Basingstoke Colorectal How Imaging Has Improved Outcome In Rectal Cancer 4 th East- West Colorectal Days Hungary Brendan Moran Basingstoke OCTOBER 2008.

Basingstoke Colorectal

How Imaging Has Improved Outcome In Rectal Cancer

4th East- West Colorectal Days Hungary

How Imaging Has Improved Outcome In Rectal Cancer

4th East- West Colorectal Days Hungary

Brendan Moran Brendan Moran

BasingstokeBasingstoke

OCTOBER 2008OCTOBER 2008

Brendan Moran Brendan Moran

BasingstokeBasingstoke

OCTOBER 2008OCTOBER 2008



Image and ImagingImage and Imaging

“ A picture is worth a

thousand words”

Chinese Proverb

“ A picture is worth a

thousand words”

Chinese Proverb


What does this illustrate ?What does this illustrate ?

Attempt to describe a

“revolutionary” theory

Heald, Husband, Ryall BJS 1982

Attempt to describe a

“revolutionary” theory

Heald, Husband, Ryall BJS 1982


But ?But ?

Inaccurate Drawing Not applicable to

upper rectal cancer Only 5 patients Nevertheless most

quoted paper ever in rectal cancer

Heald et al BJS 1982

Inaccurate Drawing Not applicable to

upper rectal cancer Only 5 patients Nevertheless most

quoted paper ever in rectal cancer



“The mesorectum in rectal cancer surgery -the clue to pelvic recurrence”“The mesorectum in rectal cancer surgery -the clue to pelvic recurrence”



TME EvolutionTME Evolution

Heald RJ Journal Royal Soc Med 1988


Rectal Cancer 80’s and 90’sRectal Cancer 80’s and 90’s

Surgery- TMEPre-operative RT –Sweden

Pathology -Quirke

Surgery- TMEPre-operative RT –Sweden

Pathology -Quirke

The Circumferential Resection Margin Quirke et al 1986

The Circumferential Resection Margin Quirke et al 1986


TME and RadiotherapyTME and Radiotherapy

Both aim at the circumferential margin

Both reduce the CRM involvement

Both aim at the circumferential margin

Both reduce the CRM involvement

0%

10%

20%

30%

40%

50%

0 1 2 3 4 5

Years

Loca

l rec

urre

nce

%

Norway

Netherlands

Enker

Moriya

Heald

Havenga, Eur J Surg Oncol 1999Havenga, Eur J Surg Oncol 1999

The rationale for TME


Long Term Follow up Swedish Radiotherapy Study

Long Term Follow up Swedish Radiotherapy Study

The benefits are long lasting – at median follow-up 13 years [3–15]

Local recurrence rate 26% versus 9%

Folkesson et al JCO Aug 2005

The benefits are long lasting – at median follow-up 13 years [3–15]

Local recurrence rate 26% versus 9%

Folkesson et al JCO Aug 2005

Dutch TME TrialLocal Recurrence patients with macroscopically complete local resection (n=1789)

Dutch TME TrialLocal Recurrence patients with macroscopically complete local resection (n=1789)

5.8% vs 11.4% 5.8% vs 11.4% p < 0.001p < 0.001

TME alone

RT + TME

Van de Velde et al. Update at 5 yrs follow Van de Velde et al. Update at 5 yrs follow upup


Should we irradiate this patient ?

Should we irradiate this patient ?

Lange M M, et al, Br J Surg Vol. 94, 10 Pages: 1278-1284Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd

Figure 1. Percentage of patients with faecal incontinence after rectal cancer surgery with or without preoperative radiotherapy. Dashed portion of curves is based on only one questionnaire for each patient, obtained between 3·3 and 7·4 years after LAR

Br J Surg 2008; 95: 206-213Time after randomization (years)

Cum

ula

tive

pro

port

ion

with

out

late

bo

wel

obs

truc

tion,

tre

ated

sur

gica

lly

Late bowel obstruction treated surgically


Basingstoke Viewpoint BJS 2003

Simunovic et al. BJS 2003;90:999-1003


Selective pre-operative radiotherapy

Selective pre-operative radiotherapy

Definitely for an involved margin

Consider for a “threatened” margin – very low or very large tumour

Definitely for an involved margin

Consider for a “threatened” margin – very low or very large tumour

Basingstoke Viewpoint

Simunovic et al. BJS 2003;90:999-1003


Problems with this paper Problems with this paper

Subjective Based on large experience with

focus on optimal surgery Not reproducible

Subjective Based on large experience with

focus on optimal surgery Not reproducible


New methods of stagingNew methods of staging

Imaging techniquesImaging

techniques


Purpose of Imaging in Colorectal CancerPurpose of Imaging in Colorectal Cancer

Staging

Stage dictates outcome but especially for rectal cancer today – Stage dictates management

Staging

Stage dictates outcome but especially for rectal cancer today – Stage dictates management



Management of Rectal Cancer Today

Management of Rectal Cancer Today

No treatment Palliative therapy Local excision/TEM Radiotherapy alone Neoadjuvant therapy +Surgery Surgery alone Chemotherapy +/- some or all

No treatment Palliative therapy Local excision/TEM Radiotherapy alone Neoadjuvant therapy +Surgery Surgery alone Chemotherapy +/- some or all


Staging Rectal CancerStaging Rectal Cancer

Local staging – local extension of the tumour and particularly the margin (CRM)

Staging for systemic disease

Local staging – local extension of the tumour and particularly the margin (CRM)

Staging for systemic disease


Staging Colorectal Cancer“Gold Standard”

