Distal Margin Requirements After Preoperative Chemoradiotherapy for Distal Rectal Carcinomas: Are 1cm Distal Margins Sufficient?

Size: px
Start display at page:

Download "Distal Margin Requirements After Preoperative Chemoradiotherapy for Distal Rectal Carcinomas: Are 1cm Distal Margins Sufficient?"

Transcription

1 Annals of Surgical Oncology, 8(2): Published by Lippincott Williams & Wilkins 2001 The Society of Surgical Oncology, Inc. Distal Margin Requirements After Preoperative Chemoradiotherapy for Distal Rectal Carcinomas: Are 1cm Distal Margins Sufficient? Boris Kuvshinoff, MD, Irfan Maghfoor, MD, Brent Miedema, MD, Mark Bryer, MD Steven Westgate, MD, John Wilkes, MD, and David Ota, MD Background: Sphincter-sparing alternatives to abdominoperineal resection (APR) in the treatment of rectal cancer often are underused out of concern for inadequate distal margins and local failure. The present study addresses whether sphincter-sparing techniques with distal margins 1 cm adversely influence oncological outcome in patients given preoperative chemoradiotherapy. Methods: Thirty-seven patients with rectal cancer 8 cm from the anal verge were enrolled in the study. Preoperative external beam radiotherapy (5400 Gy) was administered together with continuous infusion of 5-fluorouracil (300 mg/m 2 /day). Surgical resection was performed in 36 patients with pathological assessment of tumor response and margins. Patients with sphinctersparing resection and distal margins 1cmor 1 cm and those who underwent APR were compared. Results: Thirty-six patients completed preoperative chemoradiotherapy, with successful sphincter-preservation in 28 patients. At a median follow-up of 33 months, there were 12 recurrences overall, which included 11 distant failures and four pelvic failures. Disease-free survival (DFS) was not different between those who had an APR compared with sphincter-sparing resection with distal margins 1 cm. DFS was worse (P.02) when radial margins were 3 mm compared with 3 mm. Conclusions: Sphincter preservation is feasible in more than 75% of patients with tumors 8cm from the anal verge after preoperative chemoradiotherapy. Sphincter-sparing surgery with distal margins 1 cm can be used without adversely influencing local recurrence or DFS. Limited radial margins ( 3 mm), however, are associated with increased disease recurrence. Key Words: Rectal cancer Distal margins Radiation therapy Chemotherapy Sphincter preservation. Received April 14, 2000; accepted September 25, From the Departments of Surgery, Medical Oncology and Radiology, University of Missouri Ellis Fischel Cancer Center and Harry S. Truman VAMC, Columbia, Missouri. Presented at the 1998 Annual Meeting of the Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 18, Address correspondence and reprint requests to: Boris W. Kuvshinoff, MD, FACS, Ellis Fischel Cancer Center, 115 Business Loop 70 W, Columbia, MO 65203; Fax: ; Kuvshinoffb@health.missouri.edu The standard operative procedure for carcinoma of the lower rectum is an abdominoperineal resection (APR) with a permanent sigmoid colostomy. If sphincter preservation is a desirable goal, then a new treatment paradigm is needed. Recent studies have shown that there is considerable regression of rectal carcinomas with preoperative chemoradiotherapy, and this may offer an important adjunct for sphincter preservation. 1 5 Advances in surgical technique that include total mesorectal excision (TME) with transanal transection and anastomosis also have improved local control and preservation of sphincter function. 6,7 It would seem reasonable that if preoperative therapy can downstage rectal carcinomas significantly, then the use of TME with distal margin 2cm should not compromise local control and would permit sphincter preservation for many distal rectal cancers. The purpose of this study was to determine if local recurrences and survival are affected adversely with a distal margin 1 cm after preoperative chemoradiotherapy. The regimen of 5-fluorouracil (5-FU) and concurrent external beam radiotherapy has been used success- 163

2 164 B. KUVSHINOFF ET AL. fully for both preoperative and postoperative adjuvant therapy in stage II and III rectal adenocarcinomas. 5,8 15 Our aim was to use an aggressive preoperative chemoradiotherapy regimen to permit a sphincter-preserving operation in patients with rectal carcinoma who otherwise would require an APR, without compromising local disease control or disease-free survival. METHODS Patient Eligibility Requirements All eligible patients treated at the University of Missouri Ellis Fischel Cancer Center, Harry S. Truman VAMC, and Mid-Missouri Medical Foundation between 1993 and 1997 who had biopsy-proven primary (n 34) or recurrent (n 3) rectal adenocarcinoma within 8 cm from the anal verge were enrolled in the study. These patients were judged by the attending surgeon to likely require an APR for adequate treatment. Initial evaluation included a complete history and physical, digital rectal exam, complete colonoscopy, rigid proctoscopy, chest x-ray, and computed tomography of the abdomen and pelvis. Transrectal ultrasound data were available in only five patients late in the study period. Patients with distant metastases, severe comorbid disease, poor performance status (Zubrod 2), concurrent malignancy other than skin cancer, or active alcohol abuse were ineligible for this trial. This protocol was approved by the University of Missouri Institutional Review Board and included informed patient consent. Preoperative Chemoradiotherapy External beam radiotherapy consisted of 6- or 15-MV photons generated by a linear accelerator with a targetto-axis distance of 100 cm. Patients were treated primarily with a three- or four-field plan on an open tabletop in the prone position, to exclude the small bowel from the radiation portal. The top of the field was placed at the sacral promontory, with lateral borders 1.5 cm outside the bony pelvis and the inferior margin 3 cm below gross tumor. A dose of 45 Gy was delivered, given at 1.8 Gy/day for 5 days a week in 25 fractions followed by a 9-Gy boost to the tumor in 5 fractions. Patients were seen weekly to assess tolerance, weight, and complete blood counts. 5-FU was administered concomitantly during the 6 weeks of radiation therapy. A central venous access device was used and flushed with 100 U heparin on weekends. The dose of 5-FU was 300 mg/m 2 /day, delivered as a continuous infusion from Monday morning to Friday afternoon. Acute toxicity from the 5-FU was monitored closely, and appropriate dose modifications were made when NCI grade 3 toxicity or higher was identified. Nonhematologic toxicity was monitored by close clinical observation. Hematologic toxicity, mainly anemia and leukopenia, was assessed weekly by following the hemoglobin and white blood cell count, respectively. Patients with hemoglobin 8.0 gm/dl were considered for transfusion. A white blood cell count 2.0 thou/cu mm was defined as grade 3 leukopenia, and at that level chemotherapy was withheld. Operative Therapy Surgery was performed 5 to 8 weeks after completion of the chemoradiotherapy. Operative strategies included low anterior resection, transsacral resection, or APR. Total mesorectal excision was performed as described by MacFarlane et al. 6 and Enker et al. 7 A proximal diverting loop ileostomy or colostomy was performed routinely if the surgeon performed a coloanal anastomosis. Both perioperative and long-term morbidity were recorded. After surgery, four cycles of bolus 5-FU (425 mg/m 2 / day, days 1 5) and leucovorin (20 mg/m 2 /day, days 1 5) were administered every 4 weeks. Pathological Assessment of the Resected Specimen The distal margin was determined by measuring the distance of the fixed tissue from the lowest edge of the tumor or ulcer to the distal cut edge. Tumor involvement of the distal edge also was assessed by intraoperative frozen section. In four patients the distal margin was histologically involved, necessitating further distal resection until microscopically free of tumor. If a tumor-free distal margin could not be obtained, then an APR was performed. The primary site was identified for the pathologist at the time of resection, and serial sections were taken to assess the extent of residual disease. A complete response was noted when no viable tumor or residual mucin could be identified. Radial margins also were assessed to the nearest millimeter from any viable tumor to the closest radial inked surface. Radial margins in the cases of complete responses were assessed from the residual fibrosis. Standard hematoxylin and eosin staining was used to assess lymph nodes. Statistical Analysis Disease-free survival curves were generated for the 36 patients who completed therapy by using the LIFETEST procedure from the statistical package SAS (SAS/STAT Release 6.12, SAS Institute, Cary, NC). Predictors of survival were analyzed independently, because the study size was insufficient to fit multivariable models. Survival curves were compared by using the log-rank test, with significance reported at the P.05 level.

