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Locally Advanced Disease

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Modern Management of Cancer of the Rectum

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Abstract

Surgical resection is the mainstay of treatment for rectal cancers. For the vast majority of patients with rectal cancers the tumor is located within the mesorectal fascia and is resected with total mesorectal excision (TME) with excellent clinical outcomes. A small percentage of patients have tumors that extend beyond the mesorectal compartment with invasion into the fascia propria or beyond into surrounding structures or with local lymph node involvement (stage II or III). These patients with locally advanced rectal cancer are difficult to treat with surgery alone due to an increased risk in local disease recurrence. In recent years, new technologies and advances in treatment protocols have resulted in a multidisciplinary approach that has yielded improved clinical and oncological outcomes.

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References

  1. Adloff M, Arnaud JP, Bergamaschi R, Schloegel M. Synchronous carcinoma of the colon and rectum: prognostic and therapeutic implications. Am J Surg. 1989;157:299–302.

    Article  CAS  PubMed  Google Scholar 

  2. Barillari P, Ramacciato G, De Angelis R, et al. Effect of preoperative colonoscopy on the incidence of synchronous and metachronous neoplasms. Acta Chir Scand. 1990;156:163–6.

    CAS  PubMed  Google Scholar 

  3. Bat L, Neumann G, Shemesh E. The association of synchronous neoplasms with occluding colorectal cancer. Dis Colon Rectum. 1985;28:149–51.

    Article  CAS  PubMed  Google Scholar 

  4. Isler JT, Brown PC, Lewis FG, Billingham RP. The role of preoperative colonoscopy in colorectal cancer. Dis Colon Rectum. 1987;30:435–9.

    Article  CAS  PubMed  Google Scholar 

  5. Edge SB, Byrd DR, Compton CC. AJCC cancer staging manual. 7th ed. New York: Springer; 2010. p. 103–11.

    Google Scholar 

  6. Hosein PJ, Rocha-Lima CM. Role of combined-modality therapy in the management of locally advanced rectal cancer. Clin Colorectal Cancer. 2008;7:369–75.

    Article  CAS  PubMed  Google Scholar 

  7. Bipat S, Glas AS, Slors FJ, Zwinderman AH, Bossuyt PM, Stoker J. Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging–a meta-analysis. Radiology. 2004;232:773–83.

    Article  PubMed  Google Scholar 

  8. Lahaye MJ, Engelen SM, Nelemans PJ, et al. Imaging for predicting the risk factors–the circumferential resection margin and nodal disease–of local recurrence in rectal cancer: a meta-analysis. Semin Ultrasound CT MR. 2005;26:259–68.

    Article  CAS  PubMed  Google Scholar 

  9. Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol. 2008;26:303–12.

    Article  PubMed  Google Scholar 

  10. Brown G, Daniels IR, Richardson C, Revell P, Peppercorn D, Bourne M. Techniques and trouble-shooting in high spatial resolution thin slice MRI for rectal cancer. Br J Radiol. 2005;78:245–51.

    Article  CAS  PubMed  Google Scholar 

  11. NIH consensus conference. Adjuvant therapy for patients with colon and rectal cancer. JAMA. 1990;264:1444–50.

    Article  Google Scholar 

  12. Monson JR, Weiser MR, Buie WD, et al. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum. 2013;56:535–50.

    Article  CAS  PubMed  Google Scholar 

  13. Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N Engl J Med. 1997;336:980–7.

    Google Scholar 

  14. Birgisson H, Pahlman L, Gunnarsson U, Glimelius B. Adverse effects of preoperative radiation therapy for rectal cancer: long-term follow-up of the Swedish Rectal Cancer Trial. J Clin Oncol. 2005;23:8697–705.

    Article  PubMed  Google Scholar 

  15. Folkesson J, Birgisson H, Pahlman L, Cedermark B, Glimelius B, Gunnarsson U. Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate. J Clin Oncol. 2005;23:5644–50.

    Article  PubMed  Google Scholar 

  16. Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;345:638–46.

    Article  CAS  PubMed  Google Scholar 

  17. van Gijn W, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial. Lancet Oncol. 2011;12:575–82.

    Article  PubMed  Google Scholar 

  18. Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351:1731–40.

    Article  CAS  PubMed  Google Scholar 

  19. De Caluwe L, Van Nieuwenhove Y, Ceelen WP. Preoperative chemoradiation versus radiation alone for stage II and III resectable rectal cancer. Cochrane Database Syst Rev. 2013;(2):CD006041.

    Google Scholar 

  20. Quah HM, Chou JF, Gonen M, et al. Pathologic stage is most prognostic of disease-free survival in locally advanced rectal cancer patients after preoperative chemoradiation. Cancer. 2008;113:57–64.

