Skip to main content
SpringerLink
Log in

Evaluation of a Protocol-Based Management of Rectal Cancer

  • Published:
Diseases of the Colon & Rectum

Introduction

The management of rectal cancer is multidisciplinary. We have devised and implemented a standardized protocol. This study was designed to evaluate the protocol and identify areas for improvement.

Methods

All patients with a diagnosis of rectal cancer were staged preoperatively. Magnetic resonance imaging and computed tomography were used to predict whether surgical resection would be complete (RO) or involved (R1/2). Data were collected on preoperative adjuvant therapy, surgical procedure, and subsequent pathologic stage, including circumferential resection margin status.

Results

Between January 2000 and October 2002, 163 patients were studied (107 male; median age, 70 (range, 60–77) years). One hundred and fifty seven patients underwent surgical excision for rectal cancer of whom 155 were discussed in the multidisciplinary meeting. One hundred seventeen patients (75 percent) had pelvic magnetic resonance scan and staging computed tomography of chest and abdomen, whereas 38 had computed tomography only. Seventy-seven tumors were predicted as R0 and 78 as likely R1/2. In the predicted RO group, 50 had surgery alone, 25 had short-course radiotherapy, and 2 had chemoradiotherapy. Twelve patients (15.5 percent) had involved circumferential resection margin on the histologic specimen. In the predicted R1/2 group (n = 78), 40 patients received chemoradiotherapy, 11 had short-course radiotherapy, and 27 had surgery alone. Thirty patients (38.4 percent) had involved circumferential resection margin. Circumferential margin involvement was seen in 11 of 40 patients (27.5 percent) who received chemoradiotherapy, 6 of 11 patients (54.5 percent) who received short-course preoperative radiotherapy, and 13 of 27 patients (48.1 percent) who had surgery alone.

Conclusions

Protocol-driven management of rectal cancer within the context of a multidisciplinary team has been demonstrated to work. Regular audit allows for modification and improvement of the protocol as newer management strategies evolve.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1
Figure 2
Figure 3
Figure 4

Similar content being viewed by others

References

  1. ML Landheer P Therasse CJ Velde Particlevan de (2002) ArticleTitleThe importance of quality assurance in surgical oncology Eur J Surg Oncol 28 571–602 Occurrence Handle12359194 Occurrence Handle1:STN:280:DC%2BD38vpslymug%3D%3D Occurrence Handle10.1053/ejso.2002.1255

    Article  PubMed  CAS  Google Scholar 

  2. P Gibbs MW Chao JJ Tjandra (2003) ArticleTitleOptimizing the outcome for patients with rectal cancer Dis Colon Rectum 46 389–402 Occurrence Handle12626917 Occurrence Handle10.1007/s10350-004-6561-x

    Article  PubMed  Google Scholar 

  3. A Radcliffe G Brown (2001) ArticleTitleWill MRI provide maps of lines of excision for rectal cancer? Lancet 357 495–496 Occurrence Handle11229665 Occurrence Handle1:STN:280:DC%2BD3M7lt1ShsA%3D%3D Occurrence Handle10.1016/S0140-6736(00)04038-1

    Article  PubMed  CAS  Google Scholar 

  4. H Nelson DJ Sargent (2001) ArticleTitleRefining multimodal therapy for rectal cancer N Engl J Med 345 690–692 Occurrence Handle11547725 Occurrence Handle1:STN:280:DC%2BD3Mvps1ersQ%3D%3D Occurrence Handle10.1056/NEJM200108303450910

    Article  PubMed  CAS  Google Scholar 

  5. KF Birbeck CP Macklin NJ Tiffin et al. (2002) ArticleTitleRates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery Ann Surg 235 449–457 Occurrence Handle11923599 Occurrence Handle10.1097/00000658-200204000-00001

    Article  PubMed  Google Scholar 

  6. A Wibe PR Rendedal E Svensson et al. (2002) ArticleTitlePrognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer Br J Surg 89 327–334 Occurrence Handle11872058 Occurrence Handle1:STN:280:DC%2BD387jslequg%3D%3D Occurrence Handle10.1046/j.0007-1323.2001.02024.x

