Gastrointestinal Cancer R. Zenh¤usern. Rectal Cancer

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Text of Gastrointestinal Cancer R. Zenh¤usern. Rectal Cancer

  • Slide 1
  • Gastrointestinal Cancer R. Zenhusern
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  • Rectal Cancer
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  • Anatomic Location of CRC Cecum14 % Ascending colon10 % Transverse colon12 % Descending colon7 % Sigmoid colon25 % Rectosigmoid junct.9 % Rectum23 % 70%
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  • Epidemiology Increasing Incidence of CRC Incidence 30-40 / 100000 / year >70 y. of age 300 / 100000 / year third most common malignant disease second most common cause of cancer death
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  • Epidemiology 1998: 4000 new cases in Switzerland More than 350 women an 600 men die each year due to CRC 70% of CRC are resectable at diagnosis Mortality has decreased
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  • Decreasing mortality of CRC 5-year Survival 1960-701980-90 Colon cancer40-45% 60% Rectal cancer35-40% 58%
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  • WHO Classification of CRC Adenocarcinoma in situ / severe dysplasia Adenocarcinoma Mucinous (colloid) adenocarcinoma (>50% mucinous) Signet ring cell carcinoma (>50% signet ring cells) Squamous cell (epidermoid) carcinoma Adenosquamous carcinoma Small-cell (oat cell) carcinoma Medullary carcinoma Undifferentiated Carcinoma
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  • TNM Primary Lymph-node DistantDukes stage tumor metastasis metastasisstage Stage 0TisN0M0AA Stage IT1N0M0AA1 T2N0M0AB1 Stage IIT3N0M0BB2 T4N0M0BB2 Stage III Aany TN1M0CC1/C2 Bany TN2, N3M0CC1/C2 Stage IVany Tany NM1DD Astler-Coller modified Dukes stage Clinical Staging of CRC
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  • TisT 1 T 2 T 3 T 4 Extension to an adjacent organ Mucosa Muscularis mucosae Submucosa Muscularis propria SubserosaSerosa TNM Classification
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  • Stage and Prognosis Stage5-year Survival (%) 0,1 Tis,T1;No;Mo > 90 I T2;No;Mo 80-85 II T3-4;No;Mo 70-75 III T2;N1-3;Mo 70-75 III T3;N1-3;Mo 50-65 III T4;N1-2;Mo 25-45 IV M1 100 pat.) have compared preoperative RT with immediate surgery Total dose of RT: 20 40 Gy None of the studies demonstrated a survival advantage Arnott SJ et al. Int J Radiat Oncol Biol Phys 1998;41:579-583
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  • Preoperative CT for Esophageal cancer A randomized US study (N=440) showed no benefit: 3 cycles cisplatin / fluorouracil 2y survival 35% vs 37% Kelsen et al. N Engl J Med 1998;339:1979-1984 A randomized British study (N=802) suggested an increase in survival 2 y survival 43% vs 34% MRC Oesophageal Cancer Working Group. Lancet 2002;359:1727-1733
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  • Preoperative CT and RT for Esophageal cancer Eight randomized trials ( seven negativ, one showed a benefit) StudyNCTRTMS3yS (mo)(%) Le Prise 199441/45C/F20 Gy10/109/17 Apinop 199434/35C/F40 Gy7/1020/26 Walsh 199655/58C/F40 Gy11/166/32 Bosset 1997139/143 C37 Gy19/1937/39 Urba 200150/50CVF40 Gy18/1716/30 Burmeister 2002128/128 C/F35 Gy22/19
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  • Nonsurgical CT and RT Cisplatin / Fluorouracil and RT (50 Gy) Long-term survival in approximately 25 % Increasing the radiation dose was unsuccessful Minsky BD et al. J Clin Oncol 2002;20:1167-1174
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  • Gastric Cancer
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  • 9.9% of all new cancer diagnosis 12% of all cancer deaths Overall 5 y. survival 15%-35% Declining incidence in the West
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  • Surgery for Gastric Cancer Stage I:5y survival 58%-78% Stage II:5y survival 34% Local or regional recurrence after gastric resection with curative intent: 40-65% Adjuvant chemoradiotherapy ?
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  • CRT after surgery vs. surgery alone Randomized trial n=556, T1-4, No-2 Resected adenocarcinoma of the stomach or gastroesophageal junction 1 cycle leucovorin 20mg/m 2, Fluorouracil 425 mg/m 2 day 1-5 RT 45 Gy (1.8Gy per day), beginning on day 28 Lv 20mg/m 2, FU 400 mg/m 2 d. 1-4 and last 3 d. of RT 2 cycles leucovorin 20mg/m 2, Fluorouracil 425 mg/m 2 day 1-5 MacDonald et al. N Engl J Med 2001;345:725-730
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  • CRT after surgery vs. surgery alone Results:CRTSurgery 3y survival50%41% p=0.005 Med. OS36 mo27 mo 3y RFS48%31% Local reccurence19%29% MacDonald et al. N Engl J Med 2001;345:725-730
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  • Perioperative chemotherapy vs. surgery alone Randomized trial: n=503 Chemotherapy: 3 preoperative and 3 postoperative cycles Epirubicin 50mg/m 2, cisplatin 60mg/m 2, day1 Fluorouracil cont i.v. 200mg/m 2, day 1-21 Cunningham et al. N Engl J Med 2006;355:11-20
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  • Perioperative chemotherapy vs. surgery alone Results: CTSurgery 5y OS 36.3% 23% Local recurrence 14.45% 20.6% Cunningham et al. N Engl J Med 2006;355:11-20