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Surgical Staging and Treatment of Colorectal Cancer

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Surgical Staging and Treatment of Colorectal Cancer Powered By Docstoc
					   Surgical Staging and Treatment
        of Colorectal Cancer
      Brian J Mehigan MD FRCSI
     Consultant Colorectal Surgeon
          St. James’s Hospital

           Irish Cancer Society
       Inaugural Colorectal Cancer:
A Conference for Health Care Professionals
       Thursday 7th December 2006
    Overview - Surgical Staging and
      Treatment of Colorectal Cancer
• Cancer Outcomes

• Rationale for Staging in Colon & Rectum
  – Tailored Therapy


• Role of Laparoscopic Colo-rectal Resection
Cancer Outcomes
/Surgery Alone!
       Association of Coloproctogy of GB & Ireland
                     Colorectal Audit

• >8000 patients
• Prospective Audit
  –   Age
  –   ASA
  –   Urgency
  –   Dukes Stage
  –   Cancer Resected


                              Tekkis P et al. BMJ 2003;327:1196-201
      Association of Coloproctogy of GB & Ireland
                    Colorectal Audit
• How we doing?

• Currently Unknown

• Irish colorectal audit
  in gestation
  – ASGBI
  – RCSI

                             Tekkis P et al. BMJ 2003;327:1196-201
Rational for Staging
Historical Treatments
Historical Treatments
Current Treatments
Current Treatments
Current Treatments
Current Treatments
Current Treatments
Current Treatments
Current Treatments
Staging – I
        • 79 Male

        • Bulky R colon Tumour

        • Small bowel obstruction

        • ?invading Duodenum
Staging – I
        • Open (not laparoscopic

        • En-bloc resection of
          cuff of Duodenum

        • Local staging of
          Tumour (T stage)
Staging – II
        • 84 male.
        • Ascending colon CA

        • Obese and ASA III
          – COPD, CCF, NIDDM


        • CT – tumour barely see
Staging – II
         • 84 male.
         • Ascending colon CA

         • Obese and ASA III
            – COPD, CCF, NIDDM

         • Lap R Hemi.

         • Staging the tumour and the
           patient.
                Staging – III
• 48 Female
• Large Bowel Obstruction/descending colon tumour
• Large volume liver mets.
            Staging – III contd
• Endoscopic Stent placement.
           Staging – III contd
• Endoscopic Stent placement.
• Commence Folfox chemotherapy 1 week later
           Staging – III contd
• Endoscopic Stent placement.
• Commence Folfox chemotherapy 1 week later
• Repeat scan at 3 months.
             Staging – III contd
• Endoscopic Stent placement.
• Commence Folfox chemotherapy 1 week later
• Repeat scan at 3 months.
                    Staging for distant mets - liver
                Staging – IV
• 77 male
• Recto-sigmoid CA. MRI T3
• Suggestion of liver met on CT confirmed on MRI
                Staging – IV
• Recto-sigmoid CA. MRI T3 & Liver met
• Synchronous Anterior resection and Liver resection
• Result - R0 resection. Adjuvant chemotherapy
                 Staging – V
• 79 male. Recto-sigmoid Cancer
  invading bladder.

• Referred for consideration for
  pelvic exenteration

• PET scan
                 Staging – V
• 79 male. Recto-sigmoid Cancer
  invading bladder.

• Referred for consideration for
  pelvic exenteration

• PET scan
• Outcome – Stent & Palliative care
            Staging – Rectal Cancer
• 1990s                 Total Mesorectal Excision TME
          – Bill Heald et al.
          Staging – Rectal Cancer
• 2000s            Circumfernential Resection Margin
    Phil Quirke et al.
          Staging – Rectal Cancer
• 2000s            Circumfernential Resection Margin
    Phil Quirke et al.
          Staging – Rectal Cancer
• 2000s            Circumfernential Resection Margin
    Phil Quirke et al.
               Circumferential Resection Margin
% loca l recurrence




                      20


                      10


                            10mm       20mm
                           Circumferential margin
                           Wibe et al, BJS 2002
Staging – Rectal Cancer             Mucosa/
                                    Submucosa

                                     Musc. Propria

                                    Mesorectum


                                    Pelvic Side Wall


                                  Puborectalis

                            Int. Sphincter

                        Ext sphincter

                   Dentate Line
Staging – Rectal Cancer           Mucosa/
                                  Submucosa

                                   Musc. Propria
    T1   T2                       Mesorectum


     T4 T3                        Pelvic Side Wall


                                Puborectalis

                          Int. Sphincter

                      Ext sphincter

                 Dentate Line
  Staging Rectal Cancer - Objectives
• No need to slavish try and replicate pathological
  staging.