    Article  PubMed  CAS  Google Scholar 

  7. J Walker P Quirke (2002) ArticleTitlePrognosis and response to therapy in colorectal cancer Eur J Cancer 38 880–886 Occurrence Handle11978512 Occurrence Handle1:STN:280:DC%2BD383ktVyrtg%3D%3D Occurrence Handle10.1016/S0959-8049(02)00044-8

    Article  PubMed  CAS  Google Scholar 

  8. RJ Heald BJ Moran RD Ryall R Sexton JK MacFarlane (1998) ArticleTitleRectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997 Arch Surg 133 894–899 Occurrence Handle9711965 Occurrence Handle1:STN:280:DyaK1cznsFOrsQ%3D%3D Occurrence Handle10.1001/archsurg.133.8.894

    Article  PubMed  CAS  Google Scholar 

  9. G Arbman E Nilsson O Halbook R Sjodahl (1995) ArticleTitleLocal recurrence following total mesorectal excision for rectal cancer Br J Surg 83 375–379

    Google Scholar 

  10. RJ Aitken (1996) ArticleTitleMesorectal excision for rectal cancer Br J Surg 83 214–216 Occurrence Handle8689166 Occurrence Handle1:STN:280:BymB2cnps1w%3D Occurrence Handle10.1046/j.1365-2168.1996.02057.x

    Article  PubMed  CAS  Google Scholar 

  11. M Bernstein B Amarnath EJ Weiss JJ Nogueras SD Wexner (1998) ArticleTitleTotal mesorectal excision without adjuvant therapy for local control of rectal cancer: a North American experience Tech Coloproctol 2 11–15

    Google Scholar 

  12. F Kockerling MA Reymond A Altendorf-Hoffman O Dworak W Hohenberger (1998) ArticleTitleInfluence of surgery on metachronous distant metastases and survival in rectal cancer J Clin Oncol 16 613–616

    Google Scholar 

  13. J Strassberg (2004) ArticleTitleMagnetic resonance imaging in rectal cancer: the MERCURY experience Tech Coloproctol 8 IssueIDSuppl 1 S16–S18 Occurrence Handle10.1007/s10151-004-0100-6

    Article  Google Scholar 

  14. T Wiggers (2003) ArticleTitleStaging of rectal cancer Br J Surg 90 895–896 Occurrence Handle12905539 Occurrence Handle1:STN:280:DC%2BD3svgsVSksg%3D%3D Occurrence Handle10.1002/bjs.4279

    Article  PubMed  CAS  Google Scholar 

  15. RG Beets-Tan (2003) ArticleTitleMRI in rectal cancer: the T stage and circumferential resection margin Colorectal Dis 90 355–364

    Google Scholar 

  16. G Brown AG Radcliffe G Newcombe NS Dallimore MW Bourne GT Williams (2003) ArticleTitlePreoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging Br J Surg 90 355–364 Occurrence Handle12594673 Occurrence Handle1:STN:280:DC%2BD3s%2Fot1Oiug%3D%3D Occurrence Handle10.1002/bjs.4034

    Article  PubMed  CAS  Google Scholar 

  17. RG Beets-Tan GL Beets RF Vliegen et al. (2001) ArticleTitleAccuracy of magnetic resonance imaging in prediction of tumour-free resection margin in rectal cancer surgery Lancet 357 497–504 Occurrence Handle11229667 Occurrence Handle1:STN:280:DC%2BD3M7lt1Shtg%3D%3D Occurrence Handle10.1016/S0140-6736(00)04040-X

    Article  PubMed  CAS  Google Scholar 

  18. P Mathur JJ Smith C Ramsey et al. (2003) ArticleTitleComparison of CT and MRI in the preoperative staging of rectal adenocarcinoma and prediction of circumferential resection margin involvement by MRI Colorectal Dis 5 396–401 Occurrence Handle12925069 Occurrence Handle1:STN:280:DC%2BD3szovVegsA%3D%3D Occurrence Handle10.1046/j.1463-1318.2003.00537.x

    Article  PubMed  CAS  Google Scholar 

  19. ID Botterill DM Blunt P Quirke et al. (2001) ArticleTitleEvaluation of the role of pre-operative magnetic resonance imaging in the management of rectal cancer Colorectal Dis 5 295–303 Occurrence Handle10.1046/j.1463-1318.2001.00258.x

    Article  Google Scholar 

  20. G Branagan H Chave C Fuller S McGee D Finnis (2004) ArticleTitleCan magnetic resonance imaging predict circumferential margins and TNM stage in rectal cancer? Dis Colon Rectum 8 317–322

