Skip to main content

Rectal Cancer

  • Chapter
  • First Online:
Surgical Oncology Manual

Abstract

Rectal cancer is a common cause of cancer death among both men and women. The mainstay of treatment is surgical resection, but in contrast to colon cancer, neoadjuvant chemoradiotherapy plays an important role in rectal cancer management. Recent developments in the field of rectal cancer include validation of the safety of laparoscopic rectal cancer surgery, novel endoluminal techniques which have expanded the role of transanal rectal surgery, and controversy surrounding the management of a complete clinical response to neoadjuvant therapy. As in colon cancer, there is a role for metastasectomy in some stage IV rectal cancer, with the possibility of long-term survival.

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

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Canadian Cancer Society, Statistics Canada. Canadian Cancer Statistics 2014

    Google Scholar 

  2. Baxter NN, Goldwasser MA, Paszat LF, et al. Association of colonoscopy and death from colorectal cancer. Ann Intern Med. 2009;150(1):1–8.

    Article  PubMed  Google Scholar 

  3. Howlader N, Noone AM, Krapcho M, et al (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014. Accessed 28 Nov 2014.

  4. Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol. 2008;26(2):303.

    Article  PubMed  Google Scholar 

  5. Earle C, Annis R, Sussman J, et al. Follow-up care, surveillance protocol and secondary prevention measures for survivors of colon cancer. Toronto (ON): Cancer Care Ontario, 2012 Feb 3. Program in Evidence-Based Care Evidence-Based Series No.: 26-2.

    Google Scholar 

  6. Bipat S, Glas AS, Slors FJ, et al. Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging--a meta-analysis. Radiology. 2004;232(3):773.

    Article  PubMed  Google Scholar 

  7. Al-Sukhni E, Milot L, Fruitman M, et al. Diagnostic accuracy of MRI for assessment of T category, lymph node metastases, and circumferential resection margin involvement in patients with rectal cancer: a systematic review and meta-analysis. Ann Surg Oncol. 2012;19(7):2212–23.

    Article  PubMed  Google Scholar 

  8. Memon S, Lynch AC, Akhurst T, et al. Systematic review of FDG-PET prediction of complete pathological response and survival in rectal cancer. Ann Surg Oncol. 2014;21(11):3598–607.

    Article  PubMed  Google Scholar 

  9. Sajid MS, Ahamd A, Miles WFA, et al. Systematic review of oncological outcomes following laparoscopic vs open total mesorectal excision. World J Gastrointest Endosc. 2014;6(5):209–19.

    Article  PubMed  PubMed Central  Google Scholar 

  10. van der Pas M, Haglind E, Cuesta MA, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomized, phase 3 trial. Lancet Oncol. 2013;14(3):210–8.

    Article  PubMed  Google Scholar 

  11. Jeong SY, Park JW, Nam BH, et al. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomized controlled trial. Lancet Oncol. 2014;15(7):767–74.

    Article  PubMed  Google Scholar 

  12. Marr R, Birbeck K, Garvican J, et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg. 2005;242:74–82.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Nagtegaal D, van de Velde C, Marijnen CAM, et al. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol. 2005;23:9257–64.

    Article  PubMed  Google Scholar 

  14. Wibe A, Syse A, Andersen E, et al. Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs abdominoperineal resection. Dis Colon Rectum. 2004;47:48–58.

    Article  PubMed  Google Scholar 

  15. Han JG, Wang ZJ, Wei GH, et al. Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer. Am J Surg. 2012;204(3):274–82.

    Article  PubMed  Google Scholar 

  16. West NP, Finan PJ, Anderin C, et al. Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol. 2008;26(21):3517.

    Article  PubMed  Google Scholar 

  17. Persiani R, Biondi A, Gambacorta MA, et al. Prognostic implications of the lymph node count after neoadjuvant treatment for rectal cancer. Br J Surg. 2014;101(2):133–42.

    Article  CAS  PubMed  Google Scholar 

  18. Awwad GE, Tou SI, Rieger NA. Prognostic significance of lymph node yield after long-course preoperative radiotherapy in patients with rectal cancer: a systematic review. Colorectal Dis. 2013;15(4):394–403.