• Guide important management decisions

• Two main techniques
  – MRI & ERUS        Complementry
    Important Staging Decisions – I
• T1 vs T2

• Important if
  considering local
  resection for T1

• Staging of choice
  – ERUS
     Important Staging Decisions – II
CRM threatened?
T2 weighted MRI




MERCURY Study Group,   “Specificity for prediction of a clear
BMJ 2006;333:779         margin by magnetic resonance
                         imaging was 92% (327/354, 90%
                         to 95%)”
             Rectal Staging – I
• 82 female. Obstructing mid rectal cancer
• MRI stage T2 ? T3. Circumferential margin clear
             Rectal Staging – I
• 82 female. Obstructing mid rectal cancer
• Restorative anterior resection without radiotherapy
             Rectal Staging – II
• 60 female. Palpable low-rectal cancer
• T3 with close CRM on MRI
            Rectal Staging – II
• 60 female. Palpable low-rectal cancer
• Pre-op chemo-radiotherapy & Low anterior resection
            Rectal Staging – III
• 79 male. Fixed & Palpable low-rectal cancer
• CRM positive on MRI
            Rectal Staging – III
• 79 male. Fixed & Palpable low-rectal cancer
• Pre-op chemo-radiotherapy & restage ?for surgery
              Staging summary
• Colon cancer staging
  – CT Abdo/Pelvis/Thorax at least
  – MRI and PET for indeterminate lesions
  – PET prior to heroic resections

• Rectal cancer staging
  – Much more controversy
  – Determine Circumferential Resection Margin – MRI
  – Considering local resection if T1 – Endo rectal USS
Role of Laparoscopic Colo-rectal
           Resection
Laparoscopic Colorectal
                             Laparoscopic Surgery
                 100
% Laparoscopic




                                                 *78.9%
                                                                         Cholecystectomy
                 50
                                                                         Colorectal Cancer
                                                                         Resection
                                 *27.2%

                  0
                       88 89 90 91 92 93 94 95 96 97 98 99 0   1   2 3


*Nair RG et al. British Journal of Surgery 1997;84:1369-98
    Laparoscopic Colorectal – Difficult!
•   Operating in all 4 quadrants
•   Difficult Orientation
•   Unfamiliar view of Anatomy
•   Bulky specimen
•   Prolonged procedures

• Oncological safety
                        Monson et al, Prospective evaluation of laparoscopic-
                        assisted colectomy in an unselected group of patients
                        Lancet. 1992;340:831-33
                 100
% Laparoscopic




                                                 *78.9%
                                                                         Cholecystectomy
                 50
                                                                         Colorectal Cancer
                                                                         Resection
                                 *27.2%

                  0
                       88 89 90 91 92 93 94 95 96 97 98 99 0   1   2 3
                            Alexander RJ et al Laparoscopically assisted
                               colectomy and wound recurrence. Lancet
                 100
                               1993;249-50.
% Laparoscopic




                                                 *78.9%
                                                                         Cholecystectomy
                 50
                                                                         Colorectal Cancer
                                                                         Resection
                                 *27.2%

                  0
                       88 89 90 91 92 93 94 95 96 97 98 99 0   1   2 3
  Port site mets – Experimental data
                             40
                             35

                             30
        Port site tumour %




                             25

                             20                                                   Open
                                                                                  Lap
                             15

                             10
                              5
                              0
                                  1st Trial   2nd Trial   3rd Trial   4th Trial

Lee SW, Whelan RL et al. Surgical Endoscopy 2000;14:805-11
                       Reilly WT, et al. Wound recurrence following
                          conventional treatment of colorectal cancer. A rare
                          but perhaps underestimated problem. Dis Colon
                          Rectum 1996;39:200-207.
                 100
% Laparoscopic




