- The patient is a 36-year-old man who underwent neoadjuvant chemoradiotherapy in 2015 for rectal cancer. - In 2021, he presented with frequent urination. Imaging showed a large recurrent mass involving abdominal structures. - Biopsy of the skin deposit was suspicious for metastatic mucinous carcinoma. - The case discusses the current treatment approaches for locally advanced rectal cancer, including neoadjuvant and total neoadjuvant therapy options, and choices for chemotherapy and radiotherapy.

1. CASE BASED DISCUSSION
DR. R. RAJKUMAR D.M.
CONSULTANT MEDICAL ONCOLOGIST
VELAMMAL MEDICAL COLLEGE &
SPECIALITY HOSPITALS

2. CASE BASED DISCUSSION
• 36 yrs/ M
• CA RECTUM ( 2015)
• cT3

3. CASE BASED DISCUSSION

4. CASE BASED DISCUSSION
• Neoadjuvant chemoRT
Received 25 + RT/ 3×
chemo
• 8/2015

5. CASE BASED DISCUSSION

6. CASE BASED DISCUSSION

7. CASE BASED DISCUSSION
How will U treat in 2021?
1. NACT+RT SURGERY
2. TNT SURGERY

8. CASE BASED DISCUSSION
• CHOICE OF NEOADJUVANT CHEMO
1. INFUSIONAL 5 FU
2. CAPECITABINE
3. CAPEOX
4. CHEMO+BIOLOGICALS

9. CASE BASED DISCUSSION
• CHOICE OF RT
1. SCRT
2. LCRT

10. CASE BASED DISCUSSION
• CHOICE OF SURGERY
1. OPEN
2. LAPROSCOPIC
3. ROBOTIC

11. Figure 6a. Tumor location in the craniocaudal direction. (a) Illustration depicts the sagittal view of the rectum and provides the measurements of the tumor from the anal
verge, which help categorize tumor location. Blue lines separate the low, mid-, and high rectum. (Figure 6a reprinted, under a CC BY-ND 4.0 license, from Memorial Sloan
Kettering Cancer Center.) (b–d) Sagittal T2-weighted MR images show tumors (arrow) in the high (b), mid- (c), and low (d) rectum. Dotted line = measurement from the
rectum entrance to the tumor location.
Horvat N. Published Online: February 15, 2019

12. High LRfollowingAPRandAR:20-50%(35%).
Sphincter preservation.
Tolive withastoma.
Infections and sexualdysfunction.

13. Why such a complexity
?
CT RT  TME 
CT
2
1
4
5 7
8
9
Which RT?
3 6
Necessar
y ?
whic
h
CT?
Staging
?
Always
?
Which
chemo?
Always?
All neoadj ?
Preop/postop?
interval?
Avoidable
?
Staging
?

16. Surgery +/- RT postop NSABP R-01

17. SURGERY +/- PREOP RT 5X5 SWEDISH NEJM 1997
Confirmed by Stockholm 2 ( identical design ) and indirectly by Stockholm 3 ( LC vs 5x5 vs interval)

19. Surgery +/- FU postop NSABP R-01

20. GITSG.
NCCTG.
NSABPR-01.
N EnglJMed 1986;315:1294.
FJNatl CancerInst 1988;80:21.
N EnglJMed 1991;324:709.
Adjuvant
Fluoroupyremidine
X2months
CRT–6Weeks
Adjuvant
Fluoroupyremidine
X2months

21. POSTOP RT +/- FU Krook NEJM 1991

22. Best companion for postop RT : bolus or c.i. FU O’
Connell NEJM 1994

24. NSABP R-04
CI FU or capecitabine along with preop RT ?

25. NSABP R-04
Role of OXALIPLATIN on top of preop c.i. FU RT ?

26. .

27. 1. T3 –T4 Lesions:The only definitive
indication.
2. cT3N0: Should be treated(understaging).
3. Depth of ExtramuralInvasion:
 T3 lesions (>5 mm)  ++ LNs involvement  Higher CancerSpecific
Survival (54%Versus85%).
 Selection of high riskT3for treatment.
 Approved outsideUS.
4. T1–2 lesions withPositive Nodes.
5. Low situated lesions.

