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Adjuvant therapy for resected rectal adenocarcinoma

Christopher G Willett, MD
David P Ryan, MD
Section Editor
Richard M Goldberg, MD
Deputy Editor
Diane MF Savarese, MD


Surgical resection is the cornerstone of curative therapy for rectal adenocarcinoma. However, surgery alone provides a high cure rate only for patients with early stage (stage I (table 1)) disease.

Many randomized trials have attempted to improve the results of surgery alone through the addition of chemotherapy and radiation therapy (RT), both before and after surgery. RT has emerged as an important component of adjuvant therapy for rectal cancer because of the distinct patterns of failure following resection. In contrast to colon cancer, in which the failure pattern is predominantly distant metastases, the site of first failure in patients undergoing surgery for rectal cancer is equally distributed locally (ie, pelvis) and in distant sites (eg, liver, lung) [1].

The majority of early trials of combined modality therapy in rectal cancer evaluated postoperative RT with or without chemotherapy. More recently, focus has shifted to preoperative (neoadjuvant) application of combined chemoradiotherapy. Neoadjuvant rather than adjuvant chemoradiotherapy is preferred for patients with transmural (T3/4) (table 1) or node-positive tumors, particularly if they are low-lying within the rectum. Advantages of this approach include better local control, increased likelihood of sphincter saving surgery, and a lower risk of chronic anastomotic stricture. (See "Neoadjuvant chemoradiotherapy and radiotherapy for rectal adenocarcinoma", section on 'Indications for neoadjuvant treatment'.)

Nevertheless, initial surgery is still utilized in clinical practice, especially for those patients whose preoperative local staging evaluation cannot distinguish between a cT2 or T3 tumor, and proximal cT3N0 (table 1) tumors for which RT may not be recommended after a total mesorectal excision (TME). (See "Pretreatment local staging evaluation for rectal cancer" and "Neoadjuvant chemoradiotherapy and radiotherapy for rectal adenocarcinoma", section on 'T1/2 and clinically node-positive' and "Neoadjuvant chemoradiotherapy and radiotherapy for rectal adenocarcinoma", section on 'cT3N0 tumors' and 'Favorable risk tumors' below.)

Postoperative (adjuvant) therapy for resected rectal adenocarcinoma in patients who have not received neoadjuvant chemoradiotherapy will be reviewed here. Neoadjuvant treatment approaches for rectal adenocarcinomas, the role of adjuvant chemotherapy in patients who have received neoadjuvant therapy, the preoperative staging evaluation, surgical management of rectal adenocarcinomas, treatment of locally advanced unresectable or locally recurrent disease, management of rectal squamous cell cancers (which are treated similarly to anal cancers with definitive chemoradiotherapy) and posttreatment follow-up after definitive treatment are discussed separately.

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Literature review current through: Nov 2017. | This topic last updated: Jul 31, 2017.
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