3 DISTAL MARGINS FOR RECTAL CANCER 165 RESULTS There were 37 patients with biopsy-proven distal rectal adenocarcinomas ( 8 cm from the anal verge) enrolled in the protocol with a median follow-up of 33 months. The median age of the group was 60 years (range, years), and there were 26 men and 11 women. All but one patient completed the entire course of preoperative radiotherapy. External-beam radiation was stopped in this patient at 5040 cgy due to small bowel in the radiation field. 5-FU was discontinued in two patients because of grade 3 GI toxicity, one patient with both grade 3 skin and GI toxicity, and another patient with grade 4 cardiac toxicity (Table 1). Sphincter preservation was successful in 28 patients (76%), and APR was required in 8 patients (24%). Two patients who initially underwent sphincter preservation subsequently required permanent colostomy, one due to fecal incontinence and the other as a result of a persistent rectovaginal fistula. The three patients who presented with recurrent rectal cancer all were able to undergo sphincter-sparing surgery. Significant perioperative morbidity occurred in 4 of 36 patients (11%). These complications included an anastomotic leak with subsequent rectovaginal fistula, a small bowel obstruction treated nonoperatively, a prolonged ileus, and one episode of urosepsis. There was no perioperative mortality in this series. Long-term morbidity included three patients with anastomotic strictures that required rectal dilation. Four patients did not receive the four planned cycles of postoperative adjuvant chemotherapy based on their 5-FU intolerance during radiation therapy. Five patients had a complete response (14%) whereas 13 patients (35%) had only microscopic residual disease on final pathological assessment. The median distance of the lowest edge of the tumor to the anal verge for patients who underwent sphincter preservation was 5 cm (range, cm) and for APR 3.8 cm (range, cm). The median distal margin for patients who underwent sphincter preservation was 1.0 cm (range, cm) compared with 2.5 cm (range, cm) for APR (Table 2). TABLE 1. Preoperative chemoradiotherapy and maximal treatment toxicity Grade 1 Grade 2 Grade 3 Grade 4 Patients Gastrointestinal Skin Genitourinary Mucosal Cardiac Hematological Total occurrences The influence of distal margins after sphincter preservation or APR on disease-free survival is shown in Figure 1. There were 16 patients whose distal margins were 1 cm, 12 patients with distal margins 1 cm, and 8 who underwent APR. There were 12 recurrences overall, 5 (62%) in the group that underwent APR, six (38%) in those with distal margins 1 cm, and one (8%) when distal margins exceeded 1 cm. Disease-free survival was significantly different between the three groups (P.03), although there was no difference between APR and the sphincter-sparing group with margins 1 cm. Significant improvement in disease-free survival was observed in the sphincter-sparing group with 1 cm distal margins compared with APR (P.01) but not when compared with sphincter-sparing with subcentimeter margins (P.06). Pelvic or local recurrences were documented in four patients, three who underwent APR (37.5%) and one who had sphincter preservation (3.6%). Among nine patients with distal margins 5 mm, there was only one local recurrence. This patient had 21 positive lymph nodes on pathological assessment and failed throughout her pelvis. Consequently, there were no isolated intraluminal recurrences in the sphincter-preservation group. Two of the patients with pelvic failures in the APR group presented initially as a local recurrence. Only one pelvic recurrence was seen in the absence of metastatic disease, in a patient who had an APR but with a positive radial margin. Radial margins were reported in 32 patients who had evidence of residual disease or ulcerated scar after chemoradiotherapy. Radial margins were considered positive in four patients, all of whom underwent APR. Pathological assessment of radial margins demonstrated a median distance of 0.5 cm for both the sphincter preservation group (range, cm) and the APR group (range, cm; Table 2). Disease-free survival was significantly worse (P.02) when radial margins were 3 mm (Fig. 2). All four patients with positive radial margins have recurred in the pelvis but only one in the absence of prior or concurrent metastatic disease. Among the patients with 1-mm radial margins, two of five have recurred with distant disease only. Lymph nodes that contained adenocarcinoma were demonstrated in the pathological specimen in five patients from the APR group with four recurrences and in seven patients from the sphincter preservation group with two recurrences. There were six recurrences among the 25 patients without pathological evidence of lymph node metastases. Three of the four pelvic recurrences occurred among patients with positive nodes. There was no difference (P.17) in disease-free survival based on the pathological finding of lymph node metastases (Fig. 3).

4 166 B. KUVSHINOFF ET AL. TABLE 2. Patients Assessment of surgical margins according to surgical treatment Median distance from anal verge (cm) Median distal margin (cm) Median radial margin (cm) Abdominoperineal resection ( ) 2.5 ( ) 0.5 (0 0.7) Sphincter-sparing 28 5 (3.5 8) 1.0 ( ) 0.5 ( ) a a n 24. DISCUSSION Despite the increasing use of sphincter preservation for rectal cancers, nearly 50% of patients still undergo APR. 16 In many circumstances, APR is performed out of concern for adequate distal margins despite mounting evidence that more limited distal margins may be appropriate. Although distal margins as great as 5 cm were advocated in the past, 17 more recent data suggest that 2 cm distal margins are adequate Paty et al. 23 found no increase in pelvic recurrence when the distal margin was 2 cm compared with 2 cm. A number of authors also have shown that distal margins 2cmdo not increase local recurrence or compromise 5-year survival compared with distal margins 2 cm. 19,20 A number of clinical pathological studies that examined distal intramural spread suggest that smaller distal margins, even 1 cm, may be adequate in the majority of cases. This is supported by pathological evidence that distal intramural spread rarely exceeds 1 2 cm. 24,25 When significant distal spread does occur, long-term survival is affected adversely, despite treatment with APR. 19 In a recent study of 505 patients who underwent curative rectal resection, only 3.8% showed evidence of microscopic distal spread. 22 Moreover, most of these had distal spread 1 cm. The presence of distal spread was associated with decreased survival primarily due to distant disease recurrence. Although mounting evidence supports the use of 2-cm distal margins in rectal cancer resections, the use of centimeter and subcentimeter margins remains quite controversial. Karanjia et al. 26 compared patients who underwent anterior resections with TME who had 1 cm and 1 cm distal margins. The authors found no difference in either local recurrence or survival between the two groups. In contrast, Vernava et al. 21 found a decreased 5-year survival and increased anastomotic recurrence rate when distal margins were 8 mm. In the present study, we accepted even smaller distal margins, often 5 mm. Patients with margins 1 cm had an equivalent local recurrence rate and disease-free survival when compared with those with 1 cm margins. Our study does differ from many earlier reports that examined distal margins, because we used preoperative chemoradiotherapy. The effective downstaging of these lowlying tumors might well include the pathological clearance of distal microscopic spread. FIG. 1. Disease-free survival based on procedure (sphinctersparing [SS] or abdominoperineal resection [APR]) and distal margins (dm) (SS, 1cmor 1 cm). Although there was a difference when all three groups were considered together (P.03), there was no significant difference between APR and SS with distal margin 1cm(P.27) or between the two SS groups (P.06) by log-rank analysis.

5 DISTAL MARGINS FOR RECTAL CANCER 167 FIG. 2. Disease-free survival for pathological radial margins (RM) 3 mm (dashed line) and 3 mm (solid line). Log-rank comparison is significant (P.02). Pelvic recurrences were seen in 4 of 36 (11%) patients, which is in keeping with previous reports that used preoperative radiotherapy. 5,8 10 When only patients with primary disease were considered, pelvic recurrences were seen in 3 of 33 (6%) patients. We noted no isolated pelvic recurrences in our series, but rather pelvic recurrences occurred in conjunction with distant metastatic disease. A number of factors may have contributed to the low incidence of pelvic recurrences in this high-risk group. We used a dose of external beam radiation therapy (5400 cgy) that is higher than generally reported ( cgy). Concurrent infusional 5-FU also was used, which has been shown to enhance the effects of external beam radiotherapy. 27 The efficacy of preoperative chemoradiotherapy is demonstrated in the current study by the 14% complete response rate and the observation that an additional 35% of the patients had only microscopic foci of residual disease on final pathological assessment. This clinical response likely contributed to successful sphincter preservation in the majority of patients who otherwise would have required an APR. Attention to the pathological assessment of distal margins FIG. 3. Influence of pathological (routine hematoxylin and eosin staining) lymph node status on disease-free survival. Note that pathological assessment was performed after chemoradiation and surgery.

