Pretreatment local staging evaluation for rectal cancer
- Ronald Bleday, MD
Ronald Bleday, MD
- Associate Professor of Surgery
- Harvard Medical School
- David Shibata, MD
David Shibata, MD
- Professor and Chair
- Department of Surgery
- University of Tennessee Health Science Center
- Erik K Paulson, MD
Erik K Paulson, MD
- Professor and Chairman
- Department of Radiology
- Duke University School of Medicine
Surgical resection is the cornerstone of curative therapy for patients with early stage, potentially resectable rectal cancer. The type of surgery depends on tumor stage and location within the rectum. Superficially invasive, small cancers may be effectively managed with limited surgery, such as local excision. However, most patients have more deeply invasive tumors that require low anterior resection (LAR) or, in some cases, if located distally, abdominoperineal resection (APR). Locally advanced tumors that are adherent or fixed to adjoining structures (eg, sacrum, pelvic sidewalls, prostate, or bladder) require more extensive surgery. (See "Rectal cancer: Surgical principles", section on 'Selecting a surgical treatment' and "Treatment of locally recurrent rectal adenocarcinoma" and "Rectal cancer: Surgical techniques".)
The combination of adjuvant radiation therapy (RT) plus chemotherapy can enhance local control and cure rates in patients with either transmural invasion (T3/T4) or metastatic lymph nodes (table 1). Such therapy is often administered preoperatively. The more favorable long-term toxicity profile and better local control of preoperative as compared with postoperative chemoradiotherapy for transmural or node-positive rectal cancer was shown in the seminal German Rectal Cancer Study Group Trial. (See "Adjuvant therapy for resected rectal adenocarcinoma" and "Neoadjuvant chemoradiotherapy and radiotherapy for rectal adenocarcinoma", section on 'German Rectal Cancer Study'.)
Although there is not universal agreement, neoadjuvant chemoradiotherapy is generally considered for T3/4 and clinically node-positive T1/2 tumors (table 1), distal rectal tumors (ie, tumors within 5 cm of the anal verge (figure 1)) for which an abdominoperineal resection is thought to be necessary, and tumors that appear to invade or are in close proximity to the mesorectal fascia on preoperative imaging because of the decreased likelihood of achieving a tumor-free circumferential resection margin with upfront surgery. (See "Neoadjuvant chemoradiotherapy and radiotherapy for rectal adenocarcinoma", section on 'Indications for neoadjuvant treatment'.)
The selection of appropriate patients for initial RT or chemoradiotherapy rather than surgery is heavily dependent on accurate preoperative locoregional staging of the depth of transmural penetration, the presence or absence of suspicious perirectal nodes, and the likely status of the circumferential resection margin. Locoregional tumor staging is mainly accomplished through physical examination, endoscopy, computed tomography (CT) scans, magnetic resonance imaging (MRI), and transrectal ultrasound (TRUS).
This topic review will cover the preoperative local staging evaluation of patients with rectal cancer. The clinical presentation, diagnosis, and staging evaluation of patients with newly diagnosed colorectal cancer, the surgical treatment of rectal cancer, neoadjuvant chemoradiotherapy and RT for rectal cancer, adjuvant therapy following resection for rectal cancer, management of locally advanced unresectable disease, and recommendations for posttreatment surveillance are discussed elsewhere.
- McGory ML, Shekelle PG, Ko CY. Development of quality indicators for patients undergoing colorectal cancer surgery. J Natl Cancer Inst 2006; 98:1623.
- National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).
- Kim NK, Kim MJ, Yun SH, et al. Comparative study of transrectal ultrasonography, pelvic computerized tomography, and magnetic resonance imaging in preoperative staging of rectal cancer. Dis Colon Rectum 1999; 42:770.
- Butch RJ, Stark DD, Wittenberg J, et al. Staging rectal cancer by MR and CT. AJR Am J Roentgenol 1986; 146:1155.
- Rifkin MD, Ehrlich SM, Marks G. Staging of rectal carcinoma: prospective comparison of endorectal US and CT. Radiology 1989; 170:319.
- Zerhouni EA, Rutter C, Hamilton SR, et al. CT and MR imaging in the staging of colorectal carcinoma: report of the Radiology Diagnostic Oncology Group II. Radiology 1996; 200:443.
