Current Surgical Strategies in the Management of Rectal Cancer
Purpose of Review
The surgical approach to rectal cancer has become significantly more complex with the introduction of neoadjuvant therapies and organ preservation strategies. Optimal radiological imaging in association with relevant clinical findings provides critical information for final surgical management decision. The present review focuses on the surgical alternatives available in different clinical scenarios for the management of rectal cancer.
Most of evidence for surgical management of rectal cancer is provided by non-randomized studies. However, a few randomized clinical trials have attempted to address the optimal surgical approach for total mesorectal excision. In addition, recent randomized trials have also contributed to the understanding of the role of organ-preserving strategies among patients with excellent response to neoadjuvant treatment. Finally, one randomized Japanese study has provided oncological evidence in favor of prophylactic lateral node dissection among these patients.
Radical proctectomy with total or partial mesorectal excision is the standard procedure for most patients with primary rectal cancer. Optimal approach for this procedure remains controversial. The decision between sphincter-preservation strategies and abdominal perineal resections should take into account the radiological and clinical findings. More recently, organ-preserving strategies including transanal local excisions may be used in select patients with early-stage disease or among patients undergoing neoadjuvant treatment strategies after significant primary tumor regression. Extended procedures including lateral pelvic side lymphadenectomies and exenterative procedures should be done selectively and in highly specialized centers.
KeywordsRectal cancer Total mesorectal excision Neoadjuvant chemoradiation Laparoscopic surgery Robotic surgery Local excision Watch and wait Lateral lymph node dissection
Compliance With Ethical Standards
Conflict of Interest
José Moreira de Azevedo declares that he has no conflict of interest.
Bruna Borba Vailati has received compensation from Johnson & Johnson and Medtronic for Service as a consultant.
Guilherme Pagin São Julião has received compensation from Johnson & Johnson and Medtronic for Service as a consultant.
Laura Melina Fernandez declares that she has no conflict of interest.
Rodrigo Oliva Perez has received compensation from Johnson & Johnson and Medtronic for Service as a consultant.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 3.•• Fleshman J, Branda M, Sargent DJ, et al. Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA. 2015;314(13):1346–55 This trial failed to demonstrate non-inferiority of surgical pathology outcomes in rectal cancer after laparoscopic versus open approach.CrossRefGoogle Scholar
- 6.•• Stevenson AR, Solomon MJ, Lumley JW, et al. Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA. 2015;314(13):1356–63 This trial failed to demonstrate non-inferiority of surgical pathology outcomes in rectal cancer after laparoscopic versus open approach.CrossRefGoogle Scholar
- 7.Acuna SA, Chesney TR, Baxter NN. ASO author reflections: clarifying the controversy generated by non-inferiority trials of laparoscopic surgery for rectal cancer. Ann Surg Oncol. 2018.Google Scholar
- 8.Acuna SA, Chesney TR, Ramjist JK, Shah PS, Kennedy ED, Baxter NN. Laparoscopic versus open resection for rectal cancer: a noninferiority meta-analysis of quality of surgical resection outcomes. Ann Surg. 2018.Google Scholar
- 9.Acuna SA, Dossa F, Baxter NN. Frequency of misinterpretation of inconclusive noninferiority trials: the case of the laparoscopic vs open resection for rectal cancer trials. JAMA Surg. 2018.Google Scholar
- 10.• Fleshman J, Branda ME, Sargent DJ, et al. disease-free survival and local recurrence for laparoscopic resection compared with open resection of stage ii to iii rectal cancer: follow-up results of the ACOSOG Z6051 randomized controlled trial. Ann Surg. 2018; This randomized clinical trial comparing laparoscopic vs open surgery resulted in equivalent oncological outcomes.Google Scholar