6 168 B. KUVSHINOFF ET AL. at the time of surgery also may be a factor. If microscopically free distal margins were not documented by frozen section, then sphincter preservation was abandoned and an APR performed. The use of TME also must be considered as a contributing factor in reducing pelvic recurrences. TME, a technique of sharp dissection that incorporates the entire mesorectum in the resected specimen, has been championed by MacFarlane et al. 6 and Enker, 7 with reported local recurrence rates as low as 5% to 8% in high-risk patients. Quirke et al. 28 demonstrated that radial spread into the mesorectum is a common occurrence. Sharp dissection along the parietal pelvic fascia ensures resection of these small ( 5 mm) occult nodal metastases that otherwise might be left behind. In the present study we took special care to assess radial margins. In patients with radial margins 3 mm, there was an increase in overall recurrence rate (53%, 8 of 15) compared with radial margins 3 mm (12%, 2 of 17). This suggests that radial margins are a more important predictor of disease recurrence and survival than distal margins. On the contrary, the presence or absence of positive lymph nodes and tumor response to preoperative chemoradiotherapy did not have prognostic significance. This may be attributed to both the relatively small number of cases analyzed and the high incidence of clinical downstaging that occurred before pathological assessment. In the current study there was an increased recurrence rate with APR (62.5%) compared with sphincter preservation (25%). The increased risk of recurrence for patients who undergo APR has been described previously and likely reflects the worse prognosis attributed to tumors of the low rectum compared with midrectal tumors. 7 All eight cases that involved APR in the present series involved lower-third rectal tumors, as did most of the group with distal margins 1 cm. When patients who underwent sphincter-sparing surgery with distal margins 1 cm were compared with those who had an APR, no difference in disease-free survival was found. This suggests that the location of the tumor may be a more important prognostic factor than the type of operation performed. The treatment schema in the present study of preoperative chemoradiotherapy followed by surgery was well tolerated. Despite the use of slightly higher doses of external beam radiotherapy together with infusional 5-FU, we did not see toxicity beyond that reported in other studies. 4,29,30 Most of the toxicity in the present study was grade 1 and easily manageable. Although a formal functional assessment of bowel function was not performed, the majority of patients were content with their postoperative fecal continence. The present study demonstrates that sphincter preservation is feasible in approximately 75% of patients after preoperative chemoradiotherapy for low-lying rectal cancers that otherwise would require APR. Distal margin clearance 1 cm was used often in the present series without adversely affecting pelvic recurrence or diseasefree survival. Despite margins as small as 1 mm, there was only one pelvic recurrence out of 28 patients (3.6%) who underwent sphincter preservation. Radial margins seem to be a more important prognostic indicator of disease recurrence. Distant disease recurrence continues to be the predominant mode of failure and highlights the need for better systemic adjuvant therapy. Acknowledgment: We thank Debbie Layne for help in preparation of the manuscript and Richard Madden, PhD, for statistical support. REFERENCES 1. Meterissian S, Skibber J, Rich T, et al. Patterns of residual disease after preoperative chemoradiation in ultrasound T3 rectal carcinoma. Ann Surg Oncol 1994;1: Meade PG, Blatchford GJ, Thorson AG, Christensen MA, Ternent CA. Preoperative chemoradiation downstages locally advanced ultrasound-staged rectal cancer. Am J Surg 1995;170: Burke SJ, Percarpio BA, Knight DC, Kwasnik EM. Combined preoperative radiation and mitomycin/5-fluorouracil treatment for locally advanced rectal adenocarcinoma. J Am Coll Surg 1998; 187: Minsky BD, Cohen AM, Kemeny N, Enker WE, Kelsen DP, Reichman B. Enhancement of radiation-induced downstaging of rectal cancer by fluorouracil and high-dose leucovorin chemotherapy. J Clin Oncol 1992;10: Grann A, Minksy BD, Cohen AM, et al. Preliminary results of pre-operative 5-fluorouracil(5-FU), low dose leucovorin, and concurrent radiation therapy for resectable T3 rectal cancer. Dis Colon Rectum 1997;40: MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet 1993;341: Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg 1995;181: Stryker SJ, Kiel KD, Rademaker A, Shaw JM, Ujiki GT, Pticha SM. Preoperative chemoradiation for stages II and III rectal carcinoma. Arch Surg 1996;131: Rich TA, Skibber JM, Ajani JA, et al. Preoperative infusional chemoradiation therapy for stage T3 rectal cancer. Int J Radiat Oncol Biol Phys 1995;32: Chari RS, Tyler DS, Anscher MS, et al. Preoperative radiation and chemotherapy in the treatment of adenocarcinoma of the rectum. Ann Surg 1995;221: Douglass HO Jr, Moertel CG, Mayer RJ, et al. Survival after postoperative combination treatment of rectal cancer. N Engl J Med 1986;315: Krook JE, Moertel CG, Gunderson LL, et al. Effective surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med 1991;324: O Connell MJ, Martenson JA, Wieand HS, et al. Improving adjuvant therapy for rectal cancer by combining protracted-infusion fluorouracil with radiation therapy after curative surgery. N Engl J Med 1994;331: Fisher B, Wolmark N, Rockette H, et al. Postoperative adjuvant

7 DISTAL MARGINS FOR RECTAL CANCER 169 chemotherapy or radiation therapy for rectal cancer: Results from NSABP protocol R-01. J Natl Cancer Inst 1988;80: Gastrointestinal Tumor Study Group. Radiation therapy and fluorouracil with or without semustine for the treatment of patients with surgical adjuvant adenocarcinoma of the rectum. J Clin Oncol 1992;10: Beart RW, Steele GD, Menck HR, Chmiel JS, Ocwieja KE, Winchester DP. Management and survival of patients with adenocarcinoma of the colon and rectum: A national survey of the Commission on Cancer. J Am Coll Surg 1995;181: Goligher JC, Dukes CE, Bussey HJR. Local recurrences after sphincter-saving excisions for carcinomas of the rectum and rectosigmoid. Br J Surg 1951;39: Wilson SM, Beahrs OH. The curative treatment of carcinoma of the sigmoid, rectosigmoid, and rectum. Ann Surg 1976;183: Pollett WG, Nicholls RJ. The relationship between the extent of distal clearance and survival and local recurrence rates after curative anterior resection for carcinoma of the rectum. Ann Surg 1983;198: Williams NS, Dixon MF, Johnston D. Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: A study of distal intramurual spread and of the patients survival. Br J Surg 1983;70: Vernava AM, Moran M. A prospective evaluation of distal margins in carcinoma of the rectum. Surg Gynecol Obstet 1992;175: Shirouzu K, Isomoto H, Kakegawa T. Distal spread of rectal cancer and optimal margin of resection for sphincter-preserving surgery. Cancer 1995;76: Paty PB, Enker WE, Cohen AM, Lauwers GY. Treatment of rectal cancer by low anterior resection with coloanal anastomosis. Ann Surg 1994;219: Grinnell RS. Distal intramural spread of the rectum and rectosigmoid. Surg Gynecol Obstet 1954;99: Black WA, Waugh JM. The intramural extension of carcinoma of the descending colon, sigmoid, and rectosigmoid: A pathologic study. Surg Gynecol Obstet 1948;87: Karanjia ND, Schache DJ, North WRS, Heald RJ. Close shave in anterior resection. Br J Surg 1990;77: Lawrence TS, Maybaum J. Fluoro pyrimidines as radiation sensitizers. Semin Radiat Oncol 1993;3: Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection: Histopathological study of lateral tumor spread and surgical excision. Lancet 1986;2: Ooi BS, Tjandra JJ, Green MD. Morbidities of adjuvant chemotherapy and radiotherapy for resectable rectal cancer. Dis Colon Rectum 1999;42: Minsky BD, Cohen AM, Wagman R, Guillem JG, Paty PP. Sphincter preservation with preoperative radiation therapy and coloanal anastomosis: Long term follow-up. Int J Radiat Oncol Biol Phys 1998;42:51 7.