    Article  PubMed  Google Scholar 

  21. Bujko K, Nowacki MP, Nasierowska-Guttmejer A, et al. Sphincter preservation following preoperative radiotherapy for rectal cancer: report of a randomised trial comparing short-term radiotherapy vs. conventionally fractionated radiochemotherapy. Radiother Oncol. 2004;72:15–24.

    Article  CAS  PubMed  Google Scholar 

  22. Bujko K, Nowacki MP, Kepka L, Oledzki J, Bebenek M, Kryj M. Postoperative complications in patients irradiated pre-operatively for rectal cancer: report of a randomised trial comparing short-term radiotherapy vs chemoradiation. Colorectal Dis. 2005;7:410–6.

    Article  CAS  PubMed  Google Scholar 

  23. Wong RK, Tandan V, De Silva S, Figueredo A. Pre-operative radiotherapy and curative surgery for the management of localized rectal carcinoma. Cochrane Database Syst Rev. 2007;(2):CD002102.

    Google Scholar 

  24. Sebag-Montefiore D, Stephens RJ, Steele R, et al. Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial. Lancet. 2009;373:811–20.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Petrelli F, Sgroi G, Sarti E, Barni S. Increasing the interval between neoadjuvant chemoradiotherapy and surgery in rectal cancer: a meta-analysis of published studies. Ann Surg. 2013. [epub].

    Google Scholar 

  26. Taylor FG, Quirke P, Heald RJ, et al. Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multicenter, European study. Ann Surg. 2011;253:711–9.

    Article  PubMed  Google Scholar 

  27. Taylor FG, Quirke P, Heald RJ, et al. Preoperative magnetic resonance imaging assessment of circumferential resection margin predicts disease-free survival and local recurrence: 5-year follow-up results of the MERCURY study. J Clin Oncol. 2014;32:34–43.

    Article  PubMed  Google Scholar 

  28. Bosset JF, Collette L, Calais G, et al. Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med. 2006;355:1114–23.

    Article  CAS  PubMed  Google Scholar 

  29. Collette L, Bosset JF, den Dulk M, et al. Patients with curative resection of cT3-4 rectal cancer after preoperative radiotherapy or radiochemotherapy: does anybody benefit from adjuvant fluorouracil-based chemotherapy? A trial of the European Organisation for Research and Treatment of Cancer Radiation Oncology Group. J Clin Oncol. 2007;25:4379–86.

    Article  CAS  PubMed  Google Scholar 

  30. Bosset JF, Calais G, Mineur L, et al. Fluorouracil-based adjuvant chemotherapy after preoperative chemoradiotherapy in rectal cancer: long-term results of the EORTC 22921 randomised study. Lancet Oncol. 2014;15:184–90.

    Article  CAS  PubMed  Google Scholar 

  31. Andre T, Boni C, Mounedji-Boudiaf L, et al. Oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment for colon cancer. N Engl J Med. 2004;350:2343–51.

    Article  CAS  PubMed  Google Scholar 

  32. Benson AB, Bekaii-Saab T, Chan E, et al. Rectal cancer. J Natl Compr Canc Netw. 2012;10:1528–64.

    CAS  PubMed  Google Scholar 

  33. Prolongation of the disease-free interval in surgically treated rectal carcinoma. Gastrointestinal Tumor Study Group. N Engl J Med. 1985;312:1465–72.

    Google Scholar 

  34. Adam IJ, Mohamdee MO, Martin IG, et al. Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet. 1994;344:707–11.

    Article  CAS  PubMed  Google Scholar 

  35. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery–the clue to pelvic recurrence? Br J Surg. 1982;69:613–6.

    Article  CAS  PubMed  Google Scholar 

  36. Enker WE. Total mesorectal excision–the new golden standard of surgery for rectal cancer. Ann Med. 1997;29:127–33.

    Article  CAS  PubMed  Google Scholar 

  37. Hida J, Yasutomi M, Maruyama T, Fujimoto K, Uchida T, Okuno K. Lymph node metastases detected in the mesorectum distal to carcinoma of the rectum by the clearing method: justification of total mesorectal excision. J Am Coll Surg. 1997;184:584–8.

    CAS  PubMed  Google Scholar 

  38. Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet. 1986;2:996–9.

    Article  CAS  PubMed  Google Scholar 

  39. Grinnell RS. Results of ligation of inferior mesenteric artery at the aorta in resections of carcinoma of the descending and sigmoid colon and rectum. Surg Gynecol Obstet. 1965;120:1031–6.

    CAS  PubMed  Google Scholar 

  40. Titu LV, Tweedle E, Rooney PS. High tie of the inferior mesenteric artery in curative surgery for left colonic and rectal cancers: a systematic review. Dig Surg. 2008;25:148–57.

    Article  CAS  PubMed  Google Scholar 

  41. Rutegard M, Hemmingsson O, Matthiessen P, Rutegard J. High tie in anterior resection for rectal cancer confers no increased risk of anastomotic leakage. Br J Surg. 2012;99:127–32.