    Article  CAS  PubMed  Google Scholar 

  19. Miller ED, Robb BW, Cummings OW, et al. The effects of preoperative chemoradiotherapy on lymph node sampling in rectal cancer. Dis Colon Rectum. 2012;55(9):1002–7.

    Article  PubMed  Google Scholar 

  20. Fokas E, Liersch T, Fietkau R, et al. Tumor regression grading after preoperative chemoradiotherapy for locally advanced rectal carcinoma revisited: updated results of the CAO/ARO/AIO-94 trial. J Clin Oncol. 2014;32(15):1554.

    Article  PubMed  Google Scholar 

  21. Protocol for the Examinatino of Specimens from Patients with Primary Carcinoma of the Colon. http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Colon_11protocol.pdf Protocol web posting date: February 1, 2011. Accessed 28 Nov 2014.

  22. Patel UBP, Taylor F, Blomqvist L, et al. Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience. J Clin Oncol. 2011;29(28):3753–60.

    Article  PubMed  Google Scholar 

  23. Heidary B, Phang TP, Raval MJ, et al. Transanal endoscopic microsurgery: a review. Can J Surg. 2014;57(2):127–38.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Bouvet M, Milas M, Giacco GG, et al. Predictors of recurrence after local excision and postoperative chemoradiation therapy of adenocarcinoma of the rectum. Ann Surg Oncol. 1999;6:26–32.

    Article  CAS  PubMed  Google Scholar 

  25. Hahnloser D, Wolff BG, Larson DW, et al. Immediate radical resection after local excision of rectal cancer: an oncologic compromise? Dis Colon Rectum. 2005;48:429–37.

    Article  PubMed  Google Scholar 

  26. Levic K, Bulut O, Hesselfeldt P, et al. The outcome of rectal cancer after early salvage TME following TEM compared with primary TME: a case-matched study. Tech Coloproctol. 2013;17(4):397–403.

    Article  CAS  PubMed  Google Scholar 

  27. Bujko K, Richter P, Kolodziejczyk M, et al. Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders. Radiother Oncol. 2009;92(2):195–201.

    Article  PubMed  Google Scholar 

  28. Habr-Gama A, Sao Juliao GP, Perez RO. Pitfalls of transanal endoscopic microsurgery for rectal cancer following neoadjuvant chemoradiation therapy. Minim Invasive Ther. 2014;23(2):63–9.

    Article  Google Scholar 

  29. Guerrieri M, Baldarelli M, Rimini M, et al. Transanal endoscopic microsurgery for rectal tumors: an option to radical surgery? Minerva Chir. 2013;68(3):289–98.

    CAS  PubMed  Google Scholar 

  30. Perez RO, Habr-Gama A, Lynn PB, et al. Transanal endoscopic microsurgery for residual rectal cancer (ypT0-2) following neoadjuvant chemoradiation therapy: another word of caution. Dis Colon Rectum. 2013;56(1):6–13.

    Article  PubMed  Google Scholar 

  31. Pucciarelli S, De Paoli A, Guerrieri M, et al. Local excision after preoperative chemoradiotherapy for rectal cancer: results of a multicenter phase II clinical trial. Dis Colon Rectum. 2013;56(12):1349–56.

    Article  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  33. Fitzgerald TL, Brinkley J, Zervos EE. Pushing the envelope beyond a centimeter in rectal cancer: oncologic implications of close, but negative margins. J Am Coll Surg. 2011;213(5):589–95.

    Article  PubMed  Google Scholar 

  34. Nagtegaal ID, Gosens MJ, Marijnen CA, et al. Combinations of tumor and treatment parameters are more discriminative for prognosis than the present TNM system in rectal cancer. J Clin Oncol. 2007;25:1647–50.

    Article  PubMed  Google Scholar 

  35. Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N Engl J Med 1997, 336(14):980–7.

    Google Scholar 

  36. Folkesson J, Birgisson H, Pahlman L, et al. Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate. J Clin Oncol. 2005;23(24):5644–50.

    Article  PubMed  Google Scholar 

  37. Taylor FGM, 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. Ann Surg. 2011;253(4):711–9.

    Article  PubMed  Google Scholar 

  38. Taylor FGM, 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(1):34–43.

    Article  PubMed  Google Scholar 

  39. Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351(17):1731–40.