Case Conference. Craig Morgenthal Department of Surgery Long Island College Hospital

Case Conference. Craig Morgenthal Department of Surgery Long Island College Hospital Case Conference Craig Morgenthal Department of Surgery Long Island College Hospital Neoadjuvant versus Adjuvant Radiation Therapy in Rectal Carcinoma Epidemiology American Cancer Society statistics for

More information

PRINCESS MARGARET CANCER CENTRE CLINICAL PRACTICE GUIDELINES

PRINCESS MARGARET CANCER CENTRE CLINICAL PRACTICE GUIDELINES PRINCESS MARGARET CANCER CENTRE CLINICAL PRACTICE GUIDELINES GASTROINTESTINAL RECTAL CANCER GI Site Group Rectal Cancer Authors: Dr. Jennifer Knox, Dr. Mairead McNamara 1. INTRODUCTION 3 2. SCREENING AND

More information

Mini J.Elnaggar M.D. Radiation Oncology Ochsner Medical Center 9/23/2016. Background

Mini J.Elnaggar M.D. Radiation Oncology Ochsner Medical Center 9/23/2016. Background Mini J.Elnaggar M.D. Radiation Oncology Ochsner Medical Center 9/23/2016 Background Mostly adenocarcinoma (scc possible, but treated like anal cancer) 39, 220 cases annually Primary treatment: surgery

More information

Sphincter Sparing Procedures: Is it a standard for Management of Low Rectal Cancer

Sphincter Sparing Procedures: Is it a standard for Management of Low Rectal Cancer Journal of the Egyptian Nat. Cancer Inst., Vol. 16, No. 4, December: 210-215, 2004 Sphincter Sparing Procedures: Is it a standard for Management of Low Rectal Cancer EL-SAYED ASHRAF KHALIL, M.D.FRCS; MOHAMAD

More information

Rectal Cancer: Classic Hits

Rectal Cancer: Classic Hits Rectal Cancer: Classic Hits Charles M. Friel, MD Associate Professor of Surgery Section of Colon and Rectal Surgery University of Virginia September 28, 2016 None Disclosures 1 Objectives Review the Classic

More information

Adjuvant Chemotherapy for Rectal Cancer: Are we making progress?

Adjuvant Chemotherapy for Rectal Cancer: Are we making progress? Adjuvant Chemotherapy for Rectal Cancer: Are we making progress? Hagen Kennecke, MD, MHA, FRCPC Division Of Medical Oncology British Columbia Cancer Agency October 25, 2008 Objectives Review milestones

More information

A Review of Rectal Cancer. Tim Geiger, MD Assistant Professor of Surgery, Colon and Rectal Surgery Vanderbilt University Medical Center

A Review of Rectal Cancer. Tim Geiger, MD Assistant Professor of Surgery, Colon and Rectal Surgery Vanderbilt University Medical Center A Review of Rectal Cancer Tim Geiger, MD Assistant Professor of Surgery, Colon and Rectal Surgery Vanderbilt University Medical Center No disclosures Disclosures About me.. Grew up in Southern Illinois

More information

Adjuvant Therapy for Rectal Cancer: Results and Controversies

Adjuvant Therapy for Rectal Cancer: Results and Controversies Review Article [1] August 01, 1998 Gastrointestinal Cancer [2], Colorectal Cancer [3] By Bruce D. Minsky, MD [4] During the past decade, advances have been made in the adjuvant treatment of resectable

More information

Chemoradiation (CRT) Safety Analysis of ACOSOG Z6041: A Phase II Trial of Neoadjuvant CRT followed by Local Excision in ut2 Rectal Cancer

Chemoradiation (CRT) Safety Analysis of ACOSOG Z6041: A Phase II Trial of Neoadjuvant CRT followed by Local Excision in ut2 Rectal Cancer Chemoradiation (CRT) Safety Analysis of ACOSOG Z6041: A Phase II Trial of Neoadjuvant CRT followed by Local Excision in ut2 Rectal Cancer Emily Chan, Qian Shi, Julio Garcia-Aguilar, Peter Cataldo, Jorge

More information

Laparoscopic Resection Of Colon & Rectal Cancers. R Sim Centre for Advanced Laparoscopic Surgery, TTSH

Laparoscopic Resection Of Colon & Rectal Cancers. R Sim Centre for Advanced Laparoscopic Surgery, TTSH Laparoscopic Resection Of Colon & Rectal Cancers R Sim Centre for Advanced Laparoscopic Surgery, TTSH Feasibility and safety Adequacy - same radical surgery as open op. Efficacy short term benefits and

More information

Rectal Cancer. GI Practice Guideline

Rectal Cancer. GI Practice Guideline Rectal Cancer GI Practice Guideline Dr. Brian Dingle MSc, MD, FRCPC Dr. Francisco Perera MD, FRCPC (Radiation Oncologist) Dr. Jay Engel MD, FRCPC (Surgical Oncologist) Approval Date: 2006 This guideline

More information

Long Term Outcomes of Preoperative versus

Long Term Outcomes of Preoperative versus RESEARCH ARTICLE Long Term Outcomes of Preoperative versus Postoperative Concurrent Chemoradiation for Locally Advanced Rectal Cancer: Experience from Ramathibodi Medical School in Thailand Pichayada Darunikorn

More information

RADIATION THERAPY WITH ONCE-WEEKLY GEMCITABINE IN PANCREATIC CANCER: CURRENT STATUS OF CLINICAL TRIALS

RADIATION THERAPY WITH ONCE-WEEKLY GEMCITABINE IN PANCREATIC CANCER: CURRENT STATUS OF CLINICAL TRIALS doi:10.1016/s0360-3016(03)00449-8 Int. J. Radiation Oncology Biol. Phys., Vol. 56, No. 4, Supplement, pp. 10 15, 2003 Copyright 2003 Elsevier Inc. Printed in the USA. All rights reserved 0360-3016/03/$

More information

RECTAL CANCER CLINICAL CASE PRESENTATION

RECTAL CANCER CLINICAL CASE PRESENTATION RECTAL CANCER CLINICAL CASE PRESENTATION Francesco Sclafani Medical Oncologist, Clinical Research Fellow The Royal Marsden NHS Foundation Trust, London, UK esmo.org Disclosure I have nothing to declare

More information

11/21/13 CEA: 1.7 WNL

11/21/13 CEA: 1.7 WNL Case Scenario 1 A 70 year-old white male presented to his primary care physician with a recent history of rectal bleeding. He was referred for imaging and a colonoscopy and was found to have adenocarcinoma.

More information

3/8/2014. Case Presentation. Primary Treatment of Anal Cancer. Anatomy. Overview. March 6, 2014

3/8/2014. Case Presentation. Primary Treatment of Anal Cancer. Anatomy. Overview. March 6, 2014 Case Presentation Primary Treatment of Anal Cancer 65 year old female presents with perianal pain, lower GI bleeding, and anemia with Hb of 7. On exam 6 cm mass protruding through the anus with bulky R

More information

The effect of rectal washout on local recurrence following rectal cancer surgery

The effect of rectal washout on local recurrence following rectal cancer surgery COLORECTAL SURGERY Ann R Coll Surg Engl 208; 00: 46 5 doi 0.308/rcsann.207.0202 The effect of rectal washout on local recurrence following rectal cancer surgery SR Moosvi, K Manley, J Hernon Norfolk and

More information

The impact of operation center and the prognostic factors on the outcome of patients with stage II and stage III colorectal cancer

The impact of operation center and the prognostic factors on the outcome of patients with stage II and stage III colorectal cancer Turkish Journal of Cancer Volume 38, No. 4, 28 175 The impact of operation center and the prognostic factors on the outcome of patients with stage II and stage III colorectal cancer ABDULLAH BÜYÜKÇELİK

More information

Department of Radiotherapy, Pt. BDS PGIMS, Rohtak, Haryana, India

Department of Radiotherapy, Pt. BDS PGIMS, Rohtak, Haryana, India Bharti et al., IJPSR, 2010; Vol. 1 (11): 169-173 ISSN: 0975-8232 IJPSR (2010), Vol. 1, Issue 11 (Research Article) Received on 29 September, 2010; received in revised form 21 October, 2010; accepted 26

More information

8. The polyp in the illustration can be described as (circle all that apply) a. Exophytic b. Pedunculated c. Sessile d. Frank