    Article  CAS  PubMed  Google Scholar 

  42. Williams NS, Dixon MF, Johnston D. Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patients’ survival. Br J Surg. 1983;70:150–4.

    Article  CAS  PubMed  Google Scholar 

  43. Wolmark N, Fisher B. An analysis of survival and treatment failure following abdominoperineal and sphincter-saving resection in Dukes’ B and C rectal carcinoma. A report of the NSABP clinical trials. National Surgical Adjuvant Breast and Bowel Project. Ann Surg. 1986;204:480–9.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  44. Guillem JG, Chessin DB, Shia J, et al. A prospective pathologic analysis using whole-mount sections of rectal cancer following preoperative combined modality therapy: implications for sphincter preservation. Ann Surg. 2007;245:88–93.

    Article  PubMed Central  PubMed  Google Scholar 

  45. Pahlman L, Bujko K, Rutkowski A, Michalski W. Altering the therapeutic paradigm towards a distal bowel margin of <1 cm in patients with low-lying rectal cancer: a systematic review and commentary. Colorectal Dis. 2013;15:e166–74.

    Article  CAS  PubMed  Google Scholar 

  46. Gerard JP, Rostom Y, Gal J, et al. Can we increase the chance of sphincter saving surgery in rectal cancer with neoadjuvant treatments: lessons from a systematic review of recent randomized trials. Crit Rev Oncol Hematol. 2012;81:21–8.

    Article  PubMed  Google Scholar 

  47. Bordeianou L, Maguire LH, Alavi K, Sudan R, Wise PE, Kaiser AM. Sphincter-sparing surgery in patients with low-lying rectal cancer: techniques, oncologic outcomes, and functional results. J Gastrointest Surg. 2014;18(7):1358–72.

    Article  PubMed Central  PubMed  Google Scholar 

  48. Brown CJ, Fenech DS, McLeod RS. Reconstructive techniques after rectal resection for rectal cancer. Cochrane Database Syst Rev. 2008;(2):CD006040.

    Google Scholar 

  49. Liao C, Gao F, Cao Y, Tan A, Li X, Wu D. Meta-analysis of the colon J-pouch vs transverse coloplasty pouch after anterior resection for rectal cancer. Colorectal Dis. 2010;12:624–31.

    Article  CAS  PubMed  Google Scholar 

  50. Tan WS, Tang CL, Shi L, Eu KW. Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg. 2009;96:462–72.

    Article  CAS  PubMed  Google Scholar 

  51. de Wilt JH, Vermaas M, Ferenschild FT, Verhoef C. Management of locally advanced primary and recurrent rectal cancer. Clin Colon Rectal Surg. 2007;20:255–63.

    Article  PubMed Central  PubMed  Google Scholar 

  52. Fujita S, Yamamoto S, Akasu T, Moriya Y. Lateral pelvic lymph node dissection for advanced lower rectal cancer. Br J Surg. 2003;90:1580–5.

    Article  CAS  PubMed  Google Scholar 

  53. Georgiou P, Tan E, Gouvas N, et al. Extended lymphadenectomy versus conventional surgery for rectal cancer: a meta-analysis. Lancet Oncol. 2009;10:1053–62.

    Article  PubMed  Google Scholar 

  54. Abe M, Takahashi M. Intraoperative radiotherapy: the Japanese experience. Int J Radiat Oncol Biol Phys. 1981;7:863–8.

    Article  CAS  PubMed  Google Scholar 

  55. Williams CP, Reynolds HL, Delaney CP, et al. Clinical results of intraoperative radiation therapy for patients with locally recurrent and advanced tumors having colorectal involvement. Am J Surg. 2008;195:405–9.

    Article  PubMed  Google Scholar 

  56. Ellis RJ, Nag S, Kinsella TJ. Alternative techniques of intraoperative radiotherapy. Eur J Surg Oncol. 2000;26(Suppl A):S25–7.

    PubMed  Google Scholar 

  57. Harrison LB, Enker WE, Anderson LL. High-dose-rate intraoperative radiation therapy for colorectal cancer. Oncology (Williston Park). 1995;9:737–41; discussion 742.

    CAS  Google Scholar 

  58. Nielsen MB, Laurberg S, Holm T. Current management of locally recurrent rectal cancer. Colorectal Dis. 2011;13:732–42.

    Article  CAS  PubMed  Google Scholar 

  59. Nuyttens JJ, Kolkman-Deurloo IK, Vermaas M, et al. High-dose-rate intraoperative radiotherapy for close or positive margins in patients with locally advanced or recurrent rectal cancer. Int J Radiat Oncol Biol Phys. 2004;58:106–12.