    Article  CAS  PubMed  Google Scholar 

  40. Sauer R, Liersch T, Merkel S, et al. Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. J Clin Oncol. 2012;30(16):1926–33.

    Article  CAS  PubMed  Google Scholar 

  41. Roh MS, Colangelo LH, O’Connell MJ. Preoperative multimodality therapy improves disease-free survival in patients with carcinoma of the rectum: NSABP R-03. J Clin Oncol. 2009;27(31):5124–30.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Bujko K, Nowacki MP, Nasierowska-Guttmejer A, et al. Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg. 2006;93:1215–23.

    Article  CAS  PubMed  Google Scholar 

  43. Ngan S, Fisher R, Goldstein D, et al. A randomized trial comparing local recurrence (LR) rates between short-course (SC) and long-course (LC) preoperative radiotherapy (RT) for clinical T3 rectal cancer: an intergroup trial (TROG, AGITG, CSSANZ, RACS). J Clin Oncol. 2010;28:15s.

    Google Scholar 

  44. Bosset JF, Collette L, Calais G, et al. Chemotherapy with preoperative radiotherapy in rectal cancer. EORTC Radiotherapy Group Trial 22921. N Engl J Med. 2006;355(11):1114.

    Article  CAS  PubMed  Google Scholar 

  45. McCarthy K, Pearson K, Fulton R, et al. Pre-operative chemoradiation for non-metastatic locally advanced rectal cancer. Cochrane Database Syst Rev. 2012;12, CD008368.

    PubMed  Google Scholar 

  46. Martin ST, Heneghan HM, Winter DC. Systematic review and meta-analysis of outcomes following pathological complete response to neoadjuvant chemoradiotherapy for rectal cancer. Br J Surg. 2012;99(7):918.

    Article  CAS  PubMed  Google Scholar 

  47. Maas M, Beets-Tan RG, Lambregts DM, et al. Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer. J Clin Oncol. 2011;29(35):4633.

    Article  PubMed  Google Scholar 

  48. Habr-Gama A, Perez RO, Nadalin W, et al. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg. 2004;240(4):711.

    PubMed  PubMed Central  Google Scholar 

  49. 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(7):897.

    Article  CAS  PubMed  Google Scholar 

  50. Callender GG, Das P, Rodriguez-Bigas MA, et al. Local excision after preoperative chemoradiation results in an equivalent outcome to total mesorectal excision in selected patients with T3 rectal cancer. Ann Surg Oncol. 2010;17(2):441.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Borschitz T, Wachtlin D, Möhler M, et al. Neoadjuvant chemoradiation and local excision for T2-3 rectal cancer. Ann Surg Oncol. 2008;15(3):712.

    Article  PubMed  Google Scholar 

  52. Faneyte IF, Dresen RC, Edelbrok MA, et al. Preoperative staging with positron emission tomography in patients with pelvic recurrence of rectal cancer. Dig Surg. 2008;25:202–7.

    Article  PubMed  Google Scholar 

  53. Das P, Delclos ME, Skibber JM, et al. Hyperfractionated accelerated radiotherapy for rectal cancer in patients with prior irradiation. Int J Radiat Oncol Biol Phys. 2010;77:60–5.

    Article  PubMed  Google Scholar 

  54. Hyngstrom JR, Tzeng CW, Beddar S, et al. Intraoperative radiation therapy for locally advanced primary and recurrent colorectal cancer: ten-year institutional experience. J Surg Oncol. 2014;109(7):652–8.

    Article  PubMed  Google Scholar 

  55. Lehnert T, Methner M, Pollok A, et al. Multivisceral resection for locally advanced primary colon and rectal cancer. An analysis of prognostic factors in 201 patients. Anal Surg. 2002;235:217–35.

    Article  Google Scholar 

  56. Bhangu A, Ali SM, Darzi A, et al. Meta-analysis of survival based on resection margin status following surgery for recurrent rectal cancer. Colorectal Dis. 2012;14(12):1457–66.