    Google Scholar 

  21. C Ratto V Valentini AG Morganti et al. (2003) ArticleTitleCombined-modality therapy in locally advanced primary rectal cancer Dis Colon Rectum 46 59–67 Occurrence Handle12544523 Occurrence Handle10.1007/s10350-004-6497-1

    Article  PubMed  Google Scholar 

  22. D Sebag-Montefiore (2003) ArticleTitleTreatment of T4 tumours: the role of radiotherapy Colorectal Dis 5 432–435 Occurrence Handle12925075 Occurrence Handle10.1046/j.1463-1318.2003.00522.x

    Article  PubMed  Google Scholar 

  23. PJ Marsh RD James PF Schofield (1994) ArticleTitleAdjuvant preoperative radiotherapy for locally advanced rectal carcinoma: results of a prospective, randomised trial Dis Colon Rectum 37 1205–1214 Occurrence Handle7995145 Occurrence Handle1:STN:280:ByqD1cjks1c%3D Occurrence Handle10.1007/BF02257783

    Article  PubMed  CAS  Google Scholar 

  24. H Elsaleh D Joseph M Levitt A House P Robbins (1999) ArticleTitlePre-operative chemoradiotherapy in locally advanced rectal cancer ANZ J Surg 69 737–742 Occurrence Handle1:STN:280:DyaK1MvlsVCktQ%3D%3D Occurrence Handle10.1046/j.1440-1622.1999.01677.x

    Article  CAS  Google Scholar 

  25. InstitutionalAuthorNameAnonymous (1997) ArticleTitleImproved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial N Engl J Med 336 980–987 Occurrence Handle10.1056/NEJM199704033361402

    Article  Google Scholar 

  26. InstitutionalAuthorNameColorectal Cancer Collaborative Group (2001) ArticleTitleAdjuvant radiotherapy for rectal cancer: a systematic overview of 8507 patients from 22 randomised trials Lancet 358 1291–1304 Occurrence Handle10.1016/S0140-6736(01)06409-1

    Article  Google Scholar 

  27. C Camma M Giunta F Fiorica et al. (2000) ArticleTitlePreoperative radiotherapy for resectable rectal cancer: a meta-analysis JAMA 8 1008–1015 Occurrence Handle10.1001/jama.284.8.1008

    Article  Google Scholar 

  28. M Dahlberg B Glimelius W Graf L Pahlman (1998) ArticleTitlePreoperative irradiation affects functional results after surgery for rectal cancer: results from a randomized study Dis Colon Rectum 41 543–549 Occurrence Handle9593234 Occurrence Handle1:STN:280:DyaK1c3lsVSltA%3D%3D Occurrence Handle10.1007/BF02235256

    Article  PubMed  CAS  Google Scholar 

  29. CA Marijnen CJ Velde Particlevan de H Putter et al. (2005) ArticleTitleImpact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: report of a multicenter randomised trial J Clin Oncol 23 1847–1858 Occurrence Handle15774778 Occurrence Handle10.1200/JCO.2005.05.256

    Article  PubMed  Google Scholar 

  30. KC Peters CJ Velde Particlevan de JW Leer et al. (2005) ArticleTitleLate side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients: a Dutch colorectal cancer group study J Clin Oncol 23 6199–6206 Occurrence Handle10.1200/JCO.2005.14.779

    Article  Google Scholar 

  31. E Kapiteijn CA Marijnen ID Nastegaal et al. (2001) ArticleTitlePreoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer N Engl J Med 345 638–646 Occurrence Handle11547717 Occurrence Handle1:STN:280:DC%2BD3Mvps1ektw%3D%3D Occurrence Handle10.1056/NEJMoa010580

    Article  PubMed  CAS  Google Scholar 

  32. M Brink ParticleVan den AM Stiggelbout WB Hout ParticleVan den et al. (2004) ArticleTitleClinical nature and prognosis of locally recurrent rectal cancer after total mesorectal excision with or without preoperative radiotherapy J Clin Oncol 22 3958–3964 Occurrence Handle15459218 Occurrence Handle10.1200/JCO.2004.01.023

    Article  PubMed  Google Scholar 

  33. InstitutionalAuthorNameUnknown (1995) Calman-Hine report, a policy framework for commissioning cancer services Department of Health UK

