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Transcript

  • 1. Advanced Colorectal Cancer Surgery and HIPEC
    • Portugal 2011
    • Brendan Moran
  • 2. Advanced Colorectal Cancer
    • Locally advanced
    • Systemic metastases – lymphatic or bloodborne (liver, lung)
    • Combination of locally advanced and systemic disease
  • 3. Locally Advanced Colorectal Cancer without metastatic disease
    • Not uncommon
    • Cause of treatment failure where treatment of the primary is inadequate (Eg most local recurrence rectal cancer is “persistent disease”
    • TNM classification T4a and T4b
  • 4. T4a
    • Pathological definition
    • Invasion adjacent organ
    • Suspected/predictable on imaging (Number of reports now showing that adherence to neighbouring organ is cancer in approx 50%)
  • 5. Management TNM T4a
    • Diagnosis – Preoperative imaging eg ctT4a (mrT4a rectum)
    • Strategy – neoadjuvant therapy
    • Extended resection
    • Combination
  • 6. Case T4 2008
    • Male aged 64
    • Mass in right upper quadrant
    • Night sweats
    • Weight loss
  • 7. CT – “Colonic mass : Possibility Inflammatory and Duodenal involvement”
  • 8. MDT Discussion
    • Suggest OGD and Colonoscopy
    • OGD – Necrotic mass lateral wall duodenum – Biopsy
    • Colonoscopy – Necrotic mass ascending colon - Biopsy
  • 9. Surgery – Abdominal wall/Right hemi partial duodenal resection
  • 10. T4b
    • Involves peritoneum
    • Difficult/impossible to accurately diagnose by any current imaging
    • Suspect – Bulky advanced tumours on imaging
    • However – usually found at laparoscopy/laparotomy
  • 11. Peritoneal malignancy
    • Common problem – usually terminal event
    • Primary peritoneal
    • Secondary – Ovary, GI Tract, Colon/rectum/Appendix
  • 12. Colorectal carcinomatosis
    • Synchronous with primary
    • Metachronous – More common after T4a tumours, tumour perforation , mucinous tumours etc
    • “ Heart sink” finding at surgery
  • 13. Peritoneal Carcinomatosis
    • For the most part terminal
    • Median 5Yr
    • Sadeghi et al Cancer 2000) 6 months 0%
    • (Chu et al Cancer 1989) 5.2 0%
  • 14. Incidence of Peritoneal Carcinomatosis in Colorectal Cancer
    • Approx 10% at initial diagnosis
    • Approx 25% of patients with recurrent disease
    • 25-35% recurrent disease is peritoneal only
  • 15. Colorectal Carcinomatosis – What can be done ?
    • Consider surgery and HIPEC
  • 16. Emerging Strategy
    • Cytoreduction – (Complete macroscopic tumour removal)
    • H yperthermic I ntra pe ritoneal C hemotherapy (HIPEC) - Intra-operative perfusion of chemotherapy heated to 42 Degrees Celcius
  • 17. Evolution of Technique For Carcinomatosis
    • Derived from success with pseudomyxoma peritonei
    • Improved understanding of clinical and pathological features of mucinous neoplasms
  • 18. Techniques for pseudomyxoma peritonei Paul Sugarbaker Washington
    • Cytoreductive Surgery (CRS) aiming to remove all macroscopic disease
    • combined with
    • Heated Intra-operative Intraperitoneal Chemotherapy (HIPEC)
  • 19.  
  • 20. Pathophysiology of mucinous tumour distribution
    • Redistribution Phenomenon
    • Gravity
    • Concentration of tumour at sites of normal peritoneal fluid absorption
    • Relative sparing of the mobile organs –especially small bowel (Not so if scar tissue from previous surgery)
  • 21. Redistribution
  • 22.  
  • 23.  
  • 24.  
  • 25. NICE – NHS in England
    • N ational I nstitute For Health and C linical E ffectiveness
    • Evaluates Efficacy and cost –effectiveness of interventions, procedures and treatments including drugs
  • 26.  
  • 27.  
  • 28. Traditional Results PMP -1995 (WHC =Washingston, MSK= Memorial Sloan Kettering New York, Mayo Clinic Minneapolis USA) CRS + HIPEC
  • 29. * * * * * * * * * * ** * * * * * * * * * * * * * * * * * * ** * * * * * ** * * * * * ** * * * * * * *** UK and Ireland National Referral centres for Pseudomyxoma Peritonei of Appendiceal origin since 2000 (pop 80 million) Basingstoke 2000
  • 30. Pseudomyxoma Peritonei Complete Cytoreduction
  • 31. Complete cytoreduction Standard Case
    • Right parietal peritonectomy/ R Hemi
    • Greater Omentectomy/Splenectomy
    • Lesser omentectomy+/- Gastrectomy
    • Right Diaphragmatic Peritonectomy
    • Left Diaphragmatic Peritonectomy
    • Anterior resection
    • TAH/BSO
    • Cholecystectomy/Liver capsulectomy
  • 32. Technique- CRS and HIPEC
    • Average operating time – 10 hours
    • Mortality – 1-8%
    • Morbidity – 25-50%
    • Poor results unless CRS complete (predict by imaging ?)
  • 33.  
  • 34. Post –op mortality 1.4%
  • 35.  
  • 36. Question ?
    • Could peritoneal malignancy sometimes represent locoregional disease akin to liver metastases and therefore suitable for locoregional therapy ??
  • 37.  
  • 38.
    • Shen et al Ann Surg Oncol 2008
  • 39. Question ?
    • Evidence base for Liver resection – Any RCT resection versus best chemotherapy ??
    • Evidence base surgery and HIPEC for colorectal carcinomatosis ??
  • 40. Survival Verwaal,Zoetmulder et al RCT Systemic versus HIPEC 2003 Log Rank p = 0.0013 44% versus 24% at 2 years
  • 41.  
  • 42.  
  • 43.  
  • 44.  
  • 45. Glehan et al Cancer PMP Gastric Appendix Colon
  • 46. Survival Complete CRS plus HIPEC appendix colon
  • 47. What do we know about colorectal carcinomatosis and HIPEC ?
  • 48. What do we know about colorectal carcinomatosis and HIPEC ?
    • “ as we know, there are known knowns; there are things we know we know. We also know there are known unknowns, that is to say there are some things we do not know…..
  • 49. What do we know about colorectal carcinomatosis and HIPEC ?
    • “ as we know, there are known knowns; there are things we know we know. We also know there are known unknowns, that is to say there are some things we do not know . But there are unknown unknowns – the ones we don’t know we don’t know. “
    • US Defence Secretary Donald Rumsfeld
  • 50. Summary HIPEC for colorectal carcinomatosis (1)
    • Effective in highly selected cases
    • Localized disease (one quadrant or less)
    • Only effective if complete tumour removal
    • Tumour biology - Appendix adenocarcinoma best
    • Best done at primary operation
  • 51. Summary HIPEC for colorectal carcinomatosis (2)
    • Requires specialist experience
    • High morbidity
    • Expensive strategy
    • May find more suitable cases at laparoscopic colorectal surgery
  • 52. Thank you