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Angels and Demons in Rectal Cancer: Challenging the Dogmas

On 22nd-23rd February we will share with you the many dogmas that now ...

  1. 12.12.2017

    "The field of Rectal Cancer management is shifting as never before : beset indeed by "angels and demons" -

    Angels - Unprecedented opportunities for improvement - robotics to increase precision in surgery, image guidance, intensity modulation and target stabilisation to refine radiation.

    Demons - the confusion of recent studies and the mounting morbidity of current protocols.

    The Champalimaud Foundation has brought together, perhaps uniquely, the “Watch and Wait" thinking of Habr-Gama and her team with the imaging and radiotherapy skills to exploit superior radiation technology ...

    On 22nd-23rd February we will share with you the many dogmas that now need to be challenged by the modern Colorectal Cancer MDT and the many improvements that now seem possible for the patients of tomorrow."

    Prof Bill Heald, Chairman of the “Colorectal Cancer Project”, The Champalimaud Institute for the Unknown, Lisbon, Portugal

    Programme:

    DAY 1, 22 February

    7.45 - REGISTRATION

    8:15 - OPENING REMARKS – BILL HEALD

    8:30

    A. RADIATION AND SURGERY

    1. Halsted is still alive – “Positive” nodes must be treated?

    1.1. Preoperative radiation

    • Positive nodes must receive radiation? – ANE APPELT - 8 min
    • Nodes are not the main indication – SVETLANA BALYASNIKOVA - 8 min

    1.2. Persistent lateral nodes after radiation

    • Take them by lateral dissection – RODRIGO PEREZ - 8 min
    • Surgery has a high price and may not achieve much –SOREN LAURBERG – 8 min

    DISCUSSION AND VOTING 15 min – CARLOS CARVALHO

    9:20

    2. Radiation strategy

    • When do I prefer short-course radiation? – KRZYSZTOF BUJKO - 8 min
    • When do I prefer long-course chemo-radiation? – ROB GLYNNE-JONES - 8 min
    • Current delineation “standards” – ANE APPELT - 8 min
    • Total Mesorectal Irradiation – ORIOL PARES - 8 min

    DISCUSSION AND VOTING 15 min – SOREN LAURBERG

    10:10

    3. Evaluating response

    • 6-7 weeks is best to take decisions? – QUENTIN DENOST - 8 min
    • 6-7 weeks may be too soon for many patients – GEERARD BEETS - 8 min
    • TRG is the better tool – SVETLANA BALYASNIKOVA - 8 min
    • TRG is not enough - diffusion may be very useful – REGINA BEETS-TAN - 8 min
    • MRI is not enough – endoscopy and DRE are very important – NUNO FIGUEIREDO - 8 min

    DISCUSSION AND VOTING 15 min – RODRIGO PEREZ

    11.10 COFFEE

    11:30

    4. Surgery after radiation

    4.1. Planning the operation

    • What’s the guide - the initial tumor OR the response – TORBJORN HOLM - 8 min

    4.2. Margins are still at risk

    • Extensive surgery may be the only option – GEERARD BEETS - 8 min

    4.3. Defunctioning ostomy

    • YES – It’s always needed – TAHSEEN QURESHI - 8 min
    • NO – It’s NOT always needed – PIETER TANIS - 8 min

    DISCUSSION AND VOTING 15 min – CORNELIS VAN DER VELDE

    12:20

    5. Functional damage

    • Can we reduce it with better radiation? – ORIOL PARES - 8 min
    • Can we reduce it with better surgery? – AMJAD PARVAIZ - 8 min
    • Can we really improve the damaged function? – SOREN LAURBERG - 8 min

    DISCUSSION AND VOTING 15 min – KRZYSZTOF BUJKO

    13:00 LUNCH

    14:00

    B. SURGICAL OPTIONS

    1. Imaging is the key

    • MRI is better for treatment strategy – INÊS SANTIAGO - 10 min
    • MRI and ultrasound may help in some decisions – ANTONY HIGGINSON – 10 min
    • Low tumors need different staging criteria – SVETLANA BALYASNIKOVA - 10 min

    DISCUSSION AND VOTING 15 min – REGINA BEETS-TAN

    14:45

    2.“Early” tumors

    • Endoscopic mucosal resections – RICARDO RIO-TINTO – 10 min
    • Local excision and “adjuvant” radiation – ROEL HOMPES – 10 min
    • Endo-cavitary radiation – what are the best candidates – ARTHUR SUN-MYINT - 10 min

    DISCUSSION AND VOTING – PIETER TANIS – 15 min

    15:30 COFFEE

    15:50

    3. Open, Laparoscopic and Robotic TME

    • There are still indications for laparotomy in the mini-invasive era – GEERARD BEETS – 10 min
    • For some patients APE is still the better operation – TORBJORN HOLM – 10 min
    • Non-APE options are feasible in most patients – AMJAD PARVAIZ – 10 min

    DISCUSSION AND VOTING 10 min – QUENTIN DENOST

    16:30

    • Laparoscopic TME is the current standard - we don’t need more toys – QUENTIN DENOST - 10 min

