TNMR Vs.TNM and MRI Vs.RigidEndoscopy for CA rectum:

A New Tuxedo for a Growing young Athlete.

Prof. Dr. Ahmed Farag.

Dept. Of G. Surgery – Cairo University

Hypothesis

Can a Major change In classification, Staging and Grading of Rectal Cancer improve planning

for treatment , Reporting and outcome

of the disease?

• The value of all grading and staging systems of cancers is to inform on the outcome be it with or without treatment.

• Classification, TNM staging and HistologicGrading of the cancer rectum had undergone minimal changes during the last 20 years despite the major impact of them on planning, reporting and outcome of the disease.

Classification of cancer rectum.

• The classification of the rectal cancer into the upper, middle and lower thirds based on the distance from the anal verge using Rigid sigmoidospy is recommended by different international Guidelines (AJCC, NCCN and others)

Classification of cancer rectum.

• Rigid Sigmoidoscopy is not ideal for this task due to the discomfort with the use of rigid endoscopy, the variations in measurements due to inter-observer errors, intra-observer errors as well as the different stature and body mass index of the patients.

Rigid sigmoidoscopy makes measures as 0-5cm, 6-10 cm and 11-

15 cm. This mean different locations in different patients .

Preoperative MRI Vs. Rigid Sigmoidoscopy

• On the other hand, the use of MRI for preoperative staging of rectal cancer and the circumferential resection margin had been reported as compared to postoperative Histopathology and recommended by AJCC, NCCN and others as a routine preoperative investigation of Ca rectum.

• Can we use MRI as an alternative tool to classify rectal cancer?

• In other words can we have another added value from the recommended preoperative MRI?

• In the era of routine preoperative staging using MRI where the Peritoneal reflection can be accurately located in each individual patient irrespective to his stature and BMI using T2 weighted image, Ca rectum can be reclassified preoperatively as:

• CA of Intra-peritoneal rectum where the lower edge of the tumor ends 2 cm above the peritoneal reflection of the Douglas pouch irrespective to the distance from the anal verge. Those patients should not receive neoadjuvant treatment except may be in T4 cases.

• CA of extra-peritoneal rectum where the lower edge of the tumor is < 2cm from the peritoneal reflection on preoperative MRI where neoadjuvant treatment can be given. Those patients. Those cases can be subdivided into :

• Posterior Extra-peritoneal: where neoadjuvant a can be given to T3 lesions due to the mesorectalbuffer.

• Anterior Extra-peritoneal: where the neoadjuvant can be given to T2 lesions due to the lack of mesorectal buffer and marked proximity to the dennonvier fascia ( usually < 1cm) which by definition is a close circumferential margin.

TNM 6th and 7th editions

• The TNM classification in its present status does not address the other risk factors Proved by high quality evidence based research in the field such as:

TNM 6th and 7th editions

• Intravascular and Intra-lymphatic deposits , where lympho-vascular invasion-positive tumors metastasized to systemic lymph nodes more often (P < .001).

• These tumors also recurred at systemic lymph nodes after curative intent surgery more often (P = .007

Lim, Seok-Byung; Yu, Chang Sik; Jang, Se Jin; Kim, Tae Won; Kim, Jong Hoon; Kim, Jin Cheon: Prognostic Significance of Lymphovascular Invasion in Sporadic Colorectal Cancer. Diseases of the Colon & Rectum. 53(4):377-384, April 2010. doi: 10.1007/DCR.0b013e3181cf8ae5

Other risk factors

• Intraoperative blood transfusion.• Intra-operative tumor perforation.• Preoperative High CEA.• Quality of TME.• Number of retrieved (examined) LNs. • Type of advancing margin of the tumor (infiltrative vs.

Pushing)• Tumor Ploidy.• The decreased monocyte chemoattractant protein-1 ratio.• A Ki-67 labeling index of 5 percent.• A positive cytoplasmic p53 expression …..etc.

• Despite the fact that extra-nodal Tumor deposits had been addressed by the TNM version 6 as being discontinuous tumor tissue, This inclusion in the T category raised a lot of concerns about version 6.

• The situation extended into the recently released TNM version 7 where TD are either graded as discontinuous Tumor deposit or as N1c according to its histopathology appearance in a desperate trial to squeeze this risk factor into the tight TNM categories .

American Joint Commission on Cancer: Review Summary: Understanding the Changes from the Sixth to the Seventh Edition of the AJCC Cancer Staging Manual. American Joint Commission on Cancer Executive Office 633 N. Saint Clair St. Chicago, IL 60611-3211

TNMR

• Accordingly a modified TNM staging for cancer in General and in cancer rectum Specifically as TNMR as follows:

TNMR

• T: the same as in TNM.

• N: the same as in TNM

• M: E+(Can be Excised), E- (Cannot be Excised) E+/- ( may be excised after a trial of neoadjuvant)

• R (Risk Factors): IV (intravenous deposits), Il (Intralympha-tic), TD (Extra-nodal Deposits) IM (Infiltrative Margin), Qr (quality of Resection) …. etc.

• Similarly Grading of cancer with special reference to Cancer rectum should include the R Sign beside the G, in order to indicate the same risk factors in the suggested modification in TNM above as well as any other added risk factor in the Future.

• Alternatively: Grading can be added to the new R category.

The value of adding a separate Category R to the already established TNM to be TNMR, for the continuously expanding list of risk factors is to:

• avoid either squeezing them into the already established TNM categories,

• Warn the treating team about the need to have a more aggressive treatment strategies in those patients with early TNM staging with one or more risk factors.

• Much more importantly the suggested TNMR avoid Ignoring the already established risk factors in our data reporting in Cancer rectum due to our inability to accommodate them in the already non-hospitable TNM categories.

Farag A.: Can a major change in classification, staging and grading of rectal cancer improve planning for treatment, reporting and outcome of the disease? AJG. Volume 11, Issue 3, Pages 121-180 (September 2010) Editorial.

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