Karcinom rektuma- management Eminagić dr Đenana KCU Sarajevo Karcinom rektuma- management

Stage and Prognosis Stage 5-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 <3

RECTAL CANCER Progress in MULTIMODAL THERAPY of Rectal Cancer is one of the BEST examples of success of Clinical Research in the last 2 decades.

RECTAL CARCINOMA – RECENT ADVANCES -- OVERALL 1.SPHINCTER SAVING PROCEDURES – UP FROM 15% TO 50% -- NO COLOSTOMY (IMPROVED QOL) 2. OVERALL FIVE YR SURVIVAL – UP FROM 30% TO 60% 3. DEPTH OF INVASION – DECREASED BY 40-60% 4. LYMPH NODE STATUS

1. MOLECULAR BIOLOGY 2. SURGERY 3. IMAGING – MRI, CT AND PET RECENT ADVANCES 1. MOLECULAR BIOLOGY 2. SURGERY 3. IMAGING – MRI, CT AND PET 4. CHEMO/RADIOTHERAPY

STAGING ! DECIDES –TRANS ANAL LOCAL EXCISIONAPR . NEOADJUVANT CH/RT

SURGICAL CHALLANGES I STAGING II USE OF CH/RT III SURGICAL TECHNIQUE

RECENT ADVANCES DRE ERUS MRI

RECENT ADVANCES ERUS ERUS ------ BEST FOR NODAL STATUS

STAGING ERUS T STAGE ACCURACY 60 – 90% N STAGE ACCURACY 60 – 90% MRI ( NODES > 5mm)

MRI HIGH RESOLUTION THIN SLICE (<1mm) DEPTH OF EXTRAMURAL SPREAD ACCURATELY IDENTIFIED (AIDS CIRCUMFERENTIAL RESECTION MARGIN) TRADITIONAL - PROXIMAL - DISTAL RECENT ADV. – CIRCUMFERENTIAL RESEC. MARGINS IMP.

MRI DETECTS EXTRAMURAL VENOUS INVASION (EMVI) POOR PROGNOSIS WITHOUT CH/RT IF EMVI PRESENT

USE OF CH/RT (NEOADJUVANT/ADJUVANT) PTS WITH POOR HISTOLOGY PTS WITH EXTRA MURAL SPREAD (MRI) PTS WITH INVOLVED NODES (ERUS) PTS WITH EMVI (MRI)

SURGERY - TRADITIONAL ANT. RESECTION – UPPER ⅓ RECTAL CA LOW ANT.RESCETION - MID ⅓ RECTAL CA A.P.R. - LOWER ⅓ RECTAL CA ANY TUMOR 10cms FROM ANAL VERGE -- APR

RECTAL CANCER – RECENT ADVANCES CAREFUL ASSESSMENT  EARLY DIGNOSIS WITH ACCURATE STAGING CH/RT - FOR SELECTED PTS - PROCTOSCOPY - SIGMOIDOSCOPY - DRE - ERUS - MRI

ANATOMICAL DISTORTION LACK OF NEOADJUVENTS th. SURGERY MORE DIFFICULT OUR SCENARIO LATE PRESENTATION ADVANCED TUMORS ANATOMICAL DISTORTION LACK OF NEOADJUVENTS th. SURGERY MORE DIFFICULT RESULTS POORER

GOALS OF THERAPY FOR RECTAL CARCINOMA DECREASE LOCAL RECURRANCE OPTIMISE Q.O.L. AVOID COLOSTOMY

Incidence of local failure in RC T1-2,No,Mo <10% T3,No,Mo 15-35% T1,N1,Mo 15-35% T3-4,N1-2,Mo 45-65%

Local recurrence Alone or in combination with distant metastases Nodal metastases and deep bowel wall penetration are significant risk factors for locoregional failure. The use of TME significantly reduces this risk of local recurrence; however, local recurrence remains a concern in patients with stages II and III disease. Local recurrence in the pelvis is complicated by involvement of contiguous organs, soft and bony tissues, and deep nodal disease. Local recurrence in the absence of metastatic disease is more common in rectal cancer than in colon cancer.

Predicting risk of recurrence in RC Surgery-related -Low anterior resection -Excision of the mesorectum -Extend of lymphadenectomy -postoperative anastomotic leakage -Tumor perforation Tumor-related -Anatomic location -Histologic type -Tumor grade -Pathologic stage -radial resection margin -neural, venous, lymphatic invasion

Risk of local recurrence Characteristics of rectal tumors predicted by MRI High A threatened (<1 mm) or breached resection margin or Low tumors encroaching onto the inter‑ sphincter plane or  with levator involvement Moderate Any cT3b or greater, in which the potential surgical margin is not threatened or Any suspicious lymph node not threatening the surgical resection margin or The presence of extramural vascular invasion Low cT1 or cT2 or cT3a and No lymph node involvement

Purpose of Radio(chemo)therapy in Rectal Cancer to lower local failure rates and improve survival in resectable cancers to allow surgery in primarly inextirpable cancers to facilitate a sphincter-preserving procedure to cure patients without surgery: very small cancer or very high surgical risk

Management CaR KCUS Multidisciplinary approach DRE, endoscopy PHD biopsy MRI/CT /chest Xray ERUS ? PET CT ? cStage III –neoadjuv. Kt/Rt „long course” Postth. evalutation: MRI/CT Endoscopy

Onkologija KCUS 2 LinAc Siemens 2 Cobalt HDR bracytherapy