- Kobayashi H, Kikuchi A, Okazaki S, et al. Diagnostic performance of multidetector row computed tomography for assessment of lymph node metastasis in patients with distal rectal cancer. Ann Surg Oncol 2015; 22:203.
- AJCC (American Joint Committee on Cancer) Cancer Staging Manual, 7th edition, Edge, SB, Byrd, DR, Compton, CC, et al (Eds) (Eds), Springer, New York 2010. p.143.
- Sato H, Maeda K, Maruta M, et al. Who can get the beneficial effect from lateral lymph node dissection for Dukes C rectal carcinoma below the peritoneal reflection? Dis Colon Rectum 2006; 49:S3.
- Takahashi T, Ueno M, Azekura K, Ohta H. Lateral node dissection and total mesorectal excision for rectal cancer. Dis Colon Rectum 2000; 43:S59.
- 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.
- Wibe A, Rendedal PR, Svensson E, et al. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer. Br J Surg 2002; 89:327.
- Hall NR, Finan PJ, al-Jaberi T, et al. Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent. Predictor of survival but not local recurrence? Dis Colon Rectum 1998; 41:979.
- Adam IJ, Mohamdee MO, Martin IG, et al. Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet 1994; 344:707.
- 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.
- Beynon J, Foy DM, Roe AM, et al. Endoluminal ultrasound in the assessment of local invasion in rectal cancer. Br J Surg 1986; 73:474.
- Solomon MJ, McLeod RS. Endoluminal transrectal ultrasonography: accuracy, reliability, and validity. Dis Colon Rectum 1993; 36:200.
- Rafaelsen SR, Sørensen T, Jakobsen A, et al. Transrectal ultrasonography and magnetic resonance imaging in the staging of rectal cancer. Effect of experience. Scand J Gastroenterol 2008; 43:440.
- 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.
- Gualdi GF, Casciani E, Guadalaxara A, et al. Local staging of rectal cancer with transrectal ultrasound and endorectal magnetic resonance imaging: comparison with histologic findings. Dis Colon Rectum 2000; 43:338.
- Brown G, Richards CJ, Bourne MW, et al. Morphologic predictors of lymph node status in rectal cancer with use of high-spatial-resolution MR imaging with histopathologic comparison. Radiology 2003; 227:371.
- Blomqvist L, Machado M, Rubio C, et al. Rectal tumour staging: MR imaging using pelvic phased-array and endorectal coils vs endoscopic ultrasonography. Eur Radiol 2000; 10:653.
- Meyenberger C, Huch Böni RA, Bertschinger P, et al. Endoscopic ultrasound and endorectal magnetic resonance imaging: a prospective, comparative study for preoperative staging and follow-up of rectal cancer. Endoscopy 1995; 27:469.
- Dworák O. Number and size of lymph nodes and node metastases in rectal carcinomas. Surg Endosc 1989; 3:96.
- 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; 19:2212.
- Merkel S, Mansmann U, Siassi M, et al. The prognostic inhomogeneity in pT3 rectal carcinomas. Int J Colorectal Dis 2001; 16:298.
- Shin R, Jeong SY, Yoo HY, et al. Depth of mesorectal extension has prognostic significance in patients with T3 rectal cancer. Dis Colon Rectum 2012; 55:1220.
- Evans J, Patel U, Brown G. Rectal cancer: primary staging and assessment after chemoradiotherapy. Semin Radiat Oncol 2011; 21:169.
- 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.
- Hulsmans FJ, Tio TL, Fockens P, et al. Assessment of tumor infiltration depth in rectal cancer with transrectal sonography: caution is necessary. Radiology 1994; 190:715.
- Orrom WJ, Wong WD, Rothenberger DA, et al. Endorectal ultrasound in the preoperative staging of rectal tumors. A learning experience. Dis Colon Rectum 1990; 33:654.
- Ng AK, Recht A, Busse PM. Sphincter preservation therapy for distal rectal carcinoma: a review. Cancer 1997; 79:671.
- 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; 232:773.
- Frasson M, Garcia-Granero E, Roda D, et al. Preoperative chemoradiation may not always be needed for patients with T3 and T2N+ rectal cancer. Cancer 2011; 117:3118.