    Google Scholar 

  34. ID Nagtegaal CA Marijnen EK Kranenbarg et al. (2002) ArticleTitleCircumferential margin is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit Am J Surg Pathol 26 350–357 Occurrence Handle11859207 Occurrence Handle10.1097/00000478-200203000-00009

    Article  PubMed  Google Scholar 

  35. A Crawshaw T Hennigan FH Smedley MD Leslie (2003) ArticleTitlePerioperative radiotherapy for rectal cancer: the case for a selective pre-operative approach: the third way Colorectal Dis 5 367–372 Occurrence Handle12814418 Occurrence Handle1:STN:280:DC%2BD3s3oslCiug%3D%3D Occurrence Handle10.1046/j.1463-1318.2003.00446.x

    Article  PubMed  CAS  Google Scholar 

  36. M Simunovic R Sexton E Rempel BJ Moran RJ Heald (2003) ArticleTitleOptimal preoperative assessment and surgery for rectal cancer may greatly limit the need for radiotherapy Br J Surg 90 999–1003 Occurrence Handle12905555 Occurrence Handle1:STN:280:DC%2BD3szntVSksw%3D%3D Occurrence Handle10.1002/bjs.4210

    Article  PubMed  CAS  Google Scholar 

  37. A Nissan JG Guillem PB Paty et al. (2001) ArticleTitleAbdominoperineal resection for rectal cancer at a specialty center Dis Colon Rectum 44 27–36 Occurrence Handle11805560 Occurrence Handle1:STN:280:DC%2BD38%2FnvVGisw%3D%3D Occurrence Handle10.1007/BF02234816

    Article  PubMed  CAS  Google Scholar 

  38. PP Tekkis AG Heriot JJ Smith MR Thompson P Finan JD Stamatakis (2005) ArticleTitleComparison of circumferential margin involvement between restorative & non-restorative resection for rectal cancer Colorectal Dis 7 369–374 Occurrence Handle15932561 Occurrence Handle1:STN:280:DC%2BD2M3oslOqtg%3D%3D Occurrence Handle10.1111/j.1463-1318.2005.00767.x

    Article  PubMed  CAS  Google Scholar 

  39. WE Miles (1908) ArticleTitleA method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon Lancet 2 1812–1813

    Google Scholar 

  40. N Dehni N Mcfadden DA McNamara M Guiguet E Tiret R Parc (2003) ArticleTitleOncologic results following abdominoperineal resection for adenocarcinoma of the low rectum Dis Colon Rectum 46 867–874 Occurrence Handle12847358 Occurrence Handle1:STN:280:DC%2BD3szhslOjtA%3D%3D Occurrence Handle10.1007/s10350-004-6629-7

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Colorectal Surgery, The General Infirmary at Leeds, Leeds, West Yorkshire, United Kingdom

    Kishore K. Sasapu F.R.C.S. (Edinb.), Peter M. Sagar F.R.C.S., Dermot Burke F.R.C.S. & Paul J. Finan F.R.C.S.

  2. Department of Oncology, The Cookridge Hospital, Leeds, LS16 6QB, West Yorkshire, United Kingdom

    David Sebag-Montefiore F.R.C.R.

  3. Department of Radiology, The General Infirmary at Leeds, Leeds, West Yorkshire, United Kingdom

    Alan G. Chalmers F.R.C.R.

Authors
  1. Kishore K. Sasapu F.R.C.S. (Edinb.)
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. David Sebag-Montefiore F.R.C.R.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alan G. Chalmers F.R.C.R.
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Peter M. Sagar F.R.C.S.
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Dermot Burke F.R.C.S.
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Paul J. Finan F.R.C.S.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to David Sebag-Montefiore F.R.C.R..

Additional information

Reprint requests to: Paul J. Finan, F.R.C.S., Department of Colorectal Surgery, The General Infirmary at Leeds, Great George Street, LS1 3EX, United Kingdom.

About this article

Cite this article

Sasapu, K.K., Sebag-Montefiore, D., Chalmers, A.G. et al. Evaluation of a Protocol-Based Management of Rectal Cancer. Dis Colon Rectum 49, 1703–1709 (2006). https://doi.org/10.1007/s10350-006-0682-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10350-006-0682-3

Key words

Search

Navigation