8. The polyp in the illustration can be described as (circle all that apply) a. Exophytic b. Pedunculated c. Sessile d. Frank Quiz 1 Overview 1. Beginning with the cecum, which is the correct sequence of colon subsites? a. Cecum, ascending, splenic flexure, transverse, hepatic flexure, descending, sigmoid. b. Cecum, ascending,

More information

Hagit Tulchinsky, MD, 1,2 Einat Shmueli, MD, 3 Arie Figer, MD, 3 Joseph M. Klausner, MD, 2 and Micha Rabau, MD 1,2

Hagit Tulchinsky, MD, 1,2 Einat Shmueli, MD, 3 Arie Figer, MD, 3 Joseph M. Klausner, MD, 2 and Micha Rabau, MD 1,2 Annals of Surgical Oncology DOI: 10.1245/s10434-008-9892-3 An Interval [7 Weeks between Neoadjuvant Therapy and Surgery Improves Pathologic Complete Response and Disease Free Survival in Patients with

More information

Evaluation of the Efficacy of Modified De Gramont and Modified FOLFOX4 Regimens for Adjuvant Therapy of Locally Advanced Rectal Cancer

Evaluation of the Efficacy of Modified De Gramont and Modified FOLFOX4 Regimens for Adjuvant Therapy of Locally Advanced Rectal Cancer Efficacy of Modified De Gramont and FOLFOX4 Regimens for Locally Advanced Rectal Cancer RESEARCH COMMUNICATION Evaluation of the Efficacy of Modified De Gramont and Modified FOLFOX4 Regimens for Adjuvant

More information

Postoperative Chemoradiotherapy for Rectal Carcinoma on Bowel Function

Postoperative Chemoradiotherapy for Rectal Carcinoma on Bowel Function ANNALS OF SURGERY Vol. 220, No. 5, 676-682 1994 J. B. Lippincott Company The Long-Term Effect of Adjuvant Postoperative Chemoradiotherapy for Rectal Carcinoma on Bowel Function C. F. Kollmorgen,* A. P.

More information

NOVA SCOTIA RECTAL CANCER PROJECT: A POPULATION-BASED ASSESSMENT OF RECTAL CANCER CARE AND OUTCOMES. Devon Paula Richardson

NOVA SCOTIA RECTAL CANCER PROJECT: A POPULATION-BASED ASSESSMENT OF RECTAL CANCER CARE AND OUTCOMES. Devon Paula Richardson NOVA SCOTIA RECTAL CANCER PROJECT: A POPULATION-BASED ASSESSMENT OF RECTAL CANCER CARE AND OUTCOMES by Devon Paula Richardson Submitted in partial fulfilment of the requirements for the degree of Master

More information

COLON AND RECTAL CANCER

COLON AND RECTAL CANCER COLON AND RECTAL CANCER Mark Sun, MD Clinical Associate Professor of Surgery University of Minnesota No disclosures Objectives 1) Understand the epidemiology, management, and prognosis of colon and rectal

More information

Rectal Cancer Update 2008 The Last 5 cm. Consensus Building

Rectal Cancer Update 2008 The Last 5 cm. Consensus Building Rectal Cancer Update 2008 The Last 5 cm Consensus Building Case Distal Rectal Cancer 65 male physician Rectal mass: 5cm from anal verge, 1cm above sphincter? Imaging choice: CT vs MR vs ERUS? Adjuvant

More information

Operative Technique: Karen Horvath, MD, FACS. SCOAP Retreat June 17, 2011

Operative Technique: Karen Horvath, MD, FACS. SCOAP Retreat June 17, 2011 Operative Technique: Total Mesorectal Excision Karen Horvath, MD, FACS University it of Washington, Seattle SCOAP Retreat June 17, 2011 No Disclosures Purpose What is Total Mesorectal Excision (TME)? How

More information

COLON AND RECTAL CANCER

COLON AND RECTAL CANCER No disclosures COLON AND RECTAL CANCER Mark Sun, MD Clinical Assistant Professor of Surgery University of Minnesota Colon and Rectal Cancer Statistics Overall Incidence 2016 134,490 new cases 8.0% of all

More information

Differential lymph node retrieval in rectal cancer: associated factors and effect on survival

Differential lymph node retrieval in rectal cancer: associated factors and effect on survival Original Article Differential lymph node retrieval in rectal cancer: associated factors and effect on survival Cedrek McFadden 1, Brian McKinley 1, Brian Greenwell 2, Kaylee Knuckolls 1, Patrick Culumovic

More information

MULTIDISCIPLINARY MANAGEMENT OF RECTAL CANCER A RETROSPECTIVE STUDY

MULTIDISCIPLINARY MANAGEMENT OF RECTAL CANCER A RETROSPECTIVE STUDY MULTIDISCIPLINARY MANAGEMENT OF RECTAL CANCER A RETROSPECTIVE STUDY V. Scripcariu 1, Elena Dajbog 1, I. Radu 1, C. Dragomir 1, D. Ferariu 2, I. Bild 3, Elena Albulescu 3, L. Miron 3 1 Third Surgical Clinic,

More information

Preoperative adjuvant radiotherapy

Preoperative adjuvant radiotherapy Preoperative adjuvant radiotherapy Dr John Hay Radiation Oncology Program BC Cancer Agency Vancouver Cancer Centre The key question for the surgeon Do you think that this tumour can be resected with clear

More information

Current Status of Adjuvant Therapy for Colorectal Cancer

Current Status of Adjuvant Therapy for Colorectal Cancer Review Article [1] May 01, 2004 By Michael J. O connell, MD [2] Adjuvant therapy with chemotherapy and/or radiation therapy in addition to surgery improves outcome for patients with high-risk carcinomas

More information

Surgical Management of Advanced Stage Colon Cancer. Nathan Huber, MD 6/11/14

Surgical Management of Advanced Stage Colon Cancer. Nathan Huber, MD 6/11/14 Surgical Management of Advanced Stage Colon Cancer Nathan Huber, MD 6/11/14 Colon Cancer Overview Approximately 50,000 attributable deaths per year Colorectal cancer is the 3 rd most common cause of cancer-related

More information

Carcinoma del retto: Highlights

Carcinoma del retto: Highlights Carcinoma del retto: Highlights Stefano Cordio Struttura Complessa di Oncologia Medica ARNAS Garibaldi Catania Roma 17 Febbraio 2018 Disclosures Advisory Committee, research funding and speakers bureau

More information

Rectal Cancer. Madhulika G. Varma MD Associate Professor and Chief Section of Colorectal Surgery University of California, San Francisco

Rectal Cancer. Madhulika G. Varma MD Associate Professor and Chief Section of Colorectal Surgery University of California, San Francisco Rectal Cancer Madhulika G. Varma MD Associate Professor and Chief Section of Colorectal Surgery University of California, San Francisco Modern Treatment for Rectal Cancer Improve Local Control Improved

More information

IMAGING GUIDELINES - COLORECTAL CANCER

IMAGING GUIDELINES - COLORECTAL CANCER IMAGING GUIDELINES - COLORECTAL CANCER DIAGNOSIS The majority of colorectal cancers are diagnosed on colonoscopy, with some being diagnosed on Ba enema, ultrasound or CT. STAGING CT chest, abdomen and

More information

CHAPTER 7 Concluding remarks and implications for further research

CHAPTER 7 Concluding remarks and implications for further research CONCLUDING REMARKS AND IMPLICATIONS FOR FURTHER RESEARCH CHAPTER 7 Concluding remarks and implications for further research 111 CHAPTER 7 Molecular staging of large sessile rectal tumors In this thesis,

More information

Comparative Efficacy of Adjuvant Chemotherapy in Patients With Dukes B Versus Dukes C Colon Cancer: Results From

Comparative Efficacy of Adjuvant Chemotherapy in Patients With Dukes B Versus Dukes C Colon Cancer: Results From Comparative Efficacy of Adjuvant Chemotherapy in Patients With Dukes B Versus Dukes C Colon Cancer: Results From Four National Surgical Adjuvant Breast and Bowel Project Adjuvant Studies (C-01, C-02, C-03,

