Mohamed Abdulla M.D.Prof. of Clinical OncologyCairo University

GSO – Raffles Hotel – Istanbul – 28/03/2015

Amgen. Merck Serono. Roche. Jansen Cilag. Astellas. MSD. pfizer. Novartis.

Cecum 14 %

Ascending colon 10 %

Transverse colon 12 %

Descending colon 7 %

Sigmoid colon 25 %

Rectosigmoid junct 0.9 %

Rectum 23 %

CA Cancer J Clin 2011;61:69–90. VC 2011 American Cancer Society, Inc.

CA Cancer J Clin 2011;61:69–90. VC 2011 American Cancer Society, Inc.

50 Years

Risk Factors• Genetic• FH• IBD• Obesity• Smoking• Alcohol

• Aspirin• NSAIDS• Vegetables• Physical

Activity• Adequate

Folate• Decreased

Caloric Intake

Primary prevention of colorectal cancer. Gastroenterology 2010; 138:2029.

Better Life Style

Good prognostic factors Old age

Gender(F>M)

Asymptomatic pts

Polypoidal lesions

Non circumferential lesions

Diploid

Poor prognostic factors Obstruction

Perforation

Ulcerative lesion

Adjacent structures involvement

Positive margins

LVSI

Signet cell carcinoma

High CEA

Tethered and fixed cancer

Tis T1 T2 T3 T4

Extension to an adjacent organ

Mucosa

Muscularis mucosae

Submucosa

Muscularis propria

Subserosa

Serosa

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ: intraepithelial or invasion of lamina propria

T1 Tumor invades submucosa

T2 Tumor invades muscularis propria

T3 Tumor invades through the muscularis propria into pericolorectal tissues

T4a Tumor penetrates to the surface of the visceral peritoneum

T4b Tumor directly invades or is adherent to other organs or structures

Stage 5-year Survival (%)

0,1 Tis,T1;No;Mo > 90I T2;No;Mo 80-85II T3-4;No;Mo 70-75

III T2;N1-3;Mo 70-75III T3;N1-3;Mo 50-65III T4;N1-2;Mo 25-45IV M1 <3

History: Polyps & Colorectal Malignancy. Physical Examination: DRE. Routine laboratory investigations (CEA) Rigid Segmoidoscopy. Full Colonoscopy. Biopsy.

Journal of Surgical Oncology 2009;99:65–70

80-95% accurate in tumor staging 70-75% accurate in mesorectal lymph node

staging Use is limited to lesion < 14 cm from anus, not

applicable for upper rectum, for stenosingtumor

Very useful in determining extension ofdisease into anal canal (clinical important forplanning sphincter preserving surgery)

Figure. Endorectal ultrasoundof a T3 tumor of the rectum,extension through themuscularis propria, and intoperirectal fat.

Part of routine workup. Useful in identifying enlarged pelvic and extra-pelvic lymph-

nodes and visceral metastasis. Limited utility in:

1. small primary cancer.

2. T – Stage assessment.

3. Peri-rectal lymph nodes assessment.

Sensitivity 50-80% Specificity 30-80%

Shows promise as the most sensitive study forthe detection of metastatic disease in theliver and elsewhere.

Sensitivity of 97% and specificity of 76% inevaluating for recurrent colorectal cancer.

MRI may be Superior For:

1. Large field of view.

2. Better for proximal & stenotic lesions.

3. Less operator and technique dependent.

4. Size & morphologic characterization of peri-rectal nodes.

EUS may be Superior for:

1. More specific for muscularis propria invasion (T1 versus T2).

2. Significantly higher sensitivity for T3 disease.

High Resolution MRI & EUS Complementary Information.

Bipat et al.Radiology. 2004;232(3):773.

MDTSurgery

Radiation Therapy

Systemic Therapy

Imaging

Psychologist &

Rehabilitation

MDT & Multimodality Treatment Outcome is improving over time

Sauer et al. N Engl J Med 2004;351:1731-40.

High LR following APR and AR: 20-50% (35%). Sphincter preservation. To live with a stoma. Infections and sexual dysfunction. The perfect scenario.

Clinical Colorectal Cancer, Vol. 4, No. 4, 233-240, 2004

Removal of peri-rectaltissues involving lateral &circumferential margins ofmesorectal envelop.

Dis Colon Rectum. 2013 May;56(5):535-50.

Clinical Colorectal Cancer, Vol. 4, No. 4, 233-240, 2004

Clinical Colorectal Cancer, Vol. 4, No. 4, 233-240, 2004

GITSG. NCCTG. NSABP R-01.

N Engl J Med 1986; 315:1294.FJ Natl Cancer Inst 1988; 80:21. N Engl J Med 1991; 324:709.

Adjuvant Fluoroupyremidine

X 2 monthsCRT – 6 Weeks

Adjuvant Fluoroupyremidine

X 2 months

N Engl J Med 2004;351:1731-40.

10 -Year RTh + S S P

LR 5% 11% < 0.0001

OAS 48% 49% 0.86

CCSD 17% 22% 0.04

Lancet Oncol 2011; 12: 575–82

Lancet Oncol 2011; 12: 575–82

1. T3 –T4 Lesions: The only definitive indication.2. cT3N0: Should be treated (understaging).3. Depth of Extramural Invasion:

T3 lesions (>5 mm) ++ LNs involvement HigherCancer Specific Survival (54% Versus 85%).

Selection of high risk T3 for treatment.

Approved outside US.

4. T1 – 2 lesions with Positive Nodes.5. Low situated lesions.6. Invasion of mesorectal fascia.

Br J Cancer 2000; 82:1131.

Grade Regression Fibrosis

0 No All cells are viable

1 Minor < 25% fibrosis

2 Moderate 26 – 50%nFibrosis

3 Good >50%

4 Total No Viable Cells

Grade 10 – year DM P 10 –Year DFS P

0 - 1 39.6%0.005

63%0.0082 - 3 29.3% 73.6%

4 10.5 % 89.5%

J Clin Oncol 32:1554-1562. © 2014

British Journal of Surgery 2012; 99: 918–928

Can we Avoid Surgery?

The Cancer Journal • Volume 13, Number 3, May/June 2007

EQUIVALENT

Curr Opin Oncol 2012, 24:441–447

Curr Opin Oncol 2012, 24:441–447

Curr Opin Oncol 2012, 24:441–447

Polish TrialTrans-Tasman

Radiation Oncology Group

• Local Recurrence.• DFS• Distant Recurrence• OAS• Severe Late Toxicity

EQUIVALENT

J Clin Oncol 2012; 30:3827.Br J Surg 2006; 93:1215

Rectal cancer should be treated by MDT. Surgery is still the mainstay of treatment. Neoadjuvant CRT is more appealing than

postoperative schedule regarding outcome and toxicity profile for patients with stage II & III rectal cancer.

Fluoroupyremidine therapy is still the backbone of any regimen and can be substituted by the oral form.

Long course radiation therapy is still preferred by majority of treating groups.

pCR is associated with significant improvement in outcome.

Still more research is awaited.