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 "Surgical resection of primary rectal adenocarcinoma", section on 'Criteria for operative procedures' and "Treatment of locally recurrent rectal adenocarcinoma" and "Overview of surgery for the treatment of primary rectal adenocarcinoma".)
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.
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