assisi S.Giunta S. Giunta I. Sperduti

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