28. Grade Regression Fibrosis
0 No All cells areviable
1 Minor <25%fibrosis
2 Moderate 26 –50%nFibrosis
3 Good >50%
4 Total NoViable Cells
Grade 10 –yearDM P 10 –Year DFS P
0 - 1 39.6%
0.005
63%
0.008
2 - 3 29.3% 73.6%
4 10.5% 89.5%

29. PolishTrial
Trans-Tasman
Radiation
OncologyGroup
• Local Recurrence.
• DFS
• Distant Recurrence
• OAS
• Severe LateToxicity
EQUIVALENT
JClinOncol2012;30:3827.
BrJSurg2006;93:1215

30. Sobrero Pastorino in Schmoll 2018

31. Figure 1. Schematic flowchart summarizes the current management concepts of rectal cancer in the United States and Europe.
Horvat N. Published Online: February 15, 2019

32. Total neoadjuvant therapy in locally advanced rectal cancer: Role of systemic chemotherapy

33. Local recurrence: persistent
problem
1984-1993 : 99 pts – low/mid rectal cancer
Intraoperative tumor break : 12 (13%) : LRR 45% despite
postop RT
LRR
APR SSO
at 1 yr 13% 5%
at 5 yr 27% 21%
5 yr
Survival
61
%
67
%
Leuven –
data

34. TME -concept
DRM : distal resection margin
CRM : circumferential resection
margin
T
N

35. Ejaculatio
n
Erectile
dysfunction
Urinary
problems

36. TME implementation rsulted in a
significant decreaseinAPR ratein Belgium
(significant differencesremainfor distalrectalcancer))
1995 – 1997
50 %
2006 – 2009
22 %

37. Evolution in Surgery
Open surgery
Laparoscopic
surgery
Robotic surgery
SS
L NOSE
TAMI
S
NOTES
time
EMR
Endoscopic
polypectomy Endoscopic biopsy
Diagnostic endoscopy
invasivene
ss recent
evidence
disruptiv
e increment
al

38. Minimally Invasive surgery inevolution
Hand-assisted +
Pfannenstiehl
Total Laparoscopic

39. COLORII trial (non-inferiorityphase III) 2004-2010
1044 patients randomised (2:1)
699 in laparoscopic surgery group 345 in open
surgery group
Locoregional recurrence rate at 3 years : 5.0% in both groups DFS: 74.8%
(laparoscopic) and 70.8% (open)
OS : 86.7% (laparoscopic) and 83.6% (open)

40. CONVERSION TO LAPAROTOMY REMAINS
SUBSTANTIAL
%

41. Primary endpoint – conversion to open surgery
Lap
(n=230)
Robotic
(n=236)
Total
(n=466)
Difference in rates
(95% CI)
Conversion 28 (12.2%) 19 (8.1%) 47 (10.1%) 4.1% (-1.4%, 9.6%)
Overall conversion rate: 10.1%
Lap (n=28) Robotic (n=19)
Reasons for intra-op conversion to open*
Adhesions 1 (3.6%) 0 (0.0%)
Advanced cancer 3 (10.7%) 4 (21.1%)
Anaesthetic complication 0 (0.0%) 1 (5.3%)
Completion of rectal/pelvic dissection 11 (39.3%) 9 (47.4%)
Difficult colonic mobilisation 3 (10.7%) 2 (10.5%)
Haemorrhage 3 (10.7%) 3 (15.8%)
Obesity 6 (21.4%) 0 (0.0%)
Robotic collisions 0 (0.0%) 1 (5.3%)
Visceral injury 1 (3.6%) 2 (10.5%)

42. BECOMING MORE PROFICIENT : CRM
POSITIVITY (%)
Robotic versus laparoscopic
TME
Laparoscopic versus open
TME
Laparoscopic versus open colon and
rectum

43. Disease free
survival
Overall
survival

44. TransanalTME (taTME)

45. Laparoscopic low anterior resection and transanal pull-through
for low rectal cancer: a Natural Orifice Specimen Extraction
(NOSE) technique. D'Hoore A, Wolthuis AM. Colorectal Dis.
2011 Nov;13 Suppl 7:28-31
From TATAto notes, how taTME fits into the
evolutionary surgical tree

46. APE : optimizing surgical
technique “cylindrical
APE”

47. Mesorectum Quality Assessment
• Grades 3-1
• Intact > Moderate > Incomplete
• Great indicator of the patient’s prognosis