- 11.•• Jayne D, Pigazzi A, Marshall H, et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR randomized clinical trial. JAMA. 2017;318(16):1569–80 This prospective randomized trial failed to demonstrate decrease conversion rates between robotic or laparoscopic rectal cancer surgery.CrossRefGoogle Scholar
- 20.•• Rullier E, Rouanet P, Tuech JJ, et al. Organ preservation for rectal cancer (GRECCAR 2): a prospective, randomised, open-label, multicentre, phase 3 trial. Lancet. 2017; This prospective randomized study compared local excision vs TME for patients with small rectal cancers and excellent response to nCRT. Outcomes suggested equivalent oncological outcomes in an intention to treat analyses.Google Scholar
- 22.Didailler R, Denost Q, Loughlin P, et al. Antegrade enema after total mesorectal excision for rectal cancer: the last chance to avoid definitive colostomy for refractory low anterior resection syndrome and fecal incontinence. Dis Colon Rectum. 2018;61(6):667–72.Google Scholar
- 24.• Rullier E, Denost Q, Vendrely V, Rullier A, Laurent C. Low rectal cancer: classification and standardization of surgery. Dis Colon Rectum. 2013;56(5):560–7 This clinical and anatomical subclassification of distal rectal cancer provides an excellent guide for optimal surgical management of rectal cancer.CrossRefGoogle Scholar
- 29.• Prytz M, Angenete E, Bock D, Haglind E. Extralevator abdominoperineal excision for low rectal cancer–extensive surgery to be used with discretion based on 3-year local recurrence results: a registry-based, observational national cohort study. Ann Surg. 2016;263(3):516–21 This registry-based study suggested that extraelevator approach should be considered in patients with ≤ 4 cm from anal verge rectal cancers and those at higher risk for intraoperative complications.CrossRefGoogle Scholar
- 33.•• Fujita S, Mizusawa J, Kanemitsu Y, et al. Mesorectal excision with or without lateral lymph node dissection for clinical stage II/III lower rectal cancer (JCOG0212): a multicenter, randomized controlled, noninferiority trial. Ann Surg. 2017;266(2):201–7 This prospective randomized trial failed to show non-inferiority of TME plus prophylactic bilateral LLND vs TME alone.CrossRefGoogle Scholar
- 34.•• Fujita S, Akasu T, Mizusawa J, et al. Postoperative morbidity and mortality after mesorectal excision with and without lateral lymph node dissection for clinical stage II or stage III lower rectal cancer (JCOG0212): results from a multicentre, randomised controlled, non-inferiority trial. Lancet Oncol. 2012;13(6):616–21 This randomized controlled study showed that the only intraoperative complication significantly associated with lateral lymph node dissection was increase intraoperative blood loss.CrossRefGoogle Scholar
- 35.• Saito S, Fujita S, Mizusawa J, et al. Male sexual dysfunction after rectal cancer surgery: Results of a randomized trial comparing mesorectal excision with and without lateral lymph node dissection for patients with lower rectal cancer: Japan Clinical Oncology Group Study JCOG0212. Eur J Surg Oncol. 2016;42(12):1851–8 This prospective study demonstrated that lateral lymph node dissection is not a risk factor for male sexual dysfunction.CrossRefGoogle Scholar
- 36.• Yamaguchi T, Konishi T, Kinugasa Y, et al. laparoscopic versus open lateral lymph node dissection for locally advanced low rectal cancer: a subgroup analysis of a large multicenter cohort study in Japan. Dis Colon Rectum. 2017;60(9):954–64 This case-matched study demonstrated that laparoscopic approach significantly reduces blood loss when compared to open lateral lymph node dissection.CrossRefGoogle Scholar
- 37.Perez RO, Sao Juliao GP, Vailati BB, Fernandez LM, Mattacheo AE, Konishi T. Lateral node dissection in rectal cancer in the era of minimally invasive surgery: a step-by-step description for the surgeon unacquainted with this complex procedure with the use of the laparoscopic approach. Dis Colon Rectum. 2018;61(10):1237–40.CrossRefGoogle Scholar
- 38.• Ogura A, Konishi T, Cunningham C, et al. Neoadjuvant (chemo)radiotherapy with total mesorectal excision only is not Sufficient to prevent lateral local recurrence in enlarged nodes: results of the multicenter lateral node study of patients with low cT3/4 rectal cancer. J Clin Oncol. 2018;JCO1800032. This retrospective large study showed that TME plus LLND for LLNs with a short axis at least 7 mm on pretreatment MRI results in a significantly lower LLR rate when comparing to TME alone.Google Scholar
