Treatment of locally advanced unresectable or recurrent rectal adenocarcinoma
- Christopher G Willett, MD
Christopher G Willett, MD
- Section Editor — Radiation Therapy
- Duke University Medical School
- Miguel A Rodriguez-Bigas, MD
Miguel A Rodriguez-Bigas, MD
- Professor of Surgery
- MD Anderson Cancer Center
- David P Ryan, MD
David P Ryan, MD
- Associate Professor of Medicine
- Harvard Medical School
Approximately 40,000 Americans are diagnosed with rectal cancer annually . The vast majority of these are adenocarcinomas.
Surgical resection is the cornerstone of curative therapy for patients with early stage, potentially resectable rectal adenocarcinoma. The addition of radiation therapy (RT) and chemotherapy can enhance both local control and cure rates in patients with either transmural invasion or positive perirectal lymph nodes.
Such therapy is often administered preoperatively. While the only definitive indication for preoperative chemoradiotherapy is the presence of a T3 or T4 (table 1) rectal adenocarcinoma, other relative indications include a T1/2 lesion that is clinically node-positive, a distal tumor for which tumor regression may allow successful conversion of a planned APR to a sphincter-sparing surgical procedure, or if the preoperative staging evaluation suggests the presence of mesorectal invasion. While most of these patients are technically resectable at presentation, outcomes are better with preoperative chemoradiotherapy. (See "Neoadjuvant chemoradiotherapy and radiotherapy for rectal adenocarcinoma", section on 'Indications for neoadjuvant treatment'.)
In contrast, rectal squamous cell cancers are rare tumors that are difficult to distinguish from anal cancer. They are treated similarly to anal cancer with definitive chemoradiotherapy with surgery reserved for persistent or recurrent disease. Management of these tumors is addressed elsewhere. (See "Clinical features, staging, and treatment of anal cancer", section on 'Rectal squamous cell cancers'.)
DEFINITION OF LOCALLY ADVANCED DISEASE
Some patients with rectal adenocarcinoma present with more locally advanced or recurrent but nonmetastatic disease that cannot be easily resected. The criteria for unresectability are variable and not clearly defined. Some define a locally advanced tumor as one with endorectal ultrasound evidence of a T3/4 or N1 tumor, or one that is and/or clinically bulky .
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- DEFINITION OF LOCALLY ADVANCED DISEASE
- PRETREATMENT EVALUATION
- Physical and endoscopic examination
- GENERAL SURGICAL PRINCIPLES
- Exenterative procedures
- - Outcomes
- TREATMENT OF LOCALLY ADVANCED DISEASE
- RT alone
- External beam RT and surgery
- - Postoperative RT
- - Preoperative RT
- Preoperative chemoradiotherapy
- - Infusional versus bolus 5-FU
- - Oral fluoropyrimidines
- - Newer approaches
- Intraoperative irradiation
- Benefit of postoperative chemotherapy
- LOCALLY RECURRENT RECTAL CANCER
- Surgical resection
- Combined modality therapy
- - Intraoperative RT
- - Previously irradiated patients
- - Adjuvant chemotherapy
- PALLIATION OF OBSTRUCTIVE SYMPTOMS DUE TO LOCALLY ADVANCED DISEASE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Treatment of locally advanced unresectable disease
- Management of locally recurrent rectal cancer