48. KNOWING THE MARGINS
1. Mucosal
2. Serosal
3. Mesenteric radial
4. Radial
5. CRM

49. CASE BASED DISCUSSION
• DFS 6 YRS
• FREQUENT URINATION ( 2021)
• REEVALUATION

50. DEPARTMENT OF RADIODIAGNOSIS
Clinical status: A post operative follow-up case of CA rectum.
 Rectum and prostate are not visualized - post surgical status.
 Soft tissue thickening seen at the presacral level.
 Evidence of ill-defined T2 high signal intense irregular marginated lessenhancing solid mass lesion of size measuring ~ 7.9 x 6 x 10.3cm seen at the retroperitoneal region.
 The lesion is seen inferiorlyencasing and compressing the bilateral common iliac arteries and veins.
 Anteriorly and superiorlythe lesion is seen encasing and infiltrating the adjacent bowel loops (small bowel loops), mesenteryand peritoneumand extending to the anterior abdominal
wall through the defect in umbilical level.
 Laterallyand posteriorlythe lesion is seen extending upto the level of colostomy stoma.
 Left mid and distal ureter are infiltrated and encased by the lesion and causing left sided hydroureteronephrosis.
 Posteriorlythe lesion is seen eroding the anterior portion of L5 vertebra.
 The above lesion is showing restricted diffusion.
o Possibility of secondaries/ recurrent mass lesion.
 Minimal free fluid seen at the perihepatic, subdiaphragmatic space and pelvis.
 No evidence of liver and adrenal secondaries.
 Colostomy changes seen at the left iliac fossa.
 Urinarybladder is minimally filled.
 Abdominal aorta and abdominal portion of IVC appearsnormal.
Contd…..,
Name : Mr. Jesu Raj Date: 25.02.2021
Age : 42Y / M ID.No: 2102240048
MRI - ABDOMEN AND PELVIS (PLAIN & CONTRAST)
Technique: Abdomen:
T1W, T2W, FIESTA-FS Axial T2W, FIESTA-FS Coronal FIESTA-FS Sagittal
Pelvis:
T1W, T2W STIR axial T2W, T2FS, FIESTA-FS coronal T2W, FIESTA-FS sagittal

51. CASE BASED DISCUSSION

52. DEPARTMENT OF PATHOLOGY
NAME
IP NO
LAB ID
PATHOLOGY NO
: MR. JESURAJ.M
: 222700
: 33036928
: S - 663 / 2021
UHID
AGE/SEX
RECEIVED DT
REPORTED DT
: 2102240048
: 42 Years/Male
: 27/02/2021 13:09:32
: 04/03/2021 17:25:25
WARD/UNIT/DEPT : Medical Oncology Female Ward (TF) - 313 / I / MEDICAL ONCOLOGY
HistoPathology Report
CLINICAL DETAILS :
Known case of Carcinoma rectum recurrence.
Ultrasound guided biopsy from anterior abdominal wall skin deposit.
Clinical suspicion: ? Metastasis.
GROSS :
Received multiple tiny grey white tissue fragments altogether amounting to 0.1 ml. All embedded - 1
block.
MICROSCOPIC FINDINGS :
Sections show fragments of partly hyalinized fibrous connective tissue with pools of extracellular PASD+
mucin. Occasional small clusters, strips and possibly fragmented glands lined by columnar cells, including
cells resembling goblet cells with PASD+ vacuolated cytoplasm, exhibiting mild to focal moderate nuclear
pleomorphism are seen within the mucin pools. Occasional muciphages are also noted. Deeper levels
have been examined.
IMPRESSION :
SCANTY ULTRASOUND GUIDED BIOPSY FROM ANTERIOR ABDOMINAL WALL SKIN DEPOSIT
WITH EXTRACELLULAR MUCIN POOLS AND SCATTERED ATYPICAL COLUMNAR CELL
CLUSTERS.
NOTE: HISTOLOGICAL FEATURES IN THIS SCANTY BIOPSY ARE SUSPICIOUS OF METASTATIC
MUCINOUS CARCINOMA. SUGGEST CLINICO-RADIOLOGICAL CORRELATION AND REPEAT
BIOPSY, IF NECESSARY.
Dr.Jagan C
Associate Professor
**** END OF REPORT ****
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