Early colorectal cancer State-of-the-art of surgery for ... · Early colorectal cancer State-of-the-art of surgery for resectable primary tumors (Special focus on rectal cancer surgery)

Early colorectal cancer

State-of-the-art of surgery for resectable

primary tumors

(Special focus on rectal cancer surgery)

Stefan Heinrich & Hauke Lang

Department of General, Visceral and Transplantation Surgery

University Hospital of Mainz, Germany

Department of General, Visceral and

Transplantation Surgery

ESMO Clinical Practice Guidelines



Staging and risk assessment for rectal cancer

▪ History & physical examination, CEA

▪ DRE, rigid rectoscopy – biopsy (localization)

▪ Colonoscopy (20% synchronous cancers)

▪ CT scan of thorax & abdomen (metastases)

▪ Endorectal ultrasound (local tumor extension)

▪ MRI (local tumor extension)

▪ MDT – multidisciplinary team discussion



Surgical strategy for primary rectal cancer

TEM

PME upper rectal cancerLocal excision

Open surgery

RECTAL CANCER Rectal resection

TME middle/low rectal cancer

TAMIS

Multivisceral resection

Laparoscopic surgery

Robotic surgery

ISR

taTMEAbdomino-perineal

resection

Neoadjuvant

RT/CRT



Risk adapted surgical strategy for locoregional rectal

cancer

PME / TME

▪ Open Surgery

▪ Laparoscopic Surgery

▪ Robotic Surgery

▪ -- Transanal Approach (taTME and ISR)

cT1 (G3, V1, L1) or cT2-3 N0 or cN1



Total Mesorectal Resection

6

http://www.google.de/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi4xrHl_fnWAhVEfhoKHQFBD6YQjRwIBw&url=http%3A%2F%2Fwww.mysurgery.de%2Felearning%2Frektumkarzinom%2F&psig=AOvVaw0Hwh46bwQZRRvIYniJSRhP&ust=1508409599427909



In the era of TME - quality of Surgery -

Most important pathologic outcomes 1-5

▪ Negative circumferential resection margin (CRM)

▪ Complete TME

▪ Associated with lower local and distal recurrence rates and

better long-term survival

1 Quirke et al. Lancet 2009; 373: 821828

2 Kusters et al. Eur J Surg Oncol 2010; 36: 470476

3 Nagtegaal et al. J Clin Oncol 2008; 26: 303312

4 Birbeck et al. Ann Surg 2002; 235: 449-457

5 Garcia-Granero Cancer. 2009; 115: 3400-3411 Hugen & al. Nature Reviews 2016; 13: 361-369



Circumferential Resection Margin (CRM)

▪ Cohort of 563 patients with locally advanced rectal cancer

▪ Treated with neoadjuvant CRT and surgery

CRM ≤ 1mm CRM >1mm

5-year local recurrence free survival 66% 98%

Trakarnsanga et al. Ann Surg Oncol 2013; 20: 1179-1184



Completeness of Mesorectal Excision

▪ Cohort of 1156 patients with locally advanced rectal cancer

▪ Treated with neoadjuvant RT or selective postoperative CRT

Complete Nearly

complete

Incomplete

3-year local recurrence free survival 4% 7% 13%

Quirke et al. Lancet 2009; 373: 821828



10

Laparoscopic versus open rectal resection

Vennix & al. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD005200

surgical outcome oncological quality



Laparoscopic vs. Open mesorectal excision Pathologic outcome

▪ Meta-analysis - 14 RCTs, 4034 patients

LLR ORR p-value Studies

Positive CRM (≤1 mm) in % 7.9 6.1 0.26 9

M.E.R.C.U.R.Y (≥ 2) in % 13.2 10.4 0.02 5

No significant difference - distal resection margin, lymphnodes retrieved

- distance to distal and radial margins

Martinez-Perez et al. JAMA Surg. 2017; 19:152:e165665.



Laparoscopic vs. Open mesorectal excision Oncologic outcome

COREAN 1 – non-inferiority RCT LLR

(n = 170)

ORR

(n = 170)

3-year disease free survival rate (%) 72.5 79.2

1 Jeong et al. Lancet Oncol 2014; 15: 767-774

2 Bonjer et al. New Engl J Med 2015; 372: 1324-1332

COLOR II 2 – non-inferiority RCT LLR

(n = 699)

ORR

(n = 345)

3-year disease free survival rate (%) 74.8 70.8

Overall survival rate (%) 86.7 83.6

Similar rates



Transanal vs laparoscopic TME

13

Laparoscopic

TME




14

Transanal

TME



Transanal mesorectal excision

Indications for taTME – transanal Total Mesorectal Excision

Motson et al. Colorectal Dis 2015

▪ Male Gender

▪ Rectal cancer less than 12 cm from anal verge, including very low cancers

▪ Narrow and/or deep pelvis

▪ Visceral obesity and/or BMI>30

▪ Prostatic hypertrophy

▪ Tumordiameter > 4cm

▪ Distorted tissue planes due to neoadjuvant RT

▪ Impalpable, low primary tumour requiring accurate placement of distal resection margin



Penna & al. Ann Surg 2017; 266: 111–117



17

Robotic vs. laparoscopic total mesorectal excision

Prete & al. Ann Surg 2017; epub



18

Robotic and transanal total mesorectal excision

Two-team approach

with courtesy of Prof. W. Kneist




Positive circumferential

resection margin

Macroscopic

quality of tme

Circumferential

resection margin

Ma et al. BMC Cancer (2016) 16:380



Rectal resection – postoperative function

20

Low anterior resection syndrome (LARS)

5 questions regarding bowel function – stool continence

Jeminez-Gomez & al. Colorectal Dis 2017; doi: 10.1111/codi.13901.



