Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Overview of the management of rectal adenocarcinoma

David P Ryan, MD
Miguel A Rodriguez-Bigas, MD
Section Editors
Richard M Goldberg, MD
Christopher G Willett, MD
Martin Weiser, MD
Deputy Editors
Diane MF Savarese, MD
Wenliang Chen, MD, PhD


Approximately 39,220 Americans are diagnosed with rectal cancer annually [1]. The vast majority of these are adenocarcinomas. Primary rectal squamous cell carcinomas, which are very rare, can be difficult to distinguish from anal cancers and are treated according to the same approach as anal cancer, with initial chemoradiotherapy (radiotherapy with concurrent fluoropyrimidine chemotherapy) rather than surgery. (See "Clinical features, staging, and treatment of anal cancer", section on 'Rectal squamous cell cancers'.)

The optimal approach to treating rectal adenocarcinoma depends upon a number of factors, of which the location in the rectum and the local disease extent are most important. For some patients with limited invasive cancer in a polyp who have no adverse features, polypectomy alone may suffice. For others who have locally extensive, fixed, bulky tumors or extensive nodal disease, induction chemoradiotherapy or induction chemotherapy followed by chemoradiotherapy may be pursued. An algorithmic approach to treating rectal cancer that is based upon the pretreatment clinical staging evaluation is presented in the algorithm (algorithm 1).

This topic review will provide an overview of the treatment for rectal cancer. Neoadjuvant chemoradiotherapy for potentially resectable adenocarcinomas, adjuvant therapy after resection of a primary rectal adenocarcinoma, staging and the staging workup, pretreatment local staging evaluation, surgical principles, and recommendations for posttreatment surveillance are discussed elsewhere, as is the management of rectal squamous cell cancers. (See "Neoadjuvant chemoradiotherapy and radiotherapy for rectal adenocarcinoma" and "Adjuvant therapy for resected rectal adenocarcinoma" and "Pretreatment local staging evaluation for rectal cancer" and "Surgical resection of primary rectal adenocarcinoma" and "Surveillance after colorectal cancer resection" and "Clinical features, staging, and treatment of anal cancer", section on 'Rectal squamous cell cancers' and "Clinical presentation, diagnosis, and staging of colorectal cancer", section on 'Staging'.)


Most patients with rectal adenocarcinoma are diagnosed by colonoscopy after presenting with lower gastrointestinal tract bleeding; in some, the diagnosis is made by finding a lesion during a routine screening colonoscopy or incidentally on an imaging study performed for another reason. (See "Clinical presentation, diagnosis, and staging of colorectal cancer", section on 'Clinical presentation'.)

When viewed through the endoscope, the vast majority of rectal cancers are endoluminal masses that arise from the mucosa and protrude into the lumen. The mass may be exophytic or polypoid. Bleeding (oozing or frank bleeding) may be seen with lesions that are friable, necrotic, or ulcerated. A minority of neoplastic lesions are nonpolypoid and relatively flat or depressed.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Aug 31, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin 2016; 66:7.
  2. Farouk R, Nelson H, Radice E, et al. Accuracy of computed tomography in determining resectability for locally advanced primary or recurrent colorectal cancers. Am J Surg 1998; 175:283.
  3. Cranley JP, Petras RE, Carey WD, et al. When is endoscopic polypectomy adequate therapy for colonic polyps containing invasive carcinoma? Gastroenterology 1986; 91:419.
  4. Meyer JE, Cohen SJ, Ruth KJ, et al. Young Age Increases Risk of Lymph Node Positivity in Early-Stage Rectal Cancer. J Natl Cancer Inst 2015; 108.
  5. Glimelius B, Påhlman L, Cervantes A, ESMO Guidelines Working Group. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2010; 21 Suppl 5:v82.
  6. Bond JH. Polyp guideline: diagnosis, treatment, and surveillance for patients with colorectal polyps. Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 2000; 95:3053.
  7. Locker GY, Hamilton S, Harris J, et al. ASCO 2006 update of recommendations for the use of tumor markers in gastrointestinal cancer. J Clin Oncol 2006; 24:5313.
  8. Duffy MJ, van Dalen A, Haglund C, et al. Clinical utility of biochemical markers in colorectal cancer: European Group on Tumour Markers (EGTM) guidelines. Eur J Cancer 2003; 39:718.
  9. Wood WC, Willett CG. Update of the Massachusetts General Hospital experience of combined local excision and radiotherapy for rectal cancer. Surg Oncol Clin N Am 1992; 1:131.
  10. Willett CG. Sphincter preservation in rectal cancer. Local excision followed by postoperative radiation therapy. Semin Radiat Oncol 1998; 8:24.
  11. Stoffel EM, Mangu PB, Gruber SB, et al. Hereditary colorectal cancer syndromes: American Society of Clinical Oncology Clinical Practice Guideline endorsement of the familial risk-colorectal cancer: European Society for Medical Oncology Clinical Practice Guidelines. J Clin Oncol 2015; 33:209.
  12. Giardiello FM, Allen JI, Axilbund JE, et al. Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the US Multi-Society Task Force on Colorectal Cancer. Dis Colon Rectum 2014; 57:1025.
  13. Balmaña J, Balaguer F, Cervantes A, et al. Familial risk-colorectal cancer: ESMO Clinical Practice Guidelines. Ann Oncol 2013; 24 Suppl 6:vi73.
  14. Radu OM, Nikiforova MN, Farkas LM, Krasinskas AM. Challenging cases encountered in colorectal cancer screening for Lynch syndrome reveal novel findings: nucleolar MSH6 staining and impact of prior chemoradiation therapy. Hum Pathol 2011; 42:1247.
  15. de Rosa N, Rodriguez-Bigas MA, Chang GJ, et al. DNA Mismatch Repair Deficiency in Rectal Cancer: Benchmarking Its Impact on Prognosis, Neoadjuvant Response Prediction, and Clinical Cancer Genetics. J Clin Oncol 2016; 34:3039.
  16. Kahi CJ, Boland CR, Dominitz JA, et al. Colonoscopy Surveillance After Colorectal Cancer Resection: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2016; 150:758.
  17. Meyerhardt JA, Mangu PB, Flynn PJ, et al. Follow-up care, surveillance protocol, and secondary prevention measures for survivors of colorectal cancer: American Society of Clinical Oncology clinical practice guideline endorsement. J Clin Oncol 2013; 31:4465.
  18. Glimelius B, Tiret E, Cervantes A, et al. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013; 24 Suppl 6:vi81.