Rectal Cancer – Surgical Treatment

Surgical Oncological Treatment of Rectal Cancer

Treatment Priciples

  • If indicated neoadjuvant treatment (Rectal Cancer, RCT)
  • Tumor resection including regional lymphatic drainage
  • Dissection of regional blood vessels (A./V.)
  • 3-Dimensional safty margins
  • Mesocolic or Mesorectal Excision (CME, TME)
  • Multivisceral (en bloc) resection
  • Intraoperative staging
  • Resection of metastases (Liver, Lung, Peritoneum)
  • Exact pathological staging
  • If indicated postoperative chemotherapy

K.H. Link, M. Hauser, M. Mann, P. M. Schlag: Kolonkarzinom, Chirurgische Onkologie Strategien und Standards für die Praxis
Michael Gnant, Peter M. Schlag (Hrsg.), Kapitel 23, 315-329, Springer Wien/New York, 2008

The principle of rectal cancer surgery:

  • The optimal surgical technique and highest experience is mandatory for the patient´s outcome.
  • Local cure must be achieved and pelvic organ function must be preserved.
  • Local relapses or incomplete resection reduce survival quality!
  • Remove („radically“) all visible and microscopic nonvisible lymphatic/nonlymphatic malignant disease within the primary tumor region at risk.
  • No violation of surrounding structures, provide a safe anastomosis; no blood transfusion.
  • An excision of the primary tumor is only allowed in so called low risk T1 tumors limited to the nonmuscular internal layer of the bowel wall.
  • The pelvic nerves must be preserved for pelvic organ function. If possible, a permanent stoma should be avoided.

 

Apply most modern surgical technique (TME, PME etc.) to achieve local tumor control and sphincter preservation.

 

Laparoscopic surgery in (MIC) rectal cancer ?  No/Yes ?!

  • Laparoscopic surgery of colon- and rectal cancer did not improve the surgical oncological results, but may be dangerous in non expert hands! Conversion is associated with a technically related decrease in survival.
  • The original assumption, that MIC improves the long term oncological results, has not been proven.
  • Laparoscopic vs. open surgery in colon- and rectal cancer surgery is superior in hospital stay.
  • Laparoscopic surgery offers better subjective acceptance to the patients.
  • Laparoscopic surgery may be dangerous if there is the necessity to convert to open surgery.The learning curve for surgeons is high.
  • MIC may be offered to qualified patients by highly qualified laparoscopic surgeons.
  • Rectal cancer surgery somtimes must be performed open, e.g. if lateral lymph node dissection (Acc. to Mori) is required.

Anderson, EJSO 34, 1135-1142, 2008; Liang, EJSO 34, 1217-1224, 2008;
K.H.Link, multiple review presentations German Society of General- and Visceral Surgery etc..

 

Professor Link performs rectal cancer surgery according to the methods propagated by his professional friends Professors Bill Heald, Takeo Mori, and Torbjörn Holm.

The techniques prescribe to operate within embryologic sheets (as also originally described by Professor Stelzner/Univ.Bonn) and to preserve the pelvic nerves and thus organ function (bladder, anal sphinkter, sexual function). The principles of the Ulm Surgical School (Professor Beger: „careful, within anatomic planes, conservative but oncologically radical, no blood transfusion, no morbidity, follow up, scientific analysis etc.“) of course are applied and trained in the team.

As a pelvic organ function parameter, less than 1% of the rectal cancer patients treated at APK/ATC have severe problems with emptying of the urinary bladder (vs. 12% reported from other expert centers)

(pls. click to enlarge tables & pictures)

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Open surgery in rectal cancer with nerve preserving extended lateral lymph node dissection is necessary in certain patients. The technique according to T. Mori must be indicated and performed by open (not laparoscopic) surgery by expert rectal cancer surgeons.

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Rectal Cancer: Surgery – Multimodal Therapy

The aim at the beginning was to improve survival and reduce local relapses. We, the „Forschungsgruppe Onkologie Gastrointestinal Tumoren“ (FOGT) (Multidisciplinary research group on oncology of gastrointestinal tumors. Initiator/head: K.H.Link) aimed at improvement of survival time, -quality, and -rates. Protocols were designed involving the prescription of up to date standardized surgery and test protocols for better chemotherapy. Basic research studies were added.