    Article  PubMed  Google Scholar 

  60. Willett CG. Intraoperative radiation therapy. Int J Clin Oncol. 2001;6:209–14.

    Article  CAS  PubMed  Google Scholar 

  61. Heriot AG, Byrne CM, Lee P, et al. Extended radical resection: the choice for locally recurrent rectal cancer. Dis Colon Rectum. 2008;51:284–91.

    Article  PubMed  Google Scholar 

  62. Wiig JN, Poulsen JP, Tveit KM, Olsen DR, Giercksky KE. Intra-operative irradiation (IORT) for primary advanced and recurrent rectal cancer. a need for randomised studies. Eur J Cancer. 2000;36:868–74.

    Article  CAS  PubMed  Google Scholar 

  63. Wiig JN, Giercksky KE, Tveit KM. Intraoperative radiotherapy for locally advanced or locally recurrent rectal cancer: does it work at all? Acta Oncol. 2014;53(7):865–76.

    Article  CAS  PubMed  Google Scholar 

  64. Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet. 2005;365:1718–26.

    Article  PubMed  Google Scholar 

  65. Jayne DG, Thorpe HC, Copeland J, Quirke P, Brown JM, Guillou PJ. Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br J Surg. 2010;97:1638–45.

    Article  CAS  PubMed  Google Scholar 

  66. Kang SB, Park JW, Jeong SY, et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol. 2010;11:637–45.

    Article  PubMed  Google Scholar 

  67. Anderson C, Uman G, Pigazzi A. Oncologic outcomes of laparoscopic surgery for rectal cancer: a systematic review and meta-analysis of the literature. Eur J Surg Oncol. 2008;34:1135–42.

    Article  CAS  PubMed  Google Scholar 

  68. Jayne DG, Guillou PJ, Thorpe H, et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol. 2007;25:3061–8.

    Article  PubMed  Google Scholar 

  69. Laurent C, Leblanc F, Wutrich P, Scheffler M, Rullier E. Laparoscopic versus open surgery for rectal cancer: long-term oncologic results. Ann Surg. 2009;250:54–61.

    Article  PubMed  Google Scholar 

  70. Vennix S, Pelzers L, Bouvy N, et al. Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database Syst Rev. 2014;(4):CD005200.

    Google Scholar 

  71. Glynne-Jones R, Hughes R. Critical appraisal of the ‘wait and see’ approach in rectal cancer for clinical complete responders after chemoradiation. Br J Surg. 2012;99:897–909.

    Article  CAS  PubMed  Google Scholar 

  72. Habr-Gama A, de Souza PM, Ribeiro UJ, et al. Low rectal cancer: impact of radiation and chemotherapy on surgical treatment. Dis Colon Rectum. 1998;41:1087–96.

    Article  CAS  PubMed  Google Scholar 

  73. Habr-Gama A, Perez RO, Proscurshim I, et al. Patterns of failure and survival for nonoperative treatment of stage c0 distal rectal cancer following neoadjuvant chemoradiation therapy. J Gastrointest Surg. 2006;10:1319–28; discussion 1328.

    Article  PubMed  Google Scholar 

  74. Allen SD, Padhani AR, Dzik-Jurasz AS, Glynne-Jones R. Rectal carcinoma: MRI with histologic correlation before and after chemoradiation therapy. AJR Am J Roentgenol. 2007;188:442–51.

    Article  PubMed  Google Scholar 

  75. Vanagunas A, Lin DE, Stryker SJ. Accuracy of endoscopic ultrasound for restaging rectal cancer following neoadjuvant chemoradiation therapy. Am J Gastroenterol. 2004;99:109–12.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, OH, 44106, USA

    Benjamin Crawshaw MD, Knut M. Augestad MD, PhD, Harry L. Reynolds Jr. MD & Conor P. Delaney MD, PhD

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  1. Benjamin Crawshaw MD
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  2. Knut M. Augestad MD, PhD
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  3. Harry L. Reynolds Jr. MD
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  4. Conor P. Delaney MD, PhD
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Correspondence to Benjamin Crawshaw MD .

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Editors and Affiliations

  1. Colon and Rectal Surgery, Yale School of Medicine, New Haven, Connecticut, USA

    Walter E. Longo

  2. Colon and Rectal Surgery, Yale School of Medicine, New Haven, Connecticut, USA

    Vikram Reddy

  3. University of Liverpool St Helens Teaching Hospital, St Helens, United Kingdom

    Riccardo A. Audisio

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Crawshaw, B., Augestad, K.M., Reynolds, H.L., Delaney, C.P. (2015). Locally Advanced Disease. In: Longo, W., Reddy, V., Audisio, R. (eds) Modern Management of Cancer of the Rectum. Springer, London. https://doi.org/10.1007/978-1-4471-6609-2_21

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  • DOI: https://doi.org/10.1007/978-1-4471-6609-2_21

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