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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)
Rectal Cancer: TME
Circumferential resection margins determine outcome
T4 Treatment failure
Poor Judgement
Inadequate skills
Lack of knowledge
Lack of insight/arrogance
Inadequate resources
Common condition
Uncommon variant
Higher order of treatment
T4: Female
T4 Male anterior tumours
T4 Rectovesical peritoneum
T4 Seminal vesicles
T4 Male
Invading adjacent organs
T4 Seminal vesicles
T4 Male
Invading adjacent organs
Anterior T4 prostatic involvement
APR + Radical prostatectomy
APR + Radical Prostate
T4 Bladder involvement
T4: Male anterior tumours
T4: Posterior Rectal cancer
T4 Strategy: Staging
EUA, cystoscopy
MR pelvis
CT abdo, thorax
? PET scan
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?
Adjuvant Rx for fixed tumours
Current CRT schedule
Radiotherapy with 3 or 4 field plan
45 Gy in 25 # over 5 weeks
Capecitabine 825mg/m2 bd for 5 weeks
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
Stomas
Stenting
Nephrostomies
T4 Strategy: Pre-emptive surgery
TPC: Surgical candidates
Nutrition
Renal function
Liver function
? Disease confined to pelvis
Re assess clinically and radiologically after CRT
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
Christie: Total Pelvic Clearance
0
2
4
6
8
10
12
14
16
<40 40-50 50-60 60-70 >70
Age
Number
T4 Strategy: Definitive surgery
Engage the team
Stent the ureters
En bloc resection
? IP Chemotherapy (peritoneal reflection)
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
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
Christie: Total Pelvic Clearance
Operative
Stoma Revision 3Perineal wound 2Bleeding 1SBO 1
Complications
Non operative
Infections 12Ileus 10PE/DVT 1/1Bleeding 1MI 1CVA 1
Advanced/Recurrent Pelvic tumours
0
20
40
60
80
100
%
0 12 24 36 48Time (months)
Colorectal
Others
(57%)
(31%)
Cancer-specific survival
CRM +ve 9%
Perineal reconstruction
Gracilis
TRAM Flap
Perineal reconstruction
Tissue interposition Omentum
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
T4 Tumours: HIPEC
Intraperitoneal mitomycin C
3 bolus over 90min @ 41-
43°C
T4 : Palliative therapies
CRT
Pain relief
Tumour ablation
Tumour resection
Drainage of sepsis
Stenting and stomas