    Article  CAS  PubMed  Google Scholar 

  57. Rodriguez-Bigas M, Chang C, Skibber J. Multidisciplinary approach to recurrent/unresectable rectal cancer: how to prepare for the extent of resection. Surg Oncol Clin N Am. 2010;19:847–59.

    Article  PubMed  Google Scholar 

  58. Sridharan M, Hubbard JM, Grothey A. Colorectal cancer: how emerging molecular understanding affects treatment decisions. Oncology. 2014;28(2):110–8.

    PubMed  Google Scholar 

  59. Culverwell AD, Chowdhury FU, Scarsbrook AF. Optimizing the role of FDG PET-CT for potentially operable metastatic colorectal cancer. Abdom Imaging. 2012;37(6):1021–31.

    Article  CAS  PubMed  Google Scholar 

  60. Choti MA, Sitzmann JV, Tiburi MF, et al. Trends in long-term survival following liver resection for hepatic colorectal metastases. Ann Surg. 2002;235(6):759–66.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Abdalla EK, Vauthey JN. Ellis LM, et al Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases. Ann Surg. 2004;239(6):818–25.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Fernandez FG, Drebin JA, Linehan DC, et al. Five-year survival after resection of hepatic metastases from colorectal cancer in patients screened by positron emission tomography with F-18 fluorodeoxyglucose (FDG-PET). Ann Surg. 2004;240(3):438–47.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Kanzaki R, Higashiyama M, Oda K, et al. Outcome of surgical resection for recurrent pulmonary metastasis from colorectal carcinoma. Am J Surg. 2011;202(4):419–26.

    Article  PubMed  Google Scholar 

  64. Blackmon SH, Stephens EH, Correa AM, et al. Predictors of recurrent pulmonary metastases and survival after pulmonary metastasectomy for colorectal cancer. Ann Thorac Surg. 2012;94(6):1802.

    Article  PubMed  Google Scholar 

  65. Iida T, Nomori H, Shiba M, Metastatic Lung Tumor Study Group of Japan, et al. Prognostic factors after pulmonary metastasectomy for colorectal cancer and rationale for determining surgical indications: a retrospective analysis. Ann Surg. 2013;257(6):1059.

    Article  PubMed  Google Scholar 

  66. Yan TD, Black D, Savady R, et al. Systematic review on the efficacy of cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis from colorectal carcinoma. J Clin Oncol. 2006;24(24):4011.

    Article  PubMed  Google Scholar 

  67. Lemke J, Scheele J, Kapapa T, et al. Brain metastases in gastrointestinal cancers: is there a role for surgery? Int J Mol Sci. 2014;15(9):16816–30.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Poultsides GA, Servais EL, Saltz LB, et al. Outcome of primary tumor in patients with synchronous stage IV colorectal cancer receiving combination chemotherapy without surgery as initial treatment. J Clin Oncol. 2009;27:3379–84.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Tarantino I, Warschkow R, Worni M, et al. Prognostic relevance of palliative primary tumor removal in 37,793 metastatic colorectal cancer patients. Ann Surg. 2015;262(1):112–20.

    Article  PubMed  Google Scholar 

  70. Rahbari NN, Lordick F, Fink C, et al. Resection of the primary tumour versus no resection prior to systemic therapy in patients with colon cancer and synchronous unresectable metastases (UICC stage IV): SYNCHRONOUS—a randomized controlled multicenter trial (ISRCTN30964555). BMC Cancer. 2012;12:142.

    Article  PubMed  PubMed Central  Google Scholar 

  71. 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 

  72. Kapiteijn E, Marijen 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 

  73. Tan WS, Tang CL, Shi L, et al. Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg. 2009;96(5):462–72.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Andrea MacNeill M.D., M.Sc., F.R.C.S.C. .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2016 University of Toronto General Surgery Oncology Program

About this chapter

Cite this chapter

MacNeill, A., Ashamalla, S., Burnstein, M.J., Stotland, P.K. (2016). Rectal Cancer. In: Wright, F., Escallon, J., Cukier, M., Tsang, M., Hameed, U. (eds) Surgical Oncology Manual. Springer, Cham. https://doi.org/10.1007/978-3-319-26276-5_21

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-26276-5_21

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-26274-1

  • Online ISBN: 978-3-319-26276-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics