4. TOTAL MESORECTAL EXCISION TME line Blunt dissection line Mesorectal fascia

5. PATHOLOGICAL EXAMINATION OF THE CRM

13. LOCAL RECURRENCE AFTER CURATIVE RESECTION author n. CRM- CRM+ total Follow-up ( median ) Ng et al (1993) 80 17 % 60 % 20 % 26.6 Adam et al (1994) 190 8 % 66 % 23 % 63 HaasKock et al(1996) 253 8 % 29 % 11 % 29

19. CRM involvement AP’s and AR’s The frequency of involvement of the CRM is 1.5-2X higher in AP than AR APR’s AR’s Leeds 1986-1997 all cases n=686 36.5% 22.3% Classic trial Curative n=400 21% 10% Dutch TME trial Curative n=1586 29% 13%

20. APR for LOW RECTAL CANCER * Only tumours < 5cm from anal verge N. LR. 5 year LR. 5 year Survival 5 year Survival 5 year AR APR AR APR Marr et al. 2005 561 13.5% 24% 66% 52% Wibe et al. 2003 2136 10 % 15% 68% 55% Heald et al. 1997 136* 4 % 47% 68% 29%

22. TME and the low rectal cancer

23. TME and the low rectal cancer

24. CRM and the low rectal cancer

29. CRM involvement after neoadjuvant therapy. CRMI surgery Short course RT Long course RT CRT Marjnen et al ( 2003 ) 1mm 18 % 16 % CRO-7 (preliminary) 1mm 14 % 12 % Sauer et al ( 2004 ) 0 mm 3 % 2 % Bujko et al ( 2006 ) 1mm 12.9 % 4.4 %* Den Dulk et al ( 2007 ) 0 mm 6.5 % 4.9 %

34. MESORECTAL EXCISION

35. Mesorectum Excision Grading * non-irradiated ; curative ; TME. ** 54% radiotherapy ; curative ; TME. *** 27% radiotherapy ; curative & palliative ; TME. No. Mesorectal plane Intra-mesorectal plane Muscularis propria plane Nagtegaal et al. ( 2002 )* 180 56.6% 19.4% 23.9% Maslekar et al. ( 2006 )** 130 47% 40% 13% Jeyorajah et al.(2007)*** 287 53.7% 33.1% 13.2%

36. Macroscopic assessment of Mesorectal excision Dutch TME study CRM negative cases 2 year local recurrence rate 2 year distant recurrence Overall recurrence rate Complete or nearly complete 5.5 % 12.2 % 14.9 % incomplete 11.4 % 19.2 % 28.6 %

37. MRC CRO-7 TRIAL : MESORECTAL GRADING * P = 0.0039 ** P = 0.14 Quirke et al. 2009 frequency 3 year LR 3 year DFS Mesorectal fascial plane 52 % 4 % 79 % Intramesorectal plane 34 % 7 % 75 % Muscularis propria plane 13 % 13 %* 70 %**

39. CRO-7 : IMPACT OF PLANE OF SURGERY ON LOCAL RECURRENCE AT 3 YEARS. Quirke et al. 2006. No. PRE POST HR Muscularis propria plane 141 9 % 29 % 2.76 Intra mesorectal plane 382 6 % 12 % 2.02 Mesorectal plane 596 1 % 6 % 4.47

42. Who should get adjuvant chemotherapy after pre-operative chemo-radiotherapy and surgery ? Collette et al 2007 ( EORTC trial 22921 )

48. MANDARD GRADE 1

49. MANDARD GRADE 1

50. MANDARD GRADE 2

53. Beddy et al 2008

57. SURVIVAL AFTER CHEMORADIOTHERAPY IN LOCALLY ADVANCED RECTAL CARCINOMA Rullier et al 2010

58. PRE – OPERATIVE CHEMORADIOTHERAPY

59. MANDARD GRADE 1

60. ASSESSING TUMOUR REGRESSION AFTER CHEMORADIOTHERAPY Bedrossian et al 2004. No. Gross residual disease Microscopic disease No residual disease Ulcer or Tumour 184 (85%) 61 % 26 % 13 % Ulcer scar or induration 29 (13%) 3 % 38 % 59 % No visible abnormality 3 (2%) 0 / 3 1 / 3 2 / 3

62. Lymph node harvest after neoadjuvant therapy ( Numbers represent median or average no of nodes. ) Surgery only Short course RT Long course RT Marijnen et al.2001 9.7 7.7 Wichmann et al 2002 19 13 Wijesuriya et al 2005 9 4 Baxter et al 2004 10 7

65. Rullier et al 2008

66. pNX after chemoradiotherapy for rectal cancer : what does it mean ? ( ypNX v. ypN0 = N.S. ; ypN0 v. ypN1 = 0.001 ) Habr-Gama et al 2007 5yr overall survival 5yr disease free survival yp NX 91 % 74 % yp N0 91 % 59 % yp N1 or 2 66 % 30 %