K.H.Link, L. Staib, E.-D. Kreuser, H.G. Beger; Adjuvant Treatment of Colon and Rectal Cancer: Impact of Chemotherapy, Radiotherapy, and Immunotherapy on Routine Postsurgical Patient Management.
Recent Results Cancer Research 142 (1996) 311-352

K.H.Link, L. Staib, M. Schatz, P. Suhr, E. Röttinger, H.G. Beger; Rectal Cancer: Adjuvant radiochemotherapy – what is the patients benefit? Langenbeck’s Archives of Surgery 383 (1998) 416-426

K.H.Link, M. Kornmann, R.Bittner, F,Köckerling, R.Arbogast, I.Gastinger, W.Heitland, D.Henne-Bruns, H.Lang, H.Lippert, M.Mann, H.J.Meyer, M.-J.Polonius, S.Post, R.Raab, T.Schiedeck, V.Schumpelick
Qualitätsanforderungen zur Behandlung des Kolon- und Rektumkarzinoms – Aus chirurgischer Sicht.
Chirurg 81, 222-230, 2010

 

The „Forschungsgruppe Onkologie Gastrointestinale Tumolren (FOGT) (Research Group on Oncology of Gastrointestinal Tumors) improved surgery alone by multimodal therapy of rectal cancer.

In the FOGT 2 trial with participation of >790 rectal cancer patients and 55 hospitals local relapse rates in all treatment arms were significantly less than in historical controls (patient treated by surgery only) by applying better standardized (TME) surgery and postoperative radiochemotherapy. Other than in colon cancer, survival was not improved by using three various chemotherapy protocols. FOGT helped to establish multimodal therapy in rectal cancer.


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Now neoadjuvant radiochemotherapy is standard in rectal cancers stages II+III located in the lower two thirds of the rectum (up to 12 cm from anal verge). Sometimes, as to expert opinions, this may be overtreatment.

 

Multimodal Treatment in Rectal Cancer, Status 2014:

Neoadjuvant Radiochemotherapy (RCT) is superior to postoperative RCT in terms of LR-rates, not survival
(Sauer 2004).

Neoadjuvant RCT with FOLFOX is not superior to 5-FU+FA
(Aschele 2011 and German Rectal Cancer Study Group (Rödel 2007) .

Multimodal Chemotherapy with 5-FU has not been improved
(M Kornmann, KH Link, A.Formentini; Colorect Cancer 1-13, 2014)

Neoaduvant RCT induced pCR´s, may facilitate surgery in T3 tumors, and is mandatory in T4 tumors.

Response to Neoadjuvant RCT predicts benefit of the whole Neo/Adj RC concept
(Gerard 2006, Bosset 2006).

Neoadjuvant RCT may cause problems!
(K.H.Link, M.Kornmann, multiple papers; M.Kornmann, JCO 26, 4866-8, 2009).

There seems to be no benefit of multimodal RCT in the upper third
(S3 Guide Lines GCS/AWMF 2013) .

Future: Depth of mesorectal infiltration, margin. Individualize!
(Kornmann, JCO 26, 4866-8, 2008; M Kornmann, KH Link, A.Formentini; Colorect Cancer 1-13, 2014)

Colon and rectal cancer differ in chemosensitivity in multimodal (adjuvant) treatment.

Rectal cancer patients have a higher frequency of lung metastases after adjuvant therapy with identical 5-FU based CT (Lung metastasis in FOGT 1 (colon) vs. 2 (rectum);  7.3% vs. 12.7%).
M Kornmann, KH Link, A.Formentini; Colorect Cancer 1-13, 2014Marko Kornmann, Ludger Staib, Thomas Wiegel, Martina Kron, Doris Henne-Bruns, Karl-Heinrich Link,
Andrea Formentini for the Study Group Ocology of Gastrointenstinal Tumors (FOGT),
Clinical Colorectal Cancer 12 (1), 54-61, 2013