Se ha denunciado esta presentación.
Utilizamos tu perfil de LinkedIn y tus datos de actividad para personalizar los anuncios y mostrarte publicidad más relevante. Puedes cambiar tus preferencias de publicidad en cualquier momento.

cCR TO NACTRT RECTUM-WHAT NEXT?

cCR TO NACTRT RECTUM-WHAT NEXT?

  • Sé el primero en comentar

cCR TO NACTRT RECTUM-WHAT NEXT?

  1. 1. DR KANHU CHARAN PATRO MD,DNB [RADIATION ONCOLOGY], MBA. PDCR. CEPC, FAROI HOD, RADIATION ONCOLOGY. MGCHRI. VISAKHAPATNAM 1 drkcpatro@gmail.com M-9160470564 Clinical and radiological CR after NACTRT in Rectal Cancer- What next?
  2. 2. ESMO ALGORITHM
  3. 3. OPTIONS • Active surveillance • Limited surgery at cCR • Surgery after recurrence • Complete CHEMO
  4. 4. • “Planned” Organ Preservation or “Incidental” cCR? • How to Select Patients for a “Watch and Wait” Strategy? And When Is the Optimal Time Point for Response Assessment? • What Is the Optimal Surveillance Strategy? • Is Limited Surgery an Option? • Could We Harm Our Patients? Questions?
  5. 5. RESPONSE ASSEMENT • DRE • PROCTOSCOPY • REIMAGING BY MRI • CEA
  6. 6. Habr-Gama definition of cCR • Whitening of the mucosa in an area of the rectal wall may be frequently observed in patients with cCR; if this is the only finding, patients may be monitored by monthly follow-up visits including digital rectal examination and rigid proctoscopy. It is usually possible to identify the whitening on subsequent visits . • Association of any teleangiectasia, i.e, small derogative blood vessels seen on the rectal mucosa at the area previously harboring the primary cancer, is also frequently observed in complete clinical responders. This finding is seen even in long-term follow- up of patients with complete clinical response managed by observation alone . • Another feature that is also seen or felt in these patients is a subtle loss of pliability of the rectal wall harboring the scar; this is usually observed during manual insufflations at proctoscopy with light stiffness of the wall. In the context of no additional positive findings of residual cancer, this may also be considered as a feature of cCR; it should not be mistaken for rectal stenosis or wall nodularity that clearly should be considered as incomplete clinical response • Whenever a tumor cannot be felt or seen, patients should be considered as complete clinical responders
  7. 7. The cCR
  8. 8. Habr-Gama definition of residual • Any residual deep ulceration with or without a necrotic center should be considered as a positive sign for incomplete clinical response. • Any superficial ulcer, irregularity, even in the presence of only mucosal ulceration, should be regarded as a positive sign of incomplete clinical response • Any palpable nodule, easily defined by digital rectal examination, even in the presence of mucosal complete integrity should be considered as incomplete clinical response • Any significant stenosis impeding the rigid proctoscope from sliding through should be considered as incomplete clinical response
  9. 9. The nodularity-residual
  10. 10. The superficial ulcer-residual
  11. 11. The deep ulcer-residual
  12. 12. DEFINITION OF cCR • A cCR is defined as the absence of any palpable tumour or irregularity at DRE • No visible lesion at rectoscopy except a flat scar, telangiectasia or whitening of the mucosa. • These minimal criteria can be complemented by absence of any residual tumour in the primary site and draining lymph nodes on imaging with MRI or ERUS, • Negative biopsies from the scar. • An initially raised CEA level which returns to normal (< 5 ng/ml) after CRT is associated with an increased likelihood of cCR and pCR, and hence supports the opinion that a cCR has been achieved
  13. 13. cCR-ypT0N0 Flat whitish scar with some telangiectasis Fibrotic changes Diffusion-weighted Imaging Shows A Complete Disappearance Of Tumor Signal
  14. 14. Local excision
  15. 15. • 1990 and June 2002, 431 patients with clinically staged T3 rectal cancer were treated with preoperative chemoradiation followed by surgical resection • Full-thickness local excision (n 3) or a transanal excision (n 23)] was performed in 26 patients because of patient refusal of abdominoperineal resection (APR) (n 13), medical comorbidity (n 4), physician preference after a complete clinical response (n 6), and other reasons (n 3) • Actuarial overall survival at 5 years was 86% in the local- excision group compared with 81% among mesorectal- excision patients (p NS), and 85% in patients with a complete clinical response to chemoradiation followed by mesorectal excision by APR or LAR (p NS). Local excision
  16. 16. PATIENT REFUSAL OF APR, HIGHLY SELECTED PATIENTS WHO RESPONDED WELL TO CONVENTIONAL EXTERNAL-BEAM RADIOTHERAPY (CXRT) WERE SELECTED TO UNDERGO LOCAL EXCISION. MOST OF THESE PATIENTS HAD PATHOLOGIC COMPLETE RESPONSE. LOCAL CONTROL AND SURVIVAL RATES ARE COMPARABLE TO THOSE ACHIEVED WITH CHEMORADIATION FOLLOWED BY MESORECTAL EXCISION Local excision
  17. 17. What we need? • Patients should be informed that the strategy • Standardized protocol for intensive surveillance • Such patients have been subjected to rigorous and meticulous follow up, where MRI surveillance is available • More frequent than routine surveillance to ensure that surgical salvage is feasible and timely
  18. 18. What we need? • Patient selection, • Treatment sequencing, • Optimal assessment of response, • Long-term surveillance strategies