                                                *78.9%
                                                                   Cholecystectomy
                 50
                                                                   Colorectal Cancer
                                                                   Resection
                                 *27.2%

                  0
                       88 89 90 91 92 93 94 95 96 97 98 99 0 1   2 3
                            1995-1998 3 Randomised Controlled trials.
                               Lacy, Stage & Milsom
                 100
% Laparoscopic




                                                *78.9%
                                                                   Cholecystectomy
                 50
                                                                   Colorectal Cancer
                                                                   Resection
                                 *27.2%

                  0
                       88 89 90 91 92 93 94 95 96 97 98 99 0 1   2 3
  Laparoscopic Colorectal Cancer:
The Randomized Trials - Early Results
 1) Lacy AM et al. Short-term outcome analysis of a randomized
    study comparing laparoscopic vs open colectomy for colon
    cancer. Surg Endosc 1995;9:1101-5
 2) Stage JG et al. Prospective randomized study of laparoscopic
    versus open colonic resection for adenocarcinoma. Br J Surg
    1997;84:391-396.
 3) Milsom JW et al. A prospective, randomized trial comparing
    laparoscopic versus conventional techniques in colorectal
    cancer surgery: a preliminary report. J Am Coll Surg 1998;
    187:46-57.
  Laparoscopic Colorectal Cancer:
The Randomized Trials - Early Results
• Improvement in short term variables
  – Pain
  – Ileus
  – Hospital stay
  – Return to normal activities
                                  Mehigan, Monson et al. Patterns of recurrence
                                  and survival after laparoscopic and conventional
                                  resections for colorectal carcinoma.
                                  Ann Surg. 2000 Aug;232(2):181-6.
                 100
% Laparoscopic




                                                *78.9%
                                                                   Cholecystectomy
                 50
                                                                   Colorectal Cancer
                                                                   Resection
                                 *27.2%

                  0
                       88 89 90 91 92 93 94 95 96 97 98 99 0 1   2 3
             Crude Survival - Kaplan-Meier
            1
                                            p=0.6264. Log Rank Test

           .8
Probability
    of      .6
 Survival
           .4
                                                                      Open

           .2                                                         Laparoscopic


            0
                 10        20       30        40          50          60   MONTHS
   Number 58          47            40               11         2
    at risk
            53        43             28              9       2
                           Annals of Surgery 2000;232:181-186
                       Crude Survival - Node pos
              1
                                         p=0.3870. Log Rank Test
                                                                             Open
           .8
                                                                             Laparoscopic
Probability
    of      .6
 Survival

           .4


           .2

              0
                         10        20        30          40        50       60 MONTHS
   Number         27          17             15                4        0
    at risk                                  12
                  28          18                           2          1
                                   Annals of Surgery 2000;232:181-186
                                       Lacy AM et al. Lap assisted versus open
                                          colectomy for non-metastatic cancer a
                                          randomised controlled trial. Lancet
                 100                      2002;359:2224-9
% Laparoscopic




                                                *78.9%
                                                                   Cholecystectomy
                 50
                                                                   Colorectal Cancer
                                                                   Resection
                                 *27.2%

                  0
                       88 89 90 91 92 93 94 95 96 97 98 99 0 1   2 3
        The Lacy Trial – Lancet 2002
•   LAC vs Open for tx of non metastatic colon ca
•   RCT 219 pts – 111 to LAC & 108 to Open. 1993-1998
•   Single team of experienced laparoscopic surgeons
•   LAC was independently associated with reduced risk of
    tumour relapse and increased cancer related survival rate.

• Sub group analysis identified that
  survival benefit due to Stage III
  cancers.
                               Leung KL et al. Laparoscopic resection of
                                  rectosigmoid cancer: prospective
                 100              randomised trial. Lancet 2004;363:1187-92
% Laparoscopic




                                                *78.9%
                                                                   Cholecystectomy
                 50
                                                                   Colorectal Cancer
                                                                   Resection
                                 *27.2%

                  0
                       88 89 90 91 92 93 94 95 96 97 98 99 0 1   2 3


*Nair RG et al. British Journal of Surgery 1997;84:1369-98
                                       A comparison of laparoscopically assisted and
                                          open colectomy for cacncer COST group.
                                          Nelson et al NEJM 2004;350:2050
                 100
% Laparoscopic




