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Grand Rounds

Grand Rounds. Panel Discussion Moderator : Dr V Gandhi Panelists : Dr S Hegde Dr G Kanitkar Dr Sanjay MH

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Grand Rounds

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  1. Grand Rounds Panel Discussion Moderator : Dr V Gandhi Panelists : Dr S Hegde Dr G Kanitkar Dr Sanjay MH Dr Taheer C Dr Minish Jain

  2. Resection of CRLMs improves overall survival 1.0 0.8 0.6 0.4 0.2 0 89% 86% OS estimate 44% R0 resection (n=114) Any resection (n=145) No resection (n=1,769) 0 5 10 15 20 25 30 Time (months) OS >85% at 2 years in resected patients Okines, et al. Br J Cancer 2009

  3. Treatment Options: Three potential scenarios CRC 30% synchronous metastasesAdditional ~50% will develop metastases 30–35% ‘liver only’ metastases 75–90% not resectable 10–25% candidates for SURGERY Aim: R0 resection Borderline resectable Initially resectable Chu, et al. Clin Colorectal Can 2006; Kemeny, et al. NEJM 1999; Kemeny, et al. Oncologist 2007; Leichman. SurgOncolClin N Am 2007; Leonard, et al. JCO 2005; Tomlinson, et al. JCO 2007; Van Cutsem, et al. EJC 200;

  4. Consensus of the European working group on CRC liver metastases Liver metastases Resectable • Not optimally resectable • Oncological (>1 factor) • >4 metastases • size >5cm • synchronous CRC liver metastases • primary LN-positive • positive tumour marker • Technically difficult • close to all hepatic veins • close to both portal branches Unresectableand neverlikely to beresectable Neoadjuvant chemotherapy± biologics Liver resection if sufficientresponse Palliativechemotherapy±biologics Liver resection

  5. ERAS PROTOCOL Components

  6. Mechanical Bowel PreparationColon cancer • Routine use of mechanical bowel preparation prior to elective colon cancer resection should be avoided Rectal cancer resection – MBP should be given Tumors less than 2 cm , lap resections, intra op colonoscopy

  7. MRI better than CT for staging of rectal cancer Better prediction of circumferential resection margin Better selection of patients for NACTRT

  8. Good surgery • Colon – complete mesocolic excision • Rectum – Total mesorectal excision

  9. Why do you want to resect the liver ? • First filter • Good regeneration capacity • Morbidity and mortality of liver resection - low

  10. Case 1 50 male, Good performance status • Malena x 2 months • Some weight loss x 2 months • Occasional lower abdominal discomfort x 15 days • Colonoscopy + Bx : Adenocarcinoma in transverse colon

  11. CECT Abdomen & Pelvis Transverse colon mass Seg 6 liver metastasis

  12. Seg 8 liver metastasis MHV Seg 6 liver metastasis

  13. PET scan FDG avid colonic mass and segment 6,8 met

  14. MDT: Treatment Options Surgery Simultaneous resection ? Staged Resection ? Chemo / Biologicals ?

  15. What did we do? Right extended hemicolectomy HPR- pT3N1, R0 resection Resectable liver metastases Upfront Surgery!

  16. Resection of liver metastases Right Hepatectomy Uneventful postop period; planned for 4 # FOLFOX (MDT discussion) HPR- 2 deposits of metastatic adenocarcinoma; R0 resection Patient doing fine

  17. Case 2 62 male, diabetic, hypertensive • Occasional lower abdominal discomfort x 4 months • No other complaints

  18. Workup • Colonoscopy- Non-obstructing growth in sigmoid colon • Biopsy: adenocarcinoma • Serum CEA- 10.85 ng/ml

  19. FDG avid sigmoid colon mass 4 FDG avid lesions in right liver

  20. Treatment: FOLFOX 6 cycles (MDT discussion) Post-chemotherapy evaluation CEA-7.89 ng/ml

  21. Clinical significance: impact on surgery • Mortality rate not increased • Morbidity rate related to the number of cycles of CT Karoui, Nordlinger et al, Ann Surg 2006 No chemo ≤5 6-9 ≥10 • Aloia, Adam et al, 2006: Morbidityincreasedafter 12 cycles • Nakano, Jaeck et al, 2008: Morbidityincreasedafter 6 cycles

  22. Complete response

  23. What did we do? • Sigmoid Colectomy Postop uneventful HPR: pT2N2, R0 What to do about disappearing metastases? Always resect!