More information

Innovations in rectal cancer surgery TAMIS and transanal TME

Innovations in rectal cancer surgery TAMIS and transanal TME Innovations in rectal cancer surgery TAMIS and transanal TME A.D Hoore MD PhD, EBSQ CR Chair Departement of Abdominal Surgery University Hospitals Leuven, Belgium Actual treatment in rectal Early rectal

More information

Stage III Colon Cancer Susquehanna Cancer Center Warren L Robinson, MD, FACP May 9, 2007

Stage III Colon Cancer Susquehanna Cancer Center Warren L Robinson, MD, FACP May 9, 2007 Stage III Colon Cancer Susquehanna Cancer Center 1997-21 Warren L Robinson, MD, FACP May 9, 27 Stage III Colon Cancer Susquehanna Cancer Center 1997-21 Colorectal cancer is the third most common cancer

More information

Preoperative capecitabine and pelvic radiation in locally advanced rectal cancer: preliminary results (Mansoura experience)

Preoperative capecitabine and pelvic radiation in locally advanced rectal cancer: preliminary results (Mansoura experience) Original Article Preoperative capecitabine and pelvic radiation in locally advanced rectal cancer: preliminary results (Mansoura experience) Abeer Hussien Anter 1, Ghada Ezzat Eladawei 2, Mahmoud Mosbah

More information

Index. Surg Oncol Clin N Am 14 (2005) Note: Page numbers of article titles are in boldface type.

Index. Surg Oncol Clin N Am 14 (2005) Note: Page numbers of article titles are in boldface type. Surg Oncol Clin N Am 14 (2005) 433 439 Index Note: Page numbers of article titles are in boldface type. A Abdominosacral resection, of recurrent rectal cancer, 202 215 Ablative techniques, image-guided,

More information

Histologic response after neoadjuvant chemoradiotherapy in locally advanced rectal adenocarcinoma: experience from Sudan.

Histologic response after neoadjuvant chemoradiotherapy in locally advanced rectal adenocarcinoma: experience from Sudan. Histologic response after neoadjuvant chemoradiotherapy in locally advanced rectal adenocarcinoma: experience from Sudan. Ahmed Abd Elrahman Abdalla 1, Awad Ali M. Alawad 2, Hussein Abdalla M. Ali 3 1.

More information

Treatment outcomes and prognostic factors of gallbladder cancer patients after postoperative radiation therapy

Treatment outcomes and prognostic factors of gallbladder cancer patients after postoperative radiation therapy Korean J Hepatobiliary Pancreat Surg 2011;15:152-156 Original Article Treatment outcomes and prognostic factors of gallbladder cancer patients after postoperative radiation therapy Suzy Kim 1,#, Kyubo

More information

Cover Page. The handle holds various files of this Leiden University dissertation

Cover Page. The handle   holds various files of this Leiden University dissertation Cover Page The handle http://hdl.handle.net/1887/24307 holds various files of this Leiden University dissertation Author: Broek, Colette van den Title: Optimisation of colorectal cancer treatment Issue

More information

UPDATE IN THE MANAGEMENT OF INVASIVE CERVICAL CANCER

UPDATE IN THE MANAGEMENT OF INVASIVE CERVICAL CANCER UPDATE IN THE MANAGEMENT OF INVASIVE CERVICAL CANCER Susan Davidson, MD Professor Department of Obstetrics and Gynecology Division of Gynecologic Oncology University of Colorado- Denver Anatomy Review

More information

1. Background. increased sphincter preservation rate. Nonetheless, the 5- year disease-free survival and overall survival rates were

1. Background. increased sphincter preservation rate. Nonetheless, the 5- year disease-free survival and overall survival rates were Gastroenterology Research and Practice Volume 2016, Article ID 7870815, 5 pages http://dx.doi.org/10.1155/2016/7870815 Research Article Does Extending the Waiting Time of Low-Rectal Cancer Surgery after

More information

Pathohistological Assessment of the Circular Margin of Resection During Total Mesorectal Excision, Conducted on The Malignant Formations of the Rectum

Pathohistological Assessment of the Circular Margin of Resection During Total Mesorectal Excision, Conducted on The Malignant Formations of the Rectum International Journal of Research Studies in Science, Engineering and Technology Volume 4, Issue 5, 2017, PP 17-22 ISSN : 2349-476X http://dx.doi.org/10.22259/ijrsset.0405004 Pathohistological Assessment

More information

Peritoneal Involvement in Stage II Colon Cancer

Peritoneal Involvement in Stage II Colon Cancer Anatomic Pathology / PERITONEAL INVOLVEMENT IN STAGE II COLON CANCER Peritoneal Involvement in Stage II Colon Cancer A.M. Lennon, MB, MRCPI, H.E. Mulcahy, MD, MRCPI, J.M.P. Hyland, MCh, FRCS, FRCSI, C.

More information

SMJ Singapore Medical Journal

SMJ Singapore Medical Journal SMJ Singapore Medical Journal ONLINE FIRST PUBLICATION Online first papers have undergone full scientific review and copyediting, but have not been typeset or proofread. To cite this article, use the DOIs

More information

Treatment strategy of metastatic rectal cancer

Treatment strategy of metastatic rectal cancer 35.Schweizerische Koloproktologie-Tagung Treatment strategy of metastatic rectal cancer Gilles Mentha University hospital of Geneva Bern, January 18th, 2014 Colorectal cancer is the third most frequent

More information

COLORECTAL CANCER FAISALGHANISIDDIQUI MBBS; FCPS; PGDIP-BIOETHICS; MCPS-HPE

COLORECTAL CANCER FAISALGHANISIDDIQUI MBBS; FCPS; PGDIP-BIOETHICS; MCPS-HPE COLORECTAL CANCER FAISALGHANISIDDIQUI MBBS; FCPS; PGDIP-BIOETHICS; MCPS-HPE PROFESSOR OF SURGERY & DIRECTOR, PROFESSIONAL DEVELOPMENT CENTRE J I N N A H S I N D H M E D I C A L U N I V E R S I T Y faisal.siddiqui@jsmu.edu.pk

More information

Patient Presentation. 32 y.o. female complains of lower abdominal mass CEA = 433, CA125 = 201

Patient Presentation. 32 y.o. female complains of lower abdominal mass CEA = 433, CA125 = 201 Patient Presentation 32 y.o. female complains of lower abdominal mass CEA = 433, CA125 = 201 CT shows: Thickening of the right hemidiaphragm CT shows: Fluid in the right paracolic sulcus CT shows: Large

More information

Pre-operative Chemoradiotherapy with Oral Capecitabine in Locally Advanced, Resectable Rectal Cancer

Pre-operative Chemoradiotherapy with Oral Capecitabine in Locally Advanced, Resectable Rectal Cancer Pre-operative Chemoradiotherapy with Oral Capecitabine in Locally Advanced, Resectable Rectal Cancer DIMITRIS P. KORKOLIS 1, CHRISTOS S. BOSKOS 2, GEORGE D. PLATANIOTIS 1, EMMANUEL GONTIKAKIS 1, IOANNIS

More information

Colorectal Pathway Board (Clinical Subgroup): Imaging Guidelines September 2015

Colorectal Pathway Board (Clinical Subgroup): Imaging Guidelines September 2015 Colorectal Pathway Board (Clinical Subgroup): Imaging Guidelines September 2015 1 Contents Page No. 1. Objective 3 2. Imaging Techniques 3 3. Staging of Colorectal Cancer 5 4. Radiological Reporting 6

More information

Re-irradiation in recurrent rectal cancer: single institution experience

Re-irradiation in recurrent rectal cancer: single institution experience Original Article Re-irradiation in recurrent rectal cancer: single institution experience Rasha Mohammad Abdel Latif, Ghada E. El-Adawei, Wael El-Sada Clinical Oncology & Nuclear Medicine Department, Mansoura

More information

Case Report 17-Week Delay Surgery after Chemoradiation in Rectal Cancer with Complete Pathological Response

Case Report 17-Week Delay Surgery after Chemoradiation in Rectal Cancer with Complete Pathological Response Case Reports in Surgery Volume 2015, Article ID 816491, 5 pages http://dx.doi.org/10.1155/2015/816491 Case Report 17-Week Delay Surgery after Chemoradiation in Rectal Cancer with Complete Pathological

More information

Preoperative or Postoperative Therapy for the Management of Patients with Stage II or III Rectal Cancer

Preoperative or Postoperative Therapy for the Management of Patients with Stage II or III Rectal Cancer Evidence-Based Series 2-4 Version 2 A Quality Initiative of the Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO) Preoperative or Postoperative Therapy for the Management of Patients with

More information

COLORECTAL CARCINOMA

COLORECTAL CARCINOMA QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF COLORECTAL CARCINOMA Ministry of Health Malaysia Malaysian Society of Colorectal Surgeons Malaysian Society of Gastroenterology & Hepatology Malaysian

More information

ADJUVANT CHEMOTHERAPY...

