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Peritoneal spread risk in gastric, pancreatic and colon cancers

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Lecture given by Prof Gina Brown at the 10th International Congress on Peritoneal Surface Malignancies, Washington November 2016. Proforma report template available in Documents section of slideshare

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Peritoneal spread risk in gastric, pancreatic and colon cancers

  1. 1. Peritoneal spread risk in Gastric , Pancreatic and Colon cancers www.slideshare.net/GinaBrown3
  2. 2. Understanding patterns of failure • Improvements in surgical technique • Identification of subgroups benefiting from preoperative therapy • Refine radiotherapy Rx volumes • Primary endpoint of rectal cancer trials
  3. 3. Predictable patterns of recurrence • Tumour spillage • CRM involvement • Peritoneal perforation • Distal margin involvement • Residual disease
  4. 4. Space of Retzius Bladder mesorectum rectum peritoneal peritoneum Mesorectal fascia
  5. 5. Post surgical pelvis
  6. 6. Post TME pelvis
  7. 7. Marginal pattern of recurrence Starling, Scott-Mackie, Brown et al 2005
  8. 8. CRM involvement and later recurrence
  9. 9. Marginal recurrence
  10. 10. Anastomosis
  11. 11. Anastomotic recurrences
  12. 12. Tumour spillage
  13. 13. Perineal recurrence Perineal
  14. 14. Hydronephrosis = strong likelihood of local recurrence Brown et al Clinical Radiology 2003 75 patients, new hydronephrosis is a predictor for peritoneal recurrence (90% of patients).
  15. 15. Peritoneal perforation
  16. 16. Distal margin involvement
  17. 17. Nodal recurrence
  18. 18. Nodal recurrence
  19. 19. Krukenberg Tumours
  20. 20. Relapse Pattern No of Patients n=70 (a) Marginal (around the margins of the surgical bed) 43.9% (b) Lymph node (internal or external iliac groups) 24.3% (c) Pelvic peritoneal 22.0% (d) Perineal 14.6% (e) Anastomotic 12.2% (f) Krukenberg 2.4%
  21. 21. • MDT 2007-09 • 296 sigmoid cancers • 104 for palliative care • Curable sigmoid cancers: n=192 • No FU data at all: n=42 • With FU: n=150 • FU 36 months (range 1-76, median 38) • Recurrence: 62/192 (32%) • Local recurrence: 19 (11%) Recurrence sigmoid cancer
  22. 22. High risk features • Tumour involving non peritonealised fascial margin • Tumour penetration of adjacent organs • 4 or more involved nodes • Extramural venous invasion • Depth of extramural spread >5mm
  23. 23. Eur J Surg Oncol. 2005 Oct;31(8):845-53. Improved survival
  24. 24. Are we able to preoperatively identify poor prognostic features in colon cancer?
  25. 25. Burton 2006 Int. J. Radiation Oncology Biol. Phys
  26. 26. • Primary surgery n=57 • 16 at/above peritoneal reflection • 19 rectosigmoid • 22 sigmoid • Neoadj CRTx + surgery n=18 • 9 at/above peritoneal reflection • 5 rectosigmoid • 4 sigmoid Burton 2006 Int. J. Radiation Oncology Biol. Phys
  27. 27. MRI predicted prognosis with final histological prognosis in 57 patients undergoing primary surgery Final histological prognosis Good Poor Total MRI Good 31 6 37 Predicted Prognosis Poor 10 11 21 Totals 41 17 58 84% (CI =72.6-92.7%) accuracy for MRI prediction of prognosis Kappa = 0.63 Sensitivity = 90% Specificity = 72% Positive predictive value = 88% Negative predictive value = 76% Burton 2006 Int. J. Radiation Oncology Biol. Phys
  28. 28. Diagnostic dilemmas – is it recurrent disease or not? • Mass - ? Significance • Scar vs recurrence • PET-ve • Inflammatory collection vs recurrence
  29. 29. New Mass Examples of reporting criteria
  30. 30. Importance of baseline review 2004 2000
  31. 31. Peritoneal pelvic recurrence
  32. 32. Scar vs Recurrence
  33. 33. Collection vs Recurrence
  34. 34. PET-ve
  35. 35. Anatomical information – to plan resection/resectability • Which compartment? • Which sacral level? • Multifocal vs unifocal – High res MRI essential • Distant metastases, review of both contrast enhanced MDCT and CT-PET helpful • Trial of chemotherapy/RT prior to radical surgery – response assessment
  36. 36. Operation likely? – yes/ probably no • Yes: – Central compartment – Anterior compartment below peritoneal reflection – Posterior compartment below S2 – Perineal • Probably no: – Lateral compartment – Sciatic nerve infiltration (coronal imaging) – S1/S2 sacral infiltration – Peritoneal perforation
  37. 37. Post TME pelvis
  38. 38. Central compartment
  39. 39. Post Chemo
  40. 40. Lateral compartment
  41. 41. Key messages • Know patterns of recurrence • Familiarity with post surgical pelvis • FDG PET-CT helpful tool • Growing mass on CT/MRI with elevated CEA = diagnostic of recurrence
  42. 42. Conclusions • GI Radiologists now play a key role in the MDT for detecting and selecting patients with recurrent disease for radical treatment – Aggressive imaging based follow up of high risk patients results in earlier detection increases survival – Anatomic delineation and characterisation of lesions using both MDCT/MRI with contrast – Careful use of multimodality imaging in assessing extent of disease (PET/MRI/CT)
  43. 43. Gastric cancer risk factors • Published evidence – clinico pathological risk features • Imaging assessment of gastric cancer • Delineation of the primary tumour • Nodal disease versus extranodal disease and its depiction on CT
  44. 44. Pancreatic cancer • T4 and transperitoneal seeding – Known Mechanisms of transperitoneal spread in pancreatic cancer and rates of PC – Lymphatic – Vascular – Implantation and seeding
  45. 45. For the group to develop in future: • More work in determining imaging features at baseline for peritoneal relapse T category is too broad and crude a tool • Improve documentation of tumours at baseline and compare against outcomes • Patterns of spread are key • Proforma reporting and consistent documentation at diagnosis and at relapse is essential

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