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Paradigm-Shifting New Evidence for Treatment of Rectal Cancer

  • Evidence-Based Current Surgical Practice
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Treatment of rectal cancer has dramatically evolved during the last three decades shifting toward a tailored approach based on preoperative staging and response to neoadjuvant combined modality therapy (CMT).

Methods

A literature search was performed using PubMed/Medline electronic databases.

Results

Selected patients with T1 N0 rectal cancer are best treated with local excision by transanal endoscopic microsurgery (TEM). Satisfactory results have been reported after CMT and TEM for the treatment of highly selected T2 N0 rectal cancers. CMT followed by rectal resection and total mesorectal excision is considered the standard of care for the treatment of locally advanced rectal cancer. However, a subset of stage II and III patients may not require neoadjuvant radiation treatment. Finally, there are mounting data supporting a “watch and wait” approach or local excision in patients with complete clinical response after neoadjuvant CMT.

Conclusions

Current evidence shows that selected T1 N0 rectal cancers can be managed by TEM alone, while locally advanced cancers should be treated by CMT followed by radical surgery. Studies are underway to identify patients that do not benefit from neoadjuvant radiation therapy. A non-operative approach in case of complete clinical response must be validated by large prospective studies.

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Conflict of interest

The authors declare no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Surgery, University of Washington Medical Center, 1959 NE Pacific St, Box 356410, Seattle, WA, 98195, USA

    Alessandro Fichera

  2. Department of Surgery, Pritzker School of Medicine, University of Chicago, 5841 S. Maryland Ave, MC 5031, Chicago, IL, 60637, USA

    Marco E. Allaix

Authors
  1. Alessandro Fichera
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  2. Marco E. Allaix
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Corresponding author

Correspondence to Alessandro Fichera.

Additional information

moc/MOC Questions

1. The use of local excision for the surgical treatment of early rectal cancer in the United States:

a. is increasing and supported by the evidence from the literature

b. is increasing even though it is not supported by the literature data

c. is associated with higher postoperative morbidity than rectal resection

d. is associated with minimal risk of local recurrence

2. You have a 75-year old patient with cardiovascular comorbidities who presents with a 3-cm cT2N0 rectal cancer at 7 cm from the anal verge. What is the most appropriate treatment modality?

a. radiotherapy alone

b. full-thickness transanal excision

c. anterior resection + TME

d. abdominoperineal resection + TME

3. The best treatment for a 60-year old and healthy patient with a cT2N0 rectal cancer at 6 cm from the anal verge is:

a. transanal endoscopic microsurgery alone

b. transanal endoscopic microsurgery followed by combined modality therapy

c. neoadjuvant combined modality therapy followed by anterior resection and TME

d. anterior resection + TME

4. The Lyon R90-01 trial is a randomized clinical trial that

a. looked at the influence of the interval between completion of radiotherapy and surgery on downstaging

b. compared neoadjuvant combined modality therapy followed by TME to TME alone

c. compared local excision to rectal resection combined with TME for T2 N0 rectal cancer

d. compared local excision to rectal resection combined with TME for T1 N0 rectal cancer

5. You have a 50-year old and healthy patient with a complete clinical response to combined modality therapy for a T3N1 rectal cancer. Based on the current evidence:

a. the probability that he has a pathological complete response is about 75 %

b. he does not need surgery

c. a rectal resection combined with TME is the standard of care

d. full thickness transanal excision is a valid alternative to abdominal rectal surgery

6. A clinical complete response to neoadjuvant combined modality therapy:

a. strongly correlates with pathological complete response

b. can be easily assessed with the available diagnostic tools

c. may be managed with a non-operative approach and strict follow-up

d. is a clear prognostic factor for disease-free survival

7. Neoadjuvant combined modality therapy has been shown to:

a. increase overall survival

b. increase short- and long-term morbidity

c. prevent local recurrence

d. be mostly effective in node positive rectal cancer patients

8. You have a 60 year old patient diagnosed with a T3bN0 rectal cancer:

a. combined modality therapy followed by surgery is the standard of care

b. magnetic resonance imaging is a new diagnostic tool that needs validation for the evaluation of tumor and perirectal lymph nodes

c. endoscopic ultrasound is the most accurate tool for tumor staging

d. neoadjuvant combined modality therapy might be avoided if no adverse radiologic features are present

Answers

1. b

2. b

3. d

4. a

5. c

6. c

7.b

8.d

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Fichera, A., Allaix, M.E. Paradigm-Shifting New Evidence for Treatment of Rectal Cancer. J Gastrointest Surg 18, 391–397 (2014). https://doi.org/10.1007/s11605-013-2297-z

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  • DOI: https://doi.org/10.1007/s11605-013-2297-z

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