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T Staging: Rectal cancer

T1 invades submucosa. T2 invades muscularis propria. T3 invades subserosa or perirectal tissues. T4 invades peritoneum, organs or structures (15% of cases). T Staging: Rectal cancer. Rectal Cancer: TME. Circumferential resection margins determine outcome. Poor Judgement

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T Staging: Rectal cancer

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  1. T1 invades submucosa T2 invades muscularis propria T3 invades subserosa or perirectal tissues T4 invades peritoneum, organs or structures (15% of cases) T Staging: Rectal cancer

  2. Rectal Cancer: TME Circumferential resection margins determine outcome

  3. Poor Judgement Inadequate skills Lack of knowledge Lack of insight/arrogance Inadequate resources Common condition Uncommon variant Higher order of treatment T4 Treatment failure

  4. T4: Female

  5. T4 Male anterior tumours

  6. T4 Rectovesical peritoneum

  7. T4 Seminal vesicles T4 Male Invading adjacent organs

  8. T4 Seminal vesicles T4 Male Invading adjacent organs

  9. Anterior T4 prostatic involvement APR + Radical prostatectomy

  10. APR + Radical Prostate

  11. T4 Bladder involvement

  12. T4: Male anterior tumours

  13. T4: Posterior Rectal cancer

  14. T4 Strategy: Staging • EUA, cystoscopy • MR pelvis • CT abdo, thorax • ? PET scan

  15. Adjuvant Rx for fixed tumours • Pre-operative RTH has a major role • Only a minority will be cured with RTH alone • Pre-operative CRTH has increased risks • Phase II studies oxaliplatin, irinotecan capecitabine and Mabs • What do we do with complete regression?

  16. Current CRT schedule Radiotherapy with 3 or 4 field plan 45 Gy in 25 # over 5 weeks Capecitabine 825mg/m2 bd for 5 weeks

  17. CRT for fixed rectal tumours 45 - 65%have potentially curable resections after CRT When is the right time to operate? 10-12 weeks post DXT

  18. T4 Strategy: Pre-emptive surgery • Stomas • Stenting • Nephrostomies

  19. TPC: Surgical candidates • Nutrition • Renal function • Liver function ? Disease confined to pelvis Re assess clinically and radiologically after CRT

  20. Total Pelvic Clearance Christie NHS FT 2001 -2005 MDT Assessment pre and post CRT Consecutive patients 100 Total Pelvic Clearance 45 Unsuitable for surgery 55

  21. Christie: Total Pelvic Clearance Number Age

  22. T4 Strategy: Definitive surgery • Engage the team • Stent the ureters • En bloc resection • ? IP Chemotherapy (peritoneal reflection)

  23. Outcome of radical surgery • Primary v recurrent • Munro v mountain • 30 - 80% 5y survival Lenhert et al 2002, Sanfilippo et al 2001, Law et al 2000 Advanced disease

  24. Total Pelvic Clearance n mortality morbidity % % Kakuda et al 2003 22 5% 68% Jimenez et al 2003 55 5.5% 40+% Nakafusa et al 2004 53 0% 49% Sharma et al 2005 48 4.2% 75% Sagar et al 2005 18 1.6% na Christie 2008 51 0% 11% op 38% non op

  25. Christie: Total Pelvic Clearance Complications Operative Stoma Revision 3 Perineal wound 2 Bleeding 1 SBO 1 Non operative Infections 12 Ileus 10 PE/DVT 1/1 Bleeding 1 MI 1 CVA 1

  26. Advanced/Recurrent Pelvic tumours Cancer-specific survival CRM +ve 9% 100 80 Colorectal (57%) 60 % 40 (31%) Others 20 0 0 12 24 36 48 Time (months)

  27. Perineal reconstruction Gracilis

  28. Perineal reconstruction TRAM Flap

  29. Tissue interposition Omentum

  30. T4 adjuvant IORT Fixed / inoperable tumours RTH + resection N = 248 Local recurrence free survival 11% RTH + resection + IORT N = 78 Local recurrence free survival 2.6% Sadahiro et al Dis Colon Rectum 2001

  31. T4 Tumours: HIPEC Intraperitoneal mitomycin C 3 bolus over 90min @ 41- 43°C

  32. T4 : Palliative therapies • CRT • Pain relief • Tumour ablation • Tumour resection • Drainage of sepsis • Stenting and stomas

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