  24. Right Hepatectomy Uneventful recovery HPR: metastatic deposit (1.5 cm); R0 resection Planned for adjuvant Capecitabine (MDT discussion)

  25. Case 3 61 male, diabetic, hypertensive, CAD • Bleeding PR x 8 months • DRE- no growth • F/S/O SAIO

  26. Workup • Colonoscopy- Growth at 20 cm from anal verge; scope not negotiable beyond • Biopsy: adenocarcinoma • Serum CEA- 18.9 ng/ml

  27. Seg4 Seg 7 Sigmoid mass Seg6 CT scan abdomen+ pelvis

  28. What did we do? Sigmoid colectomy HPR- pT3N1, R0 resection 3 # CAP-OX + Bevacizumab Decide on targetted agent based on K-ras status

  29. Case Locally advanced rectum uT3N1 MRI Rectum EUS Rectum 37 year old male with bulky tumour 5 cm from anal verge

  30. Conventional optionAPR with permanent stoma Current options?

  31. Neoadjuvant chemo radiation as primary treatment EUS MRI-Post Rx

  32. NACTRT Subgroup analysis favoured long course CTRT

  33. Current Colorectal Cancer Reports April 2017, Volume 13, Issue 2, pp 165–174 Short-Course Radiation Therapy Versus Long-Course Chemo radiation in the Neoadjuvant Treatment of Locally Advanced Rectal Cancer: New Insights from Randomized Trials Recent Findings SCRT with early surgery results in lower pCR rates, lower severe acute toxicities, no difference in late toxicities, and no apparent difference in local control, DFS, and OS when compared with LCRT. When surgery is delayed after SCRT, cancer outcomes appear equivalent, including pCR rates. The addition of full-dose systemic therapy with SCRT prior to surgery is attractive to further downstage patients, particularly in patients at high risk of distant relapse. Summary Increasing randomized evidence is accumulating to support the use of SCRT as an acceptable preoperative treatment approach for LARC. Increasing the interval from SCRT to surgery and/or adding chemotherapy may mitigate potential concerns related to SCRT. More mature data and future results of ongoing randomized trials will help clarify the oncologic equivalence and safety of SCRT followed by preoperative chemotherapy.

  34. TIMING TO SURGERY J Am Coll Surg. 2016 Apr;222(4):367-74 Optimal Timing to Surgery after Neoadjuvant CTRT for LA Rectal Cancer. Sun Z1, Adam MA2, Kim J2, Shenoi M2, Migaly J2, Mantyh CR2. RESULTS: A total of 11,760 patients were included. Median time to surgery was 53 days (interquartile range [IQR] 43 to 63 days). After adjusting for patient demographic, clinical, tumor, and treatment characteristics, our model determined an inflection point at 56 days after end of radiotherapy associated with the highest likelihood of complete resection and pathologic down staging. With adjustment, the risk of margin positivity was increased in those who underwent surgery after 56 days from end of radiotherapy (odds ratio [OR] 1.40, 95% CI 1.21 to 1.61, p < 0.001). The likelihood of down staging was increasing up to 56 days after radiotherapy (≥56 days vs <56 days, OR 1.2, 95% CI 1.02 to 1.23, p = 0.01). CONCLUSIONS: This study objectively determined the optimal time for surgery after completion of nCRT for rectal cancer based on completeness of resection and tumor down staging. Eight weeks appears to be the critical threshold for optimal tumor response.

  35. Ultralow Anterior resection with sphincter preservation Post op chemotherapy

  36. Post op 3 yrs • Liver Mets large mets in the right lobe liver future liver remnant inadequate (left lobe) No extra hepatic disease

  37. FLR calculation- Myrian software

  38. PVE Pre-portal vein embolisation Post-portal vein embolisation

  39. FLR calculation (Post-PVE) RT Hepatectomy

  40. Scenarios • Locally advanced ca rectum with a large solitary liver met in right lobe ?

  41. Eur J SurgOncol. 2016 Feb;42(2):159-65 Colorectal cancer with synchronous hepatic metastases: Systematic review of reports comparing synchronous surgery with sequential bowel-first or liver-first approaches. Baltatzis M1, Chan AK1, Jegatheeswaran S1, Mason JM2, Siriwardena AK. CONCLUSION: This review assesses outcomes of patients with colorectal cancer with synchronous liver metastases managed by either synchronous, sequential liver-first or bowel-first surgery. Overall treatment-related mortality is low and survival is similar among the three groups. These findings provide support for the continued use of all three pathways until better evidence to guide selection of an individual treatment option is available.

  42. Locally advanced Ca rectum – NACTRT – complete response? Post CTRT Pre CTRT

  43. Options • Synchronous resection of primary and liver mets • Staged resection • Liver first approach • Two stage liver resections • Liver resection + ablative therapy • Neoadjuvant chemo followed by resection • Re resection • Loco regional therapies

  44. Take home message • MRI for staging of rectal cancer • Locally advanced Ca Rectum – NACTRT • Negative margin for resectable CRLM • Surgery is the mainstay for resectable lesions • Ablative therapies – complimentary

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