Specific considerations- Pelvic autonomic innervation -

Moszkowicz et al. Dis Colon Rectum 2012

Internal anal sphincter Genitalia

Bladder

Kneist & al. Langenbecks Arch Surg 2013

CAAD technique Intraoperative

electrophysiological test



Nerve sparing surgery

Kauff DW, Lang H, Kneist W. Risk factor analysis for newly developed urogenital

dysfunction after total mesorectal excision and impact of pelvic intraoperative

neuromonitoring-a prospective 2-year follow-up study. J Gastrointest Surg 2017



Risk adapted surgical strategy for locoregional

rectal cancer

TEM / TEO

Transanal endoscopic microsurgery

Transanal endoscopic operation

TAMIS

Transanal minimally invasive surgery

Kneist W. Chirurg 2017; 88: 656-663

cT1 N0 M0 (low risk: G1/G2, L0, V0) – Local excision

http://www.google.de/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj9-7X__fnWAhWDthoKHRaODbYQjRwIBw&url=http%3A%2F%2Fwww.turgutipek.com%2Frektum-kanseri&psig=AOvVaw3wsEHTIpI4ZmSaSpD9EYWF&ust=1508409635805275



Minimal Surgery - Local excision TEM

▪ Originally described by Buess et al. 1984 1

Compared to Transanal Excision (TAE) 2

▪ Less Fragmentation

▪ Higher rate of negative resection margins

▪ Lower recurrence rate

1 Buess et al. Chirurg 1984; 55: 677-680

2 Moore et al. Dis Colon Rectum 2008; 51: 1026-1030

http://www.google.de/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj9-7X__fnWAhWDthoKHRaODbYQjRwIBw&url=http%3A%2F%2Fwww.turgutipek.com%2Frektum-kanseri&psig=AOvVaw3wsEHTIpI4ZmSaSpD9EYWF&ust=1508409635805275



Minimal Surgery - Local excision TAMIS

▪ Originally described by Atallah et al. 2010

▪ Hybrid between TEM and single-site laparoscopy

▪ Designed on a readily available platform in most hospitals

Atallah et al. Surg Endosc 2010; 24: 2200-2205



Overview of the quality of the local excision procedures

TAE 1 TEM 1 TAMIS 2

Fragmentation rate (%) 37 0 4

Positive resection margins (%) 22 2 6

Recurrence rate (%) 24 8 2

1 Moore et al. Dis Colon Rectum 2008; 51: 1026-1030,

2 Albert et al. Dis Colon Rectum 2013; 56: 301307



TEM and TAMIS: is one technique superior?

Retrospective analysis 2012 – 2015, Omaha, Nebraska

TEM

(n = 40)

TAMIS

(n = 29)

p value

Complications (%)

(Urinary retention, bleeding, perforation)

13 10 0.55

Re-Operation 8 3 0.44

Positive resection margins (%) 3 10 0.19

Recurrence rate (%) 5 3 0.62

Melin et al. Am J Surg 2016; 212: 1063-1067



Minimal Surgery - Local excision

- Benefits of TAMIS -

Compared to TAE 1

▪ Applications to lesions further away from anal verge

▪ Better oncologic outcome

Compared to TEM 2,3

▪ Reduced cost for equipment

▪ Less post-procedural sphincteric complications

1 Saclarides Clin Colon Rectal Surg 2015; 28: 165175

2 Arezzo A et al. Surg Endosc 2014; 28: 427438,

3 Albert et al. Dis Colon Rectum 2013; 56: 301307



29

abdomino-perineal

resection (APR)Inter-spincteric

resection (ISR)



Intersphincteric Resection (ISR) versus

Abdominoperineal resection (APR)

T1-2 T3-4

Local recurrence rate

Tumor depth ISR APR p

T1 0 % 0 % n.s.

T2 4.9% 2.8% n.s.

T3-4 13.2% 3.8% 0.039

Low rectal cancer <5cm



▪ Risk of anastomotic leakage in patients with increased

cardiovascular risk based on medication history

Boström P et al. Colorectal Dis 2015;17:1018-1027

Swedish colorectal cancer registry

n.s.

Specific considerations- High tie vs. low tie -



Specific considerations- High tie vs. low tie -

▪ Impact on function

HIGHLOW - randomized multicenter Trial

Mari G et al. Trials 2015;16:21

212 patients sample size middle/low rectal cancer

Primary end point urogenital function

Secondary end point anastomotic leakage

… but no investigations on anorectal function



33

Summary

Standard of care: total mesorectal excision (TME)

- Minimal invasiveness

- Laparoscopic resection

- Robotic surgery

- TaTME/TEM sufficient for early cancer (T1 G1)

Anorectal/urogenital/sexual function

=

Quality of life

Documents

Early colorectal cancer State-of-the-art of surgery for ... · Early colorectal cancer State-of-the-art of surgery for resectable primary tumors (Special focus on rectal cancer surgery)