ADJUVANT CHEMOTHERAPY... Colorectal Pathway Board: Non-Surgical Oncology Guidelines October 2015 Organization» Table of Contents ADJUVANT CHEMOTHERAPY... 2 DUKES C/ TNM STAGE 3... 2 DUKES B/ TNM STAGE 2... 3 LOCALLY ADVANCED

More information

Local Excision of Rectal Cancer Techniques and Outcomes

Local Excision of Rectal Cancer Techniques and Outcomes Local Excision of Rectal Cancer Techniques and Outcomes Manoj J. Raval, MD, MSc, FRCSC Clinical Assistant Professor, UBC Rectal Cancer Update 2008 October 25, 2008 Overview Techniques & Description Patient

More information

Journal of the Egyptian Nat. Cancer Inst., Vol. 20, No. 1, March: 10-16, 2008

Journal of the Egyptian Nat. Cancer Inst., Vol. 20, No. 1, March: 10-16, 2008 Journal of the Egyptian Nat. Cancer Inst., Vol. 20, No. 1, March: 10-16, 2008 Prospective Phase II Study of Brachytherapy Boost as a Component of Neo-Adjuvant Chemotherapy and External Beam Radiation Therapy

More information

Intraoperative Radiation Therapy for

Intraoperative Radiation Therapy for Frontiers ofradiation Therapy and Oncology Reprint Editors: J.M. Vaeth, J.L. Meyer, San Francisco, Calif. ~' Publishers: S.Karger, Basel Printed in Switzerland Vaeth JM, Meyer JL (eds): The Role of High

More information

Guidelines for Laparoscopic Resection of Curable Colon and Rectal Cancer

Guidelines for Laparoscopic Resection of Curable Colon and Rectal Cancer SAGES Society of American Gastrointestinal and Endoscopic Surgeons http://www.sages.org Guidelines for Laparoscopic Resection of Curable Colon and Rectal Cancer Author : SAGES Webmaster PREAMBLE The following

More information

Disclosure. Acknowledgement. What is the Best Workup for Rectal Cancer Staging: US/MRI/PET? Rectal cancer imaging. None

Disclosure. Acknowledgement. What is the Best Workup for Rectal Cancer Staging: US/MRI/PET? Rectal cancer imaging. None What is the Best Workup for Rectal Cancer Staging: US/MRI/PET? Zhen Jane Wang, MD Assistant Professor in Residence UC SF Department of Radiology Disclosure None Acknowledgement Hueylan Chern, MD, Department

More information

is time consuming and expensive. An intra-operative assessment is not going to be helpful if there is no more tissue that can be taken to improve the

is time consuming and expensive. An intra-operative assessment is not going to be helpful if there is no more tissue that can be taken to improve the My name is Barry Feig. I am a Professor of Surgical Oncology at The University of Texas MD Anderson Cancer Center in Houston, Texas. I am going to talk to you today about the role for surgery in the treatment

More information

Neoadjuvant Therapy for Rectal Cancer is Overrated. Joon H. Lee, Research Resident University of Colorado 8/31/2009

Neoadjuvant Therapy for Rectal Cancer is Overrated. Joon H. Lee, Research Resident University of Colorado 8/31/2009 Neoadjuvant Therapy for Rectal Cancer is Overrated Joon H. Lee, Research Resident University of Colorado 8/31/2009 Objectives Brief overview of staging rectal cancer Current guidelines for evaluation and

More information

RECTAL CANCER: Adjuvant Therapy. Maury Rosenstein, MD Montefiore Medical Center December 2012

RECTAL CANCER: Adjuvant Therapy. Maury Rosenstein, MD Montefiore Medical Center December 2012 RECTAL CANCER: Adjuvant Therapy Maury Rosenstein, MD Montefiore Medical Center December 2012 Overview Indications for adjuvant therapy Preoperative Postoperative New Advances Epidemiology Approximately

More information

Efficacy and Toxicity of Adjuvant Chemotherapy in Elderly Patients with Colon Carcinoma

Efficacy and Toxicity of Adjuvant Chemotherapy in Elderly Patients with Colon Carcinoma 1931 Efficacy and Toxicity of Adjuvant Chemotherapy in Elderly Patients with Colon Carcinoma A 10-Year Experience of the Geisinger Medical Center Farid Fata, M.D. 1 Ayoub Mirza, M.D. 2 G. Craig Wood, M.S.

More information

Position Statement on Management of the Axilla in Patients with Invasive Breast Cancer

Position Statement on Management of the Axilla in Patients with Invasive Breast Cancer - Official Statement - Position Statement on Management of the Axilla in Patients with Invasive Breast Cancer Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) for the

More information

Conference Preview II

Conference Preview II Conference Preview II CONFERENCE PREVIEW: JOINT CANCER CONFERENCE 2000 II. CLINICAL RESEARCH 1. RECENT ADVANCES IN THE TREATMENT AND OUTCOME OF LOCALLY ADVANCED RECTAL CANCER Edward M. Copeland III, MD

More information

L impatto dell imaging sulla definizione della strategia terapeutica

L impatto dell imaging sulla definizione della strategia terapeutica GISCoR L impatto dell imaging sulla definizione della strategia terapeutica M. Galeandro U.C. Radioterapia Oncologica ASMN-IRCCS Reggio Emilia 14 Novembre 2014 Rectal Cancer TNM AJCC-7 th edition 2010

More information

Corporate Medical Policy Transanal Endoscopic Microsurgery (TEMS)

Corporate Medical Policy Transanal Endoscopic Microsurgery (TEMS) Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: transanal_endoscopic_microsurgery_(tems) 6/2008 11/2018 11/2019 11/2018 Description of Procedure or Service

More information

Pushing the Envelope Beyond a Centimeter in Rectal Cancer: Oncologic Implications of Close, But Negative Margins

Pushing the Envelope Beyond a Centimeter in Rectal Cancer: Oncologic Implications of Close, But Negative Margins Pushing the Envelope Beyond a Centimeter in Rectal Cancer: Oncologic Implications of Close, But Negative Margins Timothy L Fitzgerald, MD, FACS, Jason Brinkley, PhD, Emmanuel E Zervos, MD, FACS BACKGROUND:

More information

Treatment of Locally Advanced Rectal Cancer: Current Concepts

Treatment of Locally Advanced Rectal Cancer: Current Concepts Treatment of Locally Advanced Rectal Cancer: Current Concepts James J. Stark, MD, FACP Medical Director, Cancer Program and Palliative Care Maryview Medical Center Professor of Medicine, EVMS Case Presentation

More information

Colorectal Cancer Dashboard

Colorectal Cancer Dashboard Process Risk Assessment Presence or absence of cancer in first-degree blood relatives documented for patients with colorectal cancer Percent of patients with colorectal cancer for whom presence or absence

More information

Short course radiation therapy for rectal cancer in the elderly: can radical surgery be avoided?

Short course radiation therapy for rectal cancer in the elderly: can radical surgery be avoided? Short communication Short course radiation therapy for rectal cancer in the elderly: can radical surgery be avoided? Michael A. Cummings 1, Kenneth Y. Usuki 1, Fergal J. Fleming 2, Mohamedtaki A. Tejani

More information

LOINC. Clinical information. RCPA code. Record if different to report header Operating surgeon name and contact details. Absent.

