TME and CME Surgical Standards H. Becker Göttingen 01/2011

Total Mesorectal Excision (TME)

Surgery – Rectal Cancer - TME - Standard  Local Recurrence Prognosis 

Totale Mesorektale Excision - Prognosis – Development - Trial Therapy CRM + LR Survival Swedish Cancer Trial RT + Surgery R 0 – Res. 27 % 48 % ( 5 Y.) 1987 – 1990 30 % (10 Y.) (J Clin Oncol 2006) Dutch TME Trial RT + TME 17 % 21 % 57 % (5 Y.) 1996 – 1999 24 %  N+ (Stage III) 70 % (CRM -) (Ann Surg 2007) MRC CR07 Trial RT + TME + RCT 11 % 18 % 57 % (3 Y.) 1998 – 2005 84 % (CRM -) (ASCO 2006/Lancet 2009)

Total Mesorektal Excision (TME) Distal Mesorectal Tumor Spread – Göttingen Experience –

Total Mesorektal Excision (TME) Distal Mesorectal Tumor Spread – Göttingen Experience – 0.5 cm slices Tumor

Distribution of Mesorektal Lymph Nodes and Metastases after preoperative RCT – Göttingen Experience – Sprenger T, Liersch T, Becker H: ASCO-GI 2009 Sprenger T, Becker H: J Gastrointest Surg 2010 Localisation and Distribution of Lymph Nodes/Metastases within Mesorectum n = 64 Patients Localisation: Number LN- Metastases Micro-metastases LN - Involvement (%) P-value Distal 177 0 0 0 - Peritumoral 449 34 9 7,6 < 0,001 Proximal 1395 19 6 1,4 Total 2021 53 15 2,6

Quality of Surgery Quality has a tremendous impact on recurrence! good quality bad quality

TME Specimen after preoperative RCT and perioperative Quality Assessment: Ink Injection via Sup. Mesenteric Artery

Sexual Dysfunction – Rectal Cancer - surgery – hemostasis - - conventional sharp dissection (nerve sparing technique) - electrosurgical sources - ultrasonic energy sources

Sexual Dysfunction – TME - laparoscopic vs. conventional - author patients male active sexual dysfunction Quah 2002 lap. TME n = 40 n = 15 n = 7 (47 %) conv. TME n = 40 n = 22 n = 1 (4,5 %) p < 0.0004 Jayne 2005 lap. TME n = 74 n = 56 n = 23 (41 %) conv. TME n = 34 n = 26 n = 6 (23 %) p < 0.06 Quah, H.M., Br J Surg, 2002; 89: 1551 - 1556 Jayne, D.G., Br J Surg, 2005; 92: 1124 - 1132

Standardized Surgery Standardized Radiation

APR – Lower Rectum (4 - 8 cm) - Indications – Problems - LR Survival CRM + Author APR vs. AR APR vs. AR APR vs. AR Marr 36,5 % / 22,3 % 52,3 % / 65,8 % 41,0 % / 12,0 % Leeds 2005 Nagtegaal 30,4 % / 10,7 % 38,5 % / 57,6 % 39,9 % / 16,7 % Dutch Trial 2005 Ann Surg 242: 74 – 82 (2005) J Clin Oncol 23: 9257 – 9264 (2005)

M. Diop, Surg Radiol Anat (2003)

- RE + TME -

Surgery CT/RT CTx CT/RT Surgery CTx Sauer, Becker et al., N Engl J Med. 2004 Treatment of Rectal Cancer CAO/ARO/AIO-94 Trial

Long-Term Results: standardised Multimodal Therapy Department of General and Visceral Surgery, Göttingen 1998 – 2005 N = 177 Patients Month Month Disease Free Survival Overall Survival YES YES NO NO Total Local Recurrence (LR): 14 / 177 7.9% Local Recurrence adjuvant RCT: 10 / 82 12.2% TARR: 9 APR: 1 Local Recurrence neoadjuvant RCT: 04 / 95 4.2% TARR: 1 APR: 3

Pathologic Diagnostics of TME Specimens CRM LN-Metastasis Partial Tumor Regression

A Colorectal Cancer

TME PME – TME – Extend of Resection TU 5 cm PME Peritoneal Fold Ventral Prospect Dorsal Prospect Distal Resection Margin Distal Resection Margin with Contour ® -Stapler TU

Outcome of Colon versus Rectal Cancer (5 yr relative survival) Data from ISD % courtesy Prof. R J C Steele / Dundee

Editioral Colonic surgery for cancer: a new paradigm While these advances were being made in rectal cancer ( - Bill Heald `s TME; - Phil Quirke `s circumferential margin) surgery for colonic cancer has been left untouched . Najib Haboubi, Colorectal Disease 2003, 11; 333-334, 2009

Colon Cancer Pericolic Lymphatic Spread

Visceral plane (mesentery) kidney aorta spleen liver stomach Somatic (parietal) plane

Anatomy of the Colon Mesocolon Lymphatic drainage pancreatic LN (head) superior mesenteric LN inferior pancreatic LN pyloric LN

Surgery for Colon Cancer Complete Mesocolic Excision (CME) Preservation of the mesocolic plane by sharp dissection off the parietal plane (turning embryology back) Regional and central lymphnode dissection with high tie of suppling vessels

Methods – tissue morphometry D A = Distance from tumour to high tie B = Distance from nearest bowel wall to high tie C = Length of large intestine D = Cross sectional area of mesentery A B C D

2 % 36 % 11 % Involved LN (%) Carcinoma of the transverse Colon (right flexure) Toyota et al. Dis Col Rect 1995; 38:705-711

Colon Cancer Lymphnode Involvement N1 T 52 % N1 O/A 30 % N2 16 % N3 2 % 10 cm 5 cm 5 cm 10 cm Oral Anal N2 O N2 O N1 O N1 T N N2 A N2 A N2 N2 N3 K.Y. Tan et al 2010; n=281 node positive resection

number of OS DFS l.n. (n=1857) (n=1857) 0-10 (n=1020) 67% 65% 11-40 (n=807) 74% 70% >40 (n=30) 93% 90% Colon Cancer Extend of Lymphode Dissection Survival – pN1 5 years survival, number of l.n. examined Le Voyer et al, JCO 2003; 21: 2912