Pathology

Staging Colorectal Cancer“Gold Standard”

Pathology

Dukes Staging

TNM

Dukes Staging

TNM


Pathology PathologyDukes Staging – Post –op pathology

TNM – Increasingly being “estimated” pre -op

Dukes Staging – Post –op pathology

TNM – Increasingly being “estimated” pre -op


Clarifying the TNM staging of rectal cancer in the context of modern imaging and neo-adjuvant

treatment: ‘y’‘u’ and ‘p’ need ‘mr’ and ‘ct’

B. Moran, G. Brown, D. Cunningham, I. Daniels, R. Heald, P. Quirke, D. Sebag-Montefiore

Colorectal Disease, OnlineEarly Articles Published article online: 10-May-2007doi: 10.1111/j.1463-1318.2007.01260.x


Staging – Moran et al Colorectal Disease 2008


“TNM is pathology” “Imaging not equivalent”

“c” – clinical “u” – ultrasound “ct” – CT “mr” - MRI “p” – pathology “y” – after pre-op treatment

“TNM is pathology” “Imaging not equivalent”

“c” – clinical “u” – ultrasound “ct” – CT “mr” - MRI “p” – pathology “y” – after pre-op treatment




Thus a tumour staged by MRI as “T3N1 “should be described as

mrT3N1If given CRT eventual pathology

might beypT2N0

Thus a tumour staged by MRI as “T3N1 “should be described as

mrT3N1If given CRT eventual pathology

might beypT2N0


Local StagingLocal Staging

Depth of Tumour (“T” staging)

Mesorectal Margin

Depth of Tumour (“T” staging)

Mesorectal Margin


Imaging/ Staging Rectal Cancer Now

Imaging/ Staging Rectal Cancer Now

Finger X-ray Endoscopy US CT MRI PET

Finger X-ray Endoscopy US CT MRI PET

Colonoscopy and Cross-sectional imagingColonoscopy and Cross-sectional imaging

Stage Dictates TherapyStage Dictates Therapy


Local StagingLocal Staging

Finger- KeyEAUSMRI

Finger- KeyEAUSMRI


not for evaluation of mesorectal not for evaluation of mesorectal fasciafascia

EUS EUS

Superficial Rectal Superficial Rectal CancerCancerSuperficial Rectal Superficial Rectal CancerCancer


uT1uT1

intact outer hypoechoic layer (muscalaris propria)

intact outer hypoechoic layer (muscalaris propria)


uT3uN1uT3uN1


Limitations of EAUSLimitations of EAUS

Unable to view margins (CRM)

Stenotic tumours

Low painfull tumours

Unable to view margins (CRM)

Stenotic tumours

Low painfull tumours

Phased array coil/ no bowel prep


Accuracy of MRI Accuracy of MRI


The M.E.R.C.U.R.Y. Study

Magnetic REsonance Imaging andRectalCancerEURopean EquivalenceStudY


Aims of MERCURY


Diagnostic Accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer:prospective observational Study

MERCURY Study Group

Accuracy

1 Depth of extramural invasion – 95% to within 0.5mm

2 Prediction of a clear CRM (>1mm)- 91%

Diagnostic Accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer:prospective observational Study

MERCURY Study Group

Accuracy

1 Depth of extramural invasion – 95% to within 0.5mm

2 Prediction of a clear CRM (>1mm)- 91%

British MedicalJournal Volume 33 14th October 2006British MedicalJournal Volume 33 14th October 2006


Imaging Focal Point of MDT to plan treatment Imaging Focal Point of MDT to plan treatment

Tailored Treatment according to Risk for Local RecurrenceTailored Treatment according to Risk for Local Recurrence

The GoodSurgery

The BadSurgery + ? ( SC

RT) The Ugly

Long course CRT

Delayed surgery

The GoodSurgery

The BadSurgery + ? ( SC

RT) The Ugly

Long course CRT

Delayed surgery

The GoodThe Good

Extramural vascular invasion

The BadThe Bad

Nodal disease and EMVINodal disease and EMVI

Tumour satellite close to CRMHeterogenous nodes

The Bad The Bad

Now 2 years old

mrT3N1 Cancer at 20 weeks

Feb 06 July 06

The UglyThe Ugly


Image and ImagingImage and Imaging

“ A picture is worth a thousand words”

Chinese Proverb

“ A picture is worth a thousand words”

Chinese Proverb


Rectal Cancer Today and 1982Rectal Cancer Today and 1982

Ongoing problems with staging/MRI

Ongoing problems with staging/MRI

MRI is not pathology

Low Rectal Cancer – staging poor- Finger better

MRI is not pathology

Low Rectal Cancer – staging poor- Finger better


Low tumours involving sphincter

Low tumours involving sphincter

Combination of PR and MRI to plan

Neoadjuvant therapy Subsequent surgery (AR or APE)

Combination of PR and MRI to plan

Neoadjuvant therapy Subsequent surgery (AR or APE)

Holm et al. (Karolinska Hospital, Stockholm)

BJS 94: 232-238, 2007

Holm et al. (Karolinska Hospital, Stockholm)

BJS 94: 232-238, 2007


Future –Optimal StagingTo Select for

Future –Optimal StagingTo Select for

TME Surgery alone

Selective neoadjuvant therapy

AR or APE

TME Surgery alone

Selective neoadjuvant therapy

AR or APE


Thank You

Thank You

Basingstoke Colorectal How Imaging Has Improved Outcome In Rectal Cancer 4 th East- West Colorectal Days Hungary Brendan Moran Basingstoke OCTOBER 2008.

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