    DISCUSSION 10 MIN – AMJAD PARVAIZ

    16:50

    • Laparoscopic TME is not good enough – robotic offers a better alternative – AMJAD PARVAIZ - 10 min

    DISCUSSION 10 MIN – QUENTIN DENOST

    17:10

    • TA-TME – real advantage OR higher risks – ROEL HOMPES - 10 min

    DISCUSSION 10 min – NUNO FIGUEIREDO

    17:30

    PANEL DISCUSSION AND VOTING – BILL HEALD - 15 MIN

    DAY 2, 23 February

    8:30

    C. ORGAN PRESERVATION

    1. Which patients?

    • Lower tumors may benefit the most – ANGELITA HABR-GAMA – 8 min
    • T2 tumors may respond better to chemo-radiation – LAURA FERNANDEZ - 8 min
    • The functional cost of unneeded irradiation - surgery is still better in many lower risk patients – SOREN LAURBERG - 8 m
    • What’s the patient’s preference? – ROB GLYNNE-JONES - 8 min

    DISCUSSION AND VOTING 15 min – GEERARD BEETS

    9:20

    2. When can we wait longer?

    • Complete or near-complete clinical response? – GEERARD BEETS - 8 min
    • To biopsy or not to biopsy? – BILL HEALD - 8 min
    • How to deal with radiation induced ulcers? – NUNO FIGUEIREDO - 8 min

    DISCUSSION AND VOTING 15 min – ROB GLYNNE-JONES

    10:00

    3. Managing tumor “regrowth”

    • Local excision – problems and pitfalls – RODRIGO PEREZ - 8 min
    • ”Beyond TME” is rarely necessary – GEERARD BEETS - 8 min
    • ”Later” surgery is still very safe – NUNO FIGUEIREDO - 8 min

    DISCUSSION AND VOTING 15 min – AMJAD PARVAIZ

    10:40 COFFEE

    11.00

    4. Measuring the outcomes

    • Local failures and overall survival – ANGELITA HABR-GAMA- 10 min
    • Functional outcomes – GEERARD BEETS - 10 min

    DISCUSSION AND VOTING 15 min – SOREN LAURBERG

    11:35

    • We may still need a randomized trial – ROB GLYNNE-JONES- 10 min
    • Randomization is nonsense and even unethical – BILL HEALD - 10 min

    DISCUSSION AND VOTING 15 min - KRZYSZTOF BUDJKO

    12:10

    • Watch and Wait in a rectal cancer centre – NUNO FIGUEIREDO - 10 min
    • Meta-analysis – MIT DATTANI – 10 min
    • The International Watch and Wait Database – big data and new questions – CORNELIS VAN DER VELDE - 10 min

    DISCUSSION AND VOTING 15 MIN – RODRIGO PEREZ

    13:00 LUNCH

    14:00

    D. IMPROVING RESPONSE AND SURVIVAL

    1. More Radiation

    • Better tailoring and good targeting – ORIOL PARES - 10 min
    • The higher the dose the better the response? – ANE APPELT- 10 min

    DISCUSSION AND VOTING 10 MIN – ROB GLYNNE-JONES

    14:30

    2. More Chemotherapy

    2.1. Adjuvant chemotherapy

    • Adjuvant chemotherapy is not useful after chemo-radiation – CARLOS CARVALHO - 10 min

    2.2. Consolidation chemotherapy

    • It’s the natural option during the waiting period – KRZYSZTOF BUDJKO - 10 min
    • Best responders do not need it – GEERARD BEETS - 10 min
    • TRG may guide decisions – SVETLANA BALYASNIKOVA - 10 min

    2.3. Induction chemotherapy

    • It may be better in more aggressive or less radiosensitive tumors – ROB GLYNNE-JONES - 10 min

    DISCUSSION AND VOTING 15 MIN – CARLOS CARVALHO

    15:40 COFFEE

    16:00

    E. NEW HORIZONS

    1. Vision from the unseen – NICKOLAS PAPANIKOLAOU - 10 min

    2. Liquid biopsy and response – RODRIGO PEREZ - 10 min

    3. Immunity and response – FRANCK PAGÈS - 10 min

    4. Immuno-surgery – MARKUS MAEURER – 10 min

    5. Drug Avatars – RITA FIOR - 10 min

    6. To be or not to be – CARLOS CORDON-CARDO – 10 min

    17:00

    F. FINAL CONCLUSIONS

    1. Questions and answers – NUNO FIGUEIREDO - 15 min

    2. Training surgeons for the FUTURE – AMJAD PARVAIZ - 15 min

    3. The FUTURE of Watch and Wait – ANGELITA HABR-GAMA - 15 min

    4. Angels and Demons in rectal cancer – BILL HEALD - 15 min

    18:00 END

    Event organisers:

    R. J. (Bill) Heald. CBE, MChir, FRCS (Ed) (Eng)

    Oriol Parés MD

    Carlos Carvalho MD

    Inês Santiago MD

    Nuno Figueiredo MD, PhD, FRCS

    Amjad Parvaiz MBBS, FRCS, FRCS (Gen & Colorectal Surgery)

    Geerard Beets MD

    Full details of programme and speakers will be available shortly.




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