Overview of the management of rectal adenocarcinoma
- David P Ryan, MD
David P Ryan, MD
- Professor of Medicine
- Harvard Medical School
- Miguel A Rodriguez-Bigas, MD
Miguel A Rodriguez-Bigas, MD
- Professor of Surgery
- MD Anderson Cancer Center
- Section Editors
- Richard M Goldberg, MD
Richard M Goldberg, MD
- Section Editor — Gastrointestinal Cancer
- Director of the West Virginia University Cancer Institute and the Mary Babb Randolph Cancer Center
- Professor of Medicine
- Laurence S. & Jean J. DeLynn Chair of Oncology
- Christopher G Willett, MD
Christopher G Willett, MD
- Section Editor — Radiation Therapy
- Duke University Medical School
- Martin Weiser, MD
Martin Weiser, MD
- Section Editor — Colorectal Surgery
- Attending Surgeon
- Memorial Sloan Kettering Cancer Center
- Professor of Surgery
- Weill Cornell Medical School
Approximately 39,910 Americans are diagnosed with rectal cancer annually . 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 "Rectal cancer: Surgical principles" 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.
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- THE PRETREATMENT STAGING EVALUATION
- TNM staging
- Physical and endoscopic examination
- - Local imaging
- - Evaluation for distant metastases
- Tumor markers
- OVERVIEW OF MANAGEMENT
- Surgical approaches
- Multidisciplinary management
- - Role of intraoperative RT
- Management according to initial clinical stage
- - Clinical/pathologic T1N0
- - Clinical T2N0
- - Clinical T3-4, N0-2 or T2, N1-2
- No distant metastases
- - Clinical T3/4 or N1
- - Locally advanced, unresectable, bulky tumors, extensive nodal disease
- Distant metastases present
- - Potentially resectable metastases
- - Unresectable metastases
- GENETIC ISSUES
- POSTTREATMENT SURVEILLANCE
- Stage II and III disease
- Stage I disease
- - Guidelines from expert groups
- Resected stage IV disease
- MANAGEMENT OF LOCALLY RECURRENT DISEASE