The document discusses a case of rectal cancer and provides information on imaging and treatment options for rectal cancer. It summarizes various studies on imaging modalities for staging rectal cancer such as ERUS, CT, and MRI. It also reviews studies on the role of adjuvant chemotherapy and chemoradiation therapy after surgery for rectal cancer. Alternative non-operative approaches for locally advanced rectal cancer are presented.

1. A C A S E D I S C U S S I O N
A N D A S C O B E S T PA P E R
Prof. Shad Salim Akhtar
MBBS, MD, MRCP(UK), FRCP(Edin), FACP(USA)
Fellow AUICC, Member ASCO, ESMO
Consultant Medical Oncologist
Chairman Board of Directors
Hakim Sanaullah Specialist Hospital & Cancer Centre
Sopore, Kashmir, J & K

2. A PAT I E N T W I T H
R E C TA L C A N C E R

3. W H AT N E X T I N R E C TA L C A N C E R ?
• Good physical examination
• DRE
• Liver enzymes
• Alk phos
• Incomplete colonoscopy?
• CT Colonography
• Capsule endoscopy

4. I M A G I N G I N R E C TA L C A N C E R
• Loco-regional staging
• CT
• MRI
• Diffusion Weighted-Imaging (DW-MRI)
• Dynamic Contrast Enhanced (DCE-MRI)
• Good for assessing response
• ERUS or TEUS

5. W H AT N E X T I N R E C TA L C A N C E R ?
• CT Scan
• Abdomen pelvis
• Chest
• May be important in rectal cancer (hemorrhoidal vein)
• 10-30% indeterminate lesions
• Metastasis if
• nodal metastasis (loco regional), multiple, >=5mm,
parenchymal vs sub pleural, no calcification &
rectal primary
• MRI Liver
• Suspicious CT especially background fatty changes
• PET scans
• Prior to attempted resection of metastasis (es)

8. MRI VS ERUS ERUS VS CT MRI VS CT
Sens T1/T2 Vs
T3/T4
MRI 88.9% (79-94)
ERUS 88.0% (80-93)
NA NA
Spec T1/T2 Vs
T3/T4
MRI 85.3% (70-93)
ERUS 85.6% (66-95)
NA NA
Accuracy 1.24 (0.835-1.84) 0.359(0.238-0.541) 0.317(0.056-1.784)
Understaging 1.571(0.605-4.083) 0.626(0.438-0.894) 0.317(0.027-3.646)
Overstaging 1.05(0.518-2.16) 0.427(0.28-0.798) 0.317(0.028-3.653)
Favours None ERUS None
T S TA G E I M A G I N G M O D A L I T I E S
Bruening W et al: AHRQ 2014

9. MRI VS ERUS ERUS VS CT MRI VS CT
Sensitivity
MRI 49.5% (36-63)
ERUS 88.0% (80-93)
CT 39.6% (28-52)
ERUS 49.1% (35-63)
NA
Specificity
MRI 69.7% (52-83)
ERUS 73.7% (44-91)
CT 93.2% (59-99)
ERUS 71.7% (56-83)
NA
Accuracy 0.882 (0.542-1.408) 1.13(0.85-1.503) 1.316(0.709-2.443)
Understaging 0.972(0.563-1.679) 1.453(0.854-2.473) 1.743(1.028-2.957)
Overstaging 0.752(0.457-1.237) 1.015(0.571-1.801) 0.498(0.308-0.806)
Favours None None
MRI For Avoiding
Overstating
N S TA G E I M A G I N G M O D A L I T I E S
Bruening W et al: AHRQ 2014

11. R O L E O F M R I I N R E C TA L C A N C E R
European Scandinavian Model
Blomqvist L et al: Acta Oncol. 2008; 47:5-8

12. R O L E O F A D J U VA N T F U A F T E R N A C T / R T I N
R E C TA L C A N C E R . E R O T C 2 2 9 2 1 S T U D Y
Boset JF etal. Adj 5FU based CT Rect Ca. Lancet Oncology 2014;15:184-90