LOINC. Clinical information. RCPA code. Record if different to report header Operating surgeon name and contact details. Absent. Complete as narrative or use the structured format below 55752-0 17.02.28593 Clinical information 22027-7 17.02.30001 Record if different to report header Operating surgeon name and contact details 52101004

More information

Original Policy Date

Original Policy Date MP 7.01.92 Transanal Endoscopic Microsurgery Medical Policy Section Surgery Issue 12/2013 Original Policy Date 12/2013 Last Review Status/Date Reviewed with literature search/12/2013 Return to Medical

More information

Radiotherapy for Rectal Cancer. Kevin Palumbo Adelaide Radiotherapy Centre

Radiotherapy for Rectal Cancer. Kevin Palumbo Adelaide Radiotherapy Centre Radiotherapy for Rectal Cancer Kevin Palumbo Adelaide Radiotherapy Centre Overview CRC are common (3 rd commonest cancer) rectal Ca approx 25-30% of all CRC. Presentation PR bleeding: beware attributing

More information

Quantification of Histologic Regression of Rectal Cancer After Irradiation

Quantification of Histologic Regression of Rectal Cancer After Irradiation Quantification of Histologic Regression of Rectal Cancer After Irradiation A Proposal for a Modified Staging System J. M. D. Wheeler, M.D., F.R.C.S.,* B. F. Warren, M.R.C.Path., N. J. McC. Mortensen, M.D.,

More information

Outcome of rectal cancer after radiotherapy with a long or short waiting period before surgery, a descriptive clinical study

Outcome of rectal cancer after radiotherapy with a long or short waiting period before surgery, a descriptive clinical study Original Article Outcome of rectal cancer after radiotherapy with a long or short waiting period before surgery, a descriptive clinical study Elmer E. van Eeghen 1, Frank den Boer 2, Sandra D. Bakker 1,

More information

Cover Page. The handle holds various files of this Leiden University dissertation.

Cover Page. The handle   holds various files of this Leiden University dissertation. Cover Page The handle http://hdl.handle.net/1887/38705 holds various files of this Leiden University dissertation. Author: Gijn, Willem van Title: Rectal cancer : developments in multidisciplinary treatment,

More information

BCCA Protocol Summary for Combined Modality Adjuvant Therapy for High Risk Rectal Carcinoma using Capecitabine and Radiation Therapy

BCCA Protocol Summary for Combined Modality Adjuvant Therapy for High Risk Rectal Carcinoma using Capecitabine and Radiation Therapy BCCA Protocol Summary for Combined Modality Adjuvant Therapy for High Risk Rectal Carcinoma using Capecitabine and Radiation Therapy Protocol Code: Tumour Group: Contact Physician: GIRCRT Gastrointestinal

More information

Review Article Intersphincteric Resection for Low Rectal Cancer: An Overview

Review Article Intersphincteric Resection for Low Rectal Cancer: An Overview International Surgical Oncology Volume 2012, Article ID 241512, 4 pages doi:10.1155/2012/241512 Review Article Intersphincteric Resection for Low Rectal Cancer: An Overview Constantine P. Spanos 1st Department

More information

COLORECTAL CANCER STAGING in 2010

COLORECTAL CANCER STAGING in 2010 COLORECTAL CANCER STAGING in 2010 Robert A. Halvorsen, MD, FACR MCV Hospitals / VCU Medical Center Richmond, Virginia I do not have any relevant financial relationships with any commercial interests COLON

More information

UCL. Rectum Adenocarcinoma. Quality of conformal radiotherapy Impact for the surgeon P. Scalliet & K. Haustermans

UCL. Rectum Adenocarcinoma. Quality of conformal radiotherapy Impact for the surgeon P. Scalliet & K. Haustermans Rectum Adenocarcinoma Quality of conformal radiotherapy Impact for the surgeon P. Scalliet & K. Haustermans Fifth Belgian Surgical Week May 6th, 2004, Oostende SOR rectum adenocarcinoma Indication of radiotherapy

More information

Local Excision for early rectal cancer

Local Excision for early rectal cancer Local Excision for early rectal cancer M. Trompetto, E. Ganio, G. Clerico, A. Realis Luc, RJ Nicholls Colorectal Eporediensis Centre Clinica S. Rita Vercelli Gruppo Policlinico di Monza Mortality Morbidity

More information

PAPER. Review of Results After Endoscopic and Surgical Therapy

PAPER. Review of Results After Endoscopic and Surgical Therapy Rectal Carcinoid Tumors PAPER Review of Results After Endoscopic and Surgical Therapy Mary R. Kwaan, MD, MPH; Joel E. Goldberg, MD; Ronald Bleday, MD Objective: To assess whether endoscopic treatment can

More information

Case Scenario 1. The patient has now completed his neoadjuvant chemoradiation and has been cleared for surgery.

Case Scenario 1. The patient has now completed his neoadjuvant chemoradiation and has been cleared for surgery. Case Scenario 1 July 10, 2010 A 67-year-old male with squamous cell carcinoma of the mid thoracic esophagus presents for surgical resection. The patient has completed preoperative chemoradiation. This

More information

Medicinae Doctoris. One university. Many futures.

Medicinae Doctoris. One university. Many futures. Medicinae Doctoris The Before and The After: Can chemotherapy revise the trajectory of gastric and esophageal cancers? Dr. David Dawe MD, FRCPC Medical Oncologist Assistant Professor Disclosures None All

More information

Early Rectal Cancer Surgical options Organ Preservation? Chinna Reddy Colorectal Surgeon Western General, Edinburgh

Early Rectal Cancer Surgical options Organ Preservation? Chinna Reddy Colorectal Surgeon Western General, Edinburgh Early Rectal Cancer Surgical options Organ Preservation? Chinna Reddy Colorectal Surgeon Western General, Edinburgh What is Early rectal cancer? pt1t2n0m0 Predictors for LN involvement Size Depth Intramural

More information

PROCARE FINAL FEEDBACK Definitions

PROCARE FINAL FEEDBACK Definitions 1 PROCARE FINAL FEEDBACK 2006-2014 Definitions Version 0.2 29/10/2015 2 Table of Contents Introduction... 3 Part 1: PROCARE indicators 2006-2014... 4 1.1. Methods... 4 1.1.1. Descriptive numbers... 4 1.1.2.

More information

Melanoma Quality Reporting

Melanoma Quality Reporting Melanoma Quality Reporting September 1, 2013 December 31, 2016 Laurence McCahill, MD Surgical Oncologist Metro Health Surgical Oncology Metro Health Professional Building 2122 Health Drive SW Wyoming,

More information

NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE

NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE INTERVENTIONAL PROCEDURES PROGRAMME Interventional procedure overview of preoperative high dose rate brachytherapy for rectal cancer Rectal cancer is a

More information

Prognostic factors in squamous cell anal cancers

Prognostic factors in squamous cell anal cancers Prognostic factors in squamous cell anal cancers Zainul Abedin Kapacee Year 4-5 Intercalating Medical Student, University of Manchester Dr. Shabbir Susnerwala, Mr. Nigel Scott Dr. Falalu Danwata, Dr. Marcus

More information

Staging of cancer patients is an important tool for the selection

Staging of cancer patients is an important tool for the selection CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2007;5:997 1003 Improvement of Staging by Combining Tumor and Treatment Parameters: The Value for Prognostication in Rectal Cancer MARLEEN J. E. M. GOSENS,* J.

More information

Fourth versus eighth week surgery after neoadjuvant radiochemotherapy in T3-4/N0+ rectal cancer: Istanbul R-01 study

Fourth versus eighth week surgery after neoadjuvant radiochemotherapy in T3-4/N0+ rectal cancer: Istanbul R-01 study Original Article Fourth versus eighth week surgery after neoadjuvant radiochemotherapy in T3-4/N0+ rectal cancer: Istanbul R-01 study Sezer Saglam 1, Dursun Bugra 2, Esra K. Saglam 3, Oktar Asoglu 4, Emre

More information

Radiotherapy for rectal cancer. Karin Haustermans Department of Radiation Oncology

Radiotherapy for rectal cancer. Karin Haustermans Department of Radiation Oncology Radiotherapy for rectal cancer Karin Haustermans Department of Radiation Oncology O U T L I N E RT with TME surgery? Neoadjuvant or adjuvant RT? 5 x 5 Gy or long-course CRT? RT with new drugs? Selection

More information

The main issues of the rectal resection for carcinoma

The main issues of the rectal resection for carcinoma The main issues of the rectal resection for carcinoma - Level of the vessels transection and mobilisation of the splenic flexure - Lymphadenectomy - Distal margin - Parietal invasion of rectal wall - Functional

More information