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Angels and Demons in Rectal Cancer: Challenging the Dogmas

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Champalimaud Foundation

Avenida de Brasília

1400-038 Lisboa

Portugal

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"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


Speakers

BILL HEALD, Champalimaud Foundation, Lisbon

ANE APPELT, University of Leeds, UK

SVETLANA BALYASNIKOVA, Royal Marsden, UK

RODRIGO PEREZ, Faculdade de Medicina da Universidade de S. Paulo, Brazil

SOREN LAURBERG, Aarhaus University, Denmark

CARLOS CARVALHO, Champalimaud Foundation, Portugal

KRZYSZTOF BUJKO, Maria Sklodowska-Curie Memorial Cancer Center, Poland

ROB GLYNNE-JONES, Mount Vernon Hospital, UK

ORIOL PARES, Champalimaud Foundation, Portugal

QUENTIN DENOST, Bordeaux University Hospital, France

GEERARD BEETS, The Netherlands Cancer Institute, Netherlands

REGINA BEETS-TAN, The Netherlands Cancer Institute, Netherlands

NUNO FIGUEIREDO, Champalimaud Foundation, Portugal

TORBJORN HOLM, Karolinska University, Sweden

TAHSEEN QURESHI, Poole Hospital, UK

PIETER TANIS, Academic Medical Centre, Netherlands

CORNELIS VAN DER VELDE, Leiden University Medical Centre, Netherlands

AMJAD PARVAIZ, Champalimaud Foundation, Portugal

INÊS SANTIAGO, Champalimaud Foundation, Portugal

ANTONY HIGGINSON, Portsmouth Hospital, UK

RICARDO RIO-TINTO, Champalimaud Foundation, Portugal

ROEL HOMPES, Academic Medical Centre, Netherlands

ARTHUR SUN-MYINT, Clatterbridge-Papillon, UK

ANGELITA HABR-GAMA, Instituto Angelita Habr-Gama, Brazil

MIT DATTANI, Pelican Cancer Foundation, UK

NICKOLAS PAPANIKOLAOU, Champalimaud Foundation, Portugal

FRANCK PAGÈS, Hôpital Européen Georges Pompidou, France

MARKUS MAEURER, Champalimaud Foundation, Portugal

RITA FIOR, Champalimaud Foundation, Portugal

CARLOS CORDON-CARDO, Mount Sinai Health System, USA

LAURA FERNANDEZ, Instituto Angelita Habr-Gama, Brazil

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 resectionsRICARDO RIO-TINTO – 10 min
  • Local excision and “adjuvantradiation 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 answersNUNO FIGUEIREDO - 15 min

2. Training surgeons for the FUTUREAMJAD PARVAIZ - 15 min

3. The FUTURE of Watch and WaitANGELITA HABR-GAMA - 15 min

4. Angels and Demons in rectal cancerBILL HEALD - 15 min

18:00 END


Event organisers:

R. J. (Bill) Heald. CBE

Oriol Parés

Carlos Carvalho

Inês Santiago

Nuno Figueiredo

Amjad Parvaiz

Geerard Beets




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Champalimaud Foundation

Avenida de Brasília

1400-038 Lisboa

Portugal

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