13. R O L E O F A D J U VA N T F U A F T E R N A C T / R T I N
R E C TA L C A N C E R . E R O T C 2 2 9 2 1 S T U D Y
Boset JF etal. Adj 5FU based CT Rect Ca. Lancet Oncology 2014;15:184-90

14. Boset JF etal. Adj 5FU based CT Rect Ca. Lancet Oncology 2014;15:184-90
R O L E O F A D J U VA N T F U A F T E R N A C T / R T I N
R E C TA L C A N C E R . E R O T C 2 2 9 2 1 S T U D Y

15. P = 0.73
P R O C T O R - S C R I P T ( D U T C H T R I A L ) A D J U VA N T
F U / C A P R E C TA L C A A F T E R N A C R T
Breugom AJ et al. Adj CT after NACRT Rectal Cancer Ann Onco 2015;26:696-710

16. P = 0.11
P R O C T O R - S C R I P T ( D U T C H T R I A L ) A D J U VA N T
F U / C A P R E C TA L C A A F T E R N A C R T
Breugom AJ et al. Adj CT after NACRT Rectal Cancer Ann Onco 2015;26:696-710

17. P = 0.39
P R O C T O R - S C R I P T ( D U T C H T R I A L ) A D J U VA N T
F U / C A P R E C TA L C A A F T E R N A C R T
Breugom AJ et al. Adj CT after NACRT Rectal Cancer Ann Onco 2015;26:696-710

18. Long-term results of the ADORE trial:<br /><br />ADjuvant Oxaliplatin, leucovorin, and 5-fluorouracil (FOLFOX) versus 5-fluorouracil and leucovorin (FL) after preoperative chemoradiotherapy and surgery
for locally advanced REctal cancer
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

19. Slide 3
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

20. Study design and Rationale
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

21. Slide 5
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

22. Slide 6
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

23. Slide 7
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

24. Slide 8
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

25. Slide 9
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

26. Slide 10
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

27. Disease-free survival, ITT population
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

28. Disease-free survival, ypStage III
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

29. Slide 13
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

30. Slide 14
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

31. Slide 15
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

32. Slide 16
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

33. Slide 17
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

34. Slide 18
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

35. Slide 19
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

36. Slide 20
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

37. Slide 21
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

38. Slide 22
Presented By Yong Sang Hong at 2018 ASCO Annual Meeting

39. H E H A D A P C R
I S N O T O U R PAT I E N T D I F F E R E N T ?

40. Dossa F et al JAMA Oncol April 2018; E1-E8

41. Dossa F et al JAMA Oncol April 2018; E1-E8

42. Dossa F et al JAMA Oncol April 2018; E1-E8

43. N O N O P E R AT I V E M A N A G E M E N T
CCR
Regrowth
(%)
Time to
regrowth
months
Salvage
(%)
Os Nom
Vs Om %
Dfs Nom
Vs Om (%)
Stoma
Haabr-Gama et al 71 2(3) 60 2(100) 5 Yrs 100/88 5 Yrs 92/83 0 Vs 41%
Maas et al 21 1(5) 22 1(100) 2 Yrs 100/93 2 Yrs 89/91 0 Vs 45%
Smith et al 32 6(19) 11 6(100) 2 Yrs 96/100 2 Yrs 88/98 Na
Araujo et al 42 5(12) 48 4(80) 5 Yrs 72/90 5 Yrs 61/83 7 Vs 19%
Li et al 30 2(7) 22 2(100) 5 Yrs 100/96 5 Yrs 90/94 0 Vs 43%
Garcia-Aquilar J et al: ASCO Education Book 2016; 92

44. T O TA L N E O - A D J U VA N T C H E M O T H E R A P Y N O M
23
50
73
12
12
24
No Surgery
Cercek A et al: JAMA Oncology. 2018; 4:1-8