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Rectal cancer history
Rectal Cancer History Summery and main studies Rectal Cancer History 1826 1839 1885 1908 Lisfranc RC resection transanal Dixon Anterior resection (upper rectum) Amussat colostomy to relieve LBO 1940 Kraske Trans-sacral approach Miles APR Rectal Cancer History 1970s 1982 1982 1988 Circular stapler Gerhard Buess TEM Heald RJ Mesorectum and pelvic recurrence BJS 1982 Heald RJ. ‘The holy plane’ JR Soc Med.1988 Rectal Cancer History 2004 Neoadjuvant XRT-CT 2015 2015 COLOR II Lap TME =/> to open A. Lacy TaTME (largest single center experience) JACS 2015 Rectal Cancer History 2015 1826 They say the next big thing is here, that the revolution's near, but to me it seems quite clear that it's all just a little bit of history repeating The Propellerheads & Shirley Bassey 1998 Lisfranc RC resection transanal A. Lacy TaTME (largest single center experience) JACS 2015 Evolution of Surgery Open invasiveness surgery new evidence Laparoscopic surgery Robotic surgery MISS – surgery NOSE TAMIS NOTES time EMR Endoscopic polypectomy Endoscopic biopsy Diagnostic endoscopy Laparoscopic vs. Open Surgery for Extraperitoneal Rectal Cancer 191 consecutive patients Laparoscopic Open n = 98 n = 93 P Local recurrence (%) 3.2 12.6 < 0.05 Cumulative 5-year survival rate (%) 80.0 68.9 NS Disease-free 5-year survival rate (%) 65.4 58.9 NS Morino et al. Surg Endosc 2005 Laparoscopic vs. Open Surgery for Extraperitoneal Rectal Cancer Conclusion Laparoscopic resection for low and midrectal cancer is characterized by faster recovery and similar overall morbidity with no adverse oncologic effect Morino et al. Surg Endosc 2005 Can Adequate Lymphadenectomy be Obtained by Laparoscopic Resection in Rectal Cancer? Results of a Case Control Study in 200 Patients Laparoscopic TME Open TME (n=100) (n=100) 31.04 cm 29.45 cm all negative all negative 4 positive 9 positive Number of total nodes 13.76 12.72 Positive nodes 1.18 1.96 Bowel length Distal margins Circumferential margins Sara et al. J Gastrointest Surg. 2010 Laparoscopic resection of rectal cancer results in higher lymph node yield and better short-term outcomes • 2007-2011 • Retrospective review of all patients who underwent primary curative resection for rectal cancer in a single institute • Univariate and multivariate analyses Boutros et al. DCR 2013 Results Pathologic Outcomes Laparoscopic Open p (n=116) (n=118) univariate Circumferential margin (mm) 11.2 12.6 0.24 Completeness of TME * (%) 91.1 97.3 0.11 LN Harvested 25.9 20.9 0.02 <1 cm from distal margin (%) 16.1 10.3 0.19 * Completeness of TME: Complete, Near Complete, Incomplete Boutros et al. DCR 2013 Author Local Recurrence rate (5yrs) Number of Pts CRM (>1mm) TME integrity LNs Lap Open Lap Open Lap Open Lap Open Lap Open 253 128 88.2% 90.1% - - 12 13.5* - - 238 233 93.3% 95.3% - - - - 3.8% 5.1% 1387 3018 90.5% 83.7%* - - 14.5 14.7 3.9% 4.8% 588 300 90.5% 90% 88.5% 91.5% 13.0 14.0 - - 170 170 97.1% 95.9% 73.4% 74.8% 17.0 18.0 - - Guillou 2005 CLASSIC Laurent 2009 Lujan 2012 Van der Pas 2013 Color II Kang 2010 * p<0.05 Laparoscopic Rectal cancer surgery is oncologically adequate Meta-analysis Aim • Short term benefit • Oncological adequacy Methods • MOOSE criteria: RCTs and prospective controlled clinical trials (non-RCT) Clearence of CRM, number of LNs, distal margin clearence, R0, mesorectal fascia integrity, 5 yrs local recurrence Arezzo A. et al. Surg Endosc 2015 Laparoscopic Rectal cancer surgery is oncologically adequate Meta-analysis Results • 8 RCTs and 19 non-RCTs Laparoscopic Open P value Positive CRM 8% 12.7% p<0.001 Number of LNs 13.1 14.5 p=0.038 Distal margin clearence 2.8 cm 3.0 cm p=NS R0 83.1% 77.0% p=NS Mesorectal fascia integrity 85.2% 85.8% p=NS Local recurrence (5y) 4.1% 5.0% p=NS Arezzo A. et al. Surg Endosc 2015 Laparoscopic vs Open Surgery for Rectal Cancer (COLOR II) Short term outcomes of a randomized, phase 3 trial 1044 patients in 30 centers, 2004-2010 •Patients with rectal carcinoma within 15 cm from anal verge • Exclusions: • – – – – – Cancers invading adjacent tissues T4 tumors, or T3 within 2 mm of endopelvic fascia History of other malignancy FAP or HNPCC Active Crohn’s or UC Van der Pas et al. Lancet Oncol 2013 Bonjer et al. NEJM 2015 Laparoscopic vs Open Surgery for Rectal Cancer (COLOR II) Short term outcomes of a randomized, phase 3 trial Lap Open p value Mean blood loss (mL) 200 400 <0.0001 Time of surgery (min) 240 188 <0.0001 Bowel function return (days) 2 3 <0.0001 LOS (days) 8 9 0.036 Van der Pas et al. Lancet Oncol 2013 Bonjer et al. NEJM 2015 Laparoscopic vs Open Surgery for Rectal Cancer (COLOR II) Short term outcomes of a randomized, phase 3 trial Laparoscopic Open Surgery p value Morbidity at 28 days 40% 37% 0.424 Mortality at 28 days 1% 2% 0.109 Complete TME 88% 92% 0.250 CRM <2mm 10% 10% 0.850 9% 22% CI -23.2 to -3.0 3.0% 3.0% 0.676 CRM involved Lower rectal cancer Median DRM Van der Pas et al. Lancet Oncol 2013 Bonjer et al. NEJM 2015 Laparoscopic vs Open Surgery for Rectal Cancer (COLOR II) Short term outcomes of a randomized, phase 3 trial Laparoscopic Open Surgery p value Local Recurrence (3 years f/u) 31 (5%) 15 (5%) NS Local Recurrence Upper rectum 3.5% 2.9% NS Local Recurrence Middle 6.5% 2.4% CI 0.7-7.5 Local Recurrence Lower 4.4% 11.7% CI -13.9 to -0.7 Disease-free (3 years f/u) 74.8% 70.8% NS Disease Stage III DFS (3 years f/u) 64.9% 52.0% CI 2.2-23.6 Overall survival (3 years f/u) 86.7% 83.6% NS Bonjer et al. NEJM 2015 Bonjer et al. NEJM 2015 Laparoscopic vs Open Surgery for Rectal Cancer (COLOR II) Short term outcomes of a randomized, phase 3 trial -Conclusion- Laparoscopic surgery for rectal cancer results are similar in safety and completeness of resection to these of open surgery Recovery is improved after laparoscopic surgery Better 3yrs-DFS in stage III patients Lower rate of involved CRM in lower rectal cancer Van der Pas et al. Lancet Oncol 2013 Bonjer et al. NEJM 2015 Laparoscopic rectal cancer surgery ASCRS Statement 1994 CLASICC 2004 COLOR 2005 COLOR II 2015 Wexner SD Nat Rev Clin Oncol. 2015