  19. 19. NOMOGRAM?
  20. 20. • Mucinous adenocarcinoma, • Positive pre-treatment serum CEA • Clinical T4 and N2 stages may impart difficulty for patients to achieve pCR ODD THINGS?
  21. 21. ODDS RATIO FOR ODD THINGS? Mucinous adenocarcinoma and clinical N2 stage might be indicative of a prognostically unfavorable biological tumor profile with a greater propensity for local or distant recurrence and decreased survival.
  22. 22. Indian study-TMH
  23. 23. • 64 patients achieving pathological complete response from 2010 to 2013. • Disease-free survival (DFS), overall survival (OS), and locoregional and systemic recurrence rates were evaluated for these patients. • Results. After a median follow-up of 30.5 months (range 11–59 months), the 3-year (OS) was 94.6% and the 3-year (DFS) was 88.5%. • The locoregional and systemic recurrence rates were 4.7% and 3.1%, respectively. • Conclusion. In the Indian subcontinent, despite younger patients with aggressive tumor biology, outcome in complete responders is good Indian study
  24. 24. American study
  25. 25. • cT2-4N0-2 rectal adenocarcinoma were treated with nCRT from 2015 through 2016 • Treatment consisted of 50.4 to 54 Gy with concurrent fluoropyrimidine-based chemotherapy • A cCR was defined as the absence of mass or ulceration and the presence of flat mucosa or scar only. • In addition, (MRI) showed no evidence of residual mass. • Watchful waiting patients were followed with MRI every 3- 6 months for 2 years then every 6 months up to 5 years. • Exam with rigid proctoscopy was performed every 3 months for 2 years and every 6 months up to 5 years. American study
  26. 26. • 251 patients were treated with nCRT. 64 (25%) achieved a cCR • 32 (50%) patients with cCR had surgery at a median time from nCRT completion to surgery of 81 days. • 14 (44%) patients with cCR undergoing surgery were found to have pathologic complete response • Overall, outcomes were favorable in patients with cCR after nCRT undergoing watchful waiting with high rates of local control, disease-free survival, and overall survival. • Although all local recurrences were surgically resectable, local recurrence was associated with a poor overall outcome with a majority of these patients developing distant metastases • Only N-stage was predictive of distant recurrence on multivariate analysis American study
  27. 27. 1. The two patient groups did not differ in distant metastasis rates or disease- free and overall survival, but the nonsurgical group had a higher risk of 1, 2, 3, and 5-year local recurrence. 2. Hence, we concluded that for rectal cancer patients achieving a cCR after NCRT, a wait-and-see strategy with strict selection criteria, an appropriate follow-up schedule, and salvage treatments achieved outcomes at least as good as radical surgery
  28. 28. Important points • First – Clinicians should select patients • Second – Early identification of cCR • Third – The time interval between NCRT and response assessment is critical • Fourth – Success of the wait-and-see strategy
  29. 29. FOLLOWUP SCHEDULE IN ACTIVE SURVILLANCE
  30. 30. IS RAPIDO NEW STANDARD OF CARE FOR RECTUM? Renu R Bahadoer/LANCET ONCOLOGY/2020 10th MAY 2021/RECTUM Rectal cancer And Preoperative Induction therapy followed by Dedicated Operation (RAPIDO) SHORT COURSE RT CHEMOTME LONG COURSE RT TMEADJ. CHEMO • The observed decreased probability of disease-related treatment failure in the experimental group is probably indicative of the increased efficacy of preoperative chemotherapy as opposed to adjuvant chemotherapy in this setting. • Therefore, the experimental treatment can be considered as a new standard of care in high-risk locally advanced rectal cancer • Median follow-up was 4·6 years .At 3 years after randomization, the cumulative probability of disease-related treatment failure was 23·7% (95% CI 19·8–27·6) in the experimental group versus 30·4% (26·1–34·6) in the standard of care group (HR 0·75, p=0·019) CHEMO PROTOCOL 6 CYCLES OF CAPOX OR 9 CYCLES OF FOLFOX CHEMO PROTOCOL 8 CYCLES OF CAPOX OR 12 CYCLES OF FOLFOX
  31. 31. Summary
  32. 32. • Molecular analysis • Nomograms • More prospective studies I wish
  33. 33. Observation or local excision for patients thought to be complete responders should be undertaken with caution.
  34. 34. NOW cCR
  35. 35. Patient emotion
  36. 36. DOCTOR-What should I do? • Organ preservation, • Deferred surgery • Conservative surgery • Watch and wait NO EVIDENCE
  37. 37. My algorithm POST NACTRT DRE,MRI,CEA,PROCOTSCOPY cCR ODDS ACTIVE SURVILLENCE/CHEMO ODDS PR MUCINOUS CEA>5 TAKE ACTION <PR MORE CHEMO SUSPICIOUS LOCAL EXCISION IS AN OPTION
  38. 38. 1. The Bar Rectum was an actual bar built inside a giant anatomical model representing the human digestive system, from tongue to anus. 2. Dutch design firm Atelier Van Lieshout created it several years ago for the Vienna Museum Quarter 3. Bar Rectum, Arsch Bar, Asshole Bar, Bar Anus. 4. While the translations sound different, the form is universally recognizable. 5. The bar takes its shape from the human digestive system: starting with the tongue, continuing to the stomach, moving through the small and the large intestines and exiting through the anus. 6. While Bar Rectum is anatomically correct, the last part of the large intestine has been inflated to a humongous size to hold as many drinking customers at the bar as possible. RECTUM BAR

×