                                                *78.9%
                                                                   Cholecystectomy
                 50
                                                                   Colorectal Cancer
                                                                   Resection
                                 *27.2%

                  0
                       88 89 90 91 92 93 94 95 96 97 98 99 0 1   2 3


*Nair RG et al. British Journal of Surgery 1997;84:1369-98
  The NIH/COST trial – NEJM 2004
• n=872, multicentre randomised controlled trial.
• No significant difference between groups in time
  to recurrence or overall survival with any stage of
  Ca. Short term variables improved.
• 21% conversion rate
• 66 surgeons at 48 institutions
• Needed to have performed >20 previous
  procedures
• No data on how many procedures per surgeon
                                       MRC CLASSIC – Short term endpoints of
                                         conventional vs lap assisted surgery in
                                         patients with colorectal cancer. Guillou PJ
                                         et al Lancet 2005;365:1718-26
                 100
% Laparoscopic




                                                 *78.9%
                                                                     Cholecystectomy
                 50
                                                                     Colorectal Cancer
                                                                     Resection
                                 *27.2%

                  0
                       88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4 5


*Nair RG et al. British Journal of Surgery 1997;84:1369-98
            The CLASSIC trial 2005
• 526 Lap vs 268 Open patients colorectal cancer
• 27 Centres
    – Single centre submitted >50% patients
•   Equivalent pathologically & oncologically
•   29% conversion rate
•   Some improvements in short term variables
•   Converted patients did significantly worse.
    – Adverse effect on trial result as intention to treat analysis
• Worrying increase in margin positive in rectal CA
            The CLASSIC trial 2005
• 526 Lap vs 268 Open patients colorectal cancer
• 27 Centres
    – Single centre submitted >50% patients
•   Equivalent pathologically & oncologically
•   29% conversion rate
                                                                      ess
•   Some improvements in short term variables
                                            ve   n
•
                                          ti l
    Converted patients did significantly worse.
                                       c CA
                                     ein rectalria
    – Adverse effect on trial result as intention to treat analysis

                              E  ff T
• Worrying increase in margin positive
  The NIH/COST trial – NEJM 2004
• n=872, multicentre randomised controlled trial.
• No significant difference between groups in time
  to recurrence or overall survival with any stage of
  Ca. Short term variables improved.
• 66 surgeons at 48 institutions
                                                  ess
                                     ve
• Needed to have performed >20 previous n
  procedures                       ti l
                                e c ria
                              ff T
• No data on how many procedures per surgeon
                             E
        The Lacy Trial – Lancet 2002
•   LAC vs Open for tx of non metastatic colon ca
•   RCT 219 pts – 111 to LAC & 108 to Open. 1993-1998
•   Single team of experienced laparoscopic surgeons
•   LAC was independently associated with reduced risk of
    tumour relapse and increased cancer related survival rate.
                                                             ia l
                                                       T r
• Sub group analysis identified that
                                      ca cy
                                   ffi
  survival benefit due to Stage III
  cancers.
                                  E
  Laparoscopic Colorectal Resection
           Current Status
• Oncologically
   – No worse ?better

• Surgically
   – Technically difficult but improves with time
   – Hospital costs increased

• Patient perspective
   – Certain short term benefits to patients & community
 Laparoscopic Colorectal Resection
 Current Status – Cochrane review
  • “Under traditional perioperative treatment,
    laparoscopic colonic resections show
    clinically relevant advantages in selected
    patients. If the long-term oncological
    results of laparoscopic and conventional
    resection of colonic carcinoma show
    equivalent results, the laparoscopic
    approach should be preferred in patients
    suitable for this approach to colectomy”
Schwenk et al. Cochrane Database Syst Rev 2005
 Laparoscopic Colorectal Resection
  Current Status – Lancet Editorial


    • “……….Laparoscopic surgery for colorectal
      cancer may be the new gold standard.”




Curet et al. Laparoscopic-assisted resection of
colorectal carcinoma. Lancet 2005;365: 1666-1668
                     Conclusions
• Surgery mainstay of treatment
  – Must ensure excellence in outcomes

• Staging to allow tailored therapy

• Laparoscopic colorectal cancer surgery’s time has
  finally come.
  – Hasten slowly!
Thank You!

				
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