- 39.Bhangu A, Brown G, Nicholls RJ, Wong J, Darzi A, Tekkis P. Survival outcome of local excision versus radical resection of colon or rectal carcinoma: a surveillance, epidemiology, and end results (SEER) population-based study. Ann Surg. 2013;258(4):563–9 discussion 569-571.Google Scholar
- 48.Perez RO, Habr-Gama A, Sao Juliao GP, Proscurshim I, Scanavini Neto A, Gama-Rodrigues J. Transanal endoscopic microsurgery for residual rectal cancer after neoadjuvant chemoradiation therapy is associated with significant immediate pain and hospital readmission rates. Dis Colon Rectum. 2011;54(5):545–51.CrossRefGoogle Scholar
- 50.• Garcia-Aguilar J, Renfro LA, Chow OS, et al. Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol. 2015;16(15):1537–46 This prospective study reported excellent oncological outcomes for early rectal cancer managed by nCRT followed by local excision.CrossRefGoogle Scholar
- 55.•• Lefevre JH, Mineur L, Kotti S, et al. Effect of interval (7 or 11 weeks) between neoadjuvant radiochemotherapy and surgery on complete pathologic response in rectal cancer: a multicenter, randomized, controlled trial (GRECCAR-6). J Clin Oncol. 2016. This randomized controlled trial comparing 7 to 11 weeks interval from CRT to radical surgery failed to demonstrate increase complete pathological response rate between groups. Google Scholar
- 57.• Dattani M, Heald RJ, Goussous G, et al. Oncological and survival outcomes in watch and wait patients with a clinical complete response after neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and pooled analysis. Ann Surg. 2018;268(6):955–67 This systematic review and meta-analysis showed similar overall disease-free and incident of distant metastases between patients managed nonoperatively or with radical surgery after complete response to nCRT.CrossRefGoogle Scholar
- 58.•• Chadi SA, Malcomson L, Ensor J, et al. Factors affecting local regrowth after watch and wait for patients with a clinical complete response following chemoradiotherapy in rectal cancer (InterCoRe consortium): an individual participant data meta-analysis. Lancet Gastroenterol Hepatol. 2018. This meta-analysis with individual participant data demonstrates a good correlation between baseline staging and risk off local regrowth after nonoperative management of patients with rectal cancer and complete response after nCRT. Google Scholar
- 59.•• van der Valk MJM, Hilling DE, Bastiaannet E, et al. Long-term outcomes of clinical complete responders after neoadjuvant treatment for rectal cancer in the International Watch & Wait Database (IWWD): an international multicentre registry study. Lancet. 2018;391(10139):2537–45 This registry-based data reports long-term oncological (local regrowth rates) among nearly 900 patients with rectal cancer managed nonoperatively after a complete clinical response following nCRT.CrossRefGoogle Scholar
- 60.Habr-Gama A, Sao Juliao GP, Gama-Rodrigues J, et al. Baseline T classification predicts early tumor regrowth after nonoperative management in distal rectal cancer after extended neoadjuvant chemoradiation and initial complete clinical response. Dis Colon Rectum. 2017;60(6):586–94.CrossRefGoogle Scholar
- 61.• Habr-Gama A, Sao Juliao GP, Vailati BB, et al. Organ preservation in cT2N0 rectal cancer after neoadjuvant chemoradiation therapy: the impact of radiation therapy dose-escalation and consolidation chemotherapy. Ann Surg. 2019;269(1):102–7 This study compared outcomes of organ preservation strategies among cT2N0 rectal cancer patients undergoing 2 distinct nCRT regimens. Patients undergoing nCRT with RT dose escalation and consolidation CT were more likely to result in successful organ preservation.CrossRefGoogle Scholar
- 62.•• Garcia-Aguilar J, Chow OS, Smith DD, et al. Effect of adding mFOLFOX6 after neoadjuvant chemoradiation in locally advanced rectal cancer: a multicentre, phase 2 trial. Lancet Oncol. 2015;16(8):957–66 This prospective non-randomized study showed that patients with rectal cancer undergoing additional cycles of consolidation CT are more likely to develop complete pathological response after nCRT.CrossRefGoogle Scholar
- 64.Borstlap WAA, van Oostendorp SE, Klaver CEL, et al. Organ preservation in rectal cancer: a synopsis of current guidelines. Color Dis. 2017.Google Scholar