Colorectal cancer (CRC) is a common and
lethal disease. It is estimated that approximately 141,210 new cases of large
bowel cancer will be diagnosed in the United States in 2011 including 40,000 rectal cancers.
Surgical resection is the primary
treatment modality for CRC, and outcome is most closely related to the extent
of disease at presentation.
Screening with fecal occult blood
testing, endoscopy, or radiology can lead to diagnosis at an earlier stage of
disease and thereby reduce cause-specific mortality.
Five-year survival rates according to
tumor stage at diagnosis (using the older 2002 AJCC staging criteriafor 119,363 patients with colon cancer
reported to the SEER (Surveillance, Epidemiology and End Results) database
between 1991 and 2000 were as follows:
Stage
I (T1-2 N0) — 93 percent
Stage
IIA (T3N0) — 85 percent
Stage
IIB (T4N0) — 72 percent
Stage
IIIA (T1-2 N1) — 83 percent
Stage
IIIB (T3-4 N1) — 64 percent
Stage
IIIC (N2 disease) — 44 percent
Surgery for Rectal Cancer:
The surgeon has three major curative
options for rectal cancer: local excision, sphincter-preserving abdominal
surgery (low anterior resection or LAR), and abdominal perineal resection
(APR). The depth of tumor invasion into the rectal wall, the presence or
absence of regional lymph node metastases, the size and macroscopic appearance
of the cancer, and tumor location are all critical in determining the best
surgical option. Although superficially invasive small cancers may be effectively
managed with local excision, the majority of patients have more deeply invasive
tumors that require more extensive surgery, such as LAR or APR.
Even
patients with advanced disease may benefit from palliative surgery since local
disease symptoms (eg, colonic obstruction, bleeding) can impact significantly
on long-term quality of life. If resection of the primary lesion is not
feasible or desired, then diversion of the fecal stream with a colostomy can
also improve the patient's immediate status.
The usual criteria used to determine
suitability for potentially curative local excision are:
Tumor
size less than 4 cm
Location
8 cm or less from the anal verge
Well
or moderately well differentiated histology
Mobile,
not ulcerated tumor
No
suspicion of perirectal or presacral nodes (by CT or endoscopic ultrasound
[EUS])
Tumor
involves less than one-third of the circumference of the rectal wall
Tumor
stage ≤T2
Chemoradiation
Therapy for Locally Advanced Rectal Cancer:
The only definitive indication for
neoadjuvant chemoradiotherapy, supported by the results of randomized trials,
is the presence of T3 or T4 rectal cancer.
These are patients who, if resected initially, would likely require
postoperative RT. Data from randomized trials suggest that the preoperative
approach is associated with a more favorable long-term toxicity profile and
fewer local recurrences than postoperative therapy.
cT3N0
tumors — The optimal management of clinical T3N0
rectal cancer (cT3N0 based upon preoperative transrectal ultrasound [TRUS]
and/or MRI) is unclear. Some of these patients have a sufficiently favorable
prognosis that questions have been raised as to the necessity of postoperative
adjuvant therapy after upfront total mesorectal excision.
On the other hand, as many as
one-fifth of these patients may be understaged by preoperative imaging. In a
review of 188 patients with TRUS/MRI staged T3N0 rectal cancer patients who
received preoperative chemoradiotherapy, 41 (22 percent) were found to have
pathologically positive mesorectal lymph nodes at the time of surgery [6]. Given the downstaging effect of
chemoradiotherapy, it is likely that an even larger number of these patients
would have been found to have node-positive disease (and recommended for
postoperative adjuvant therapy) had surgery been undertaken initially.
Thus, given the limitations of current
imaging, all patients with cT3N0 rectal cancer by TRUS or MRI are appropriate
candidates for neoadjuvant chemoradiotherapy.
Issues related to locoregional staging
in patients with newly diagnosed rectal cancer are discussed in detail
elsewhere.
Thanks uptodate.com
Here, Dr. Tony Talebi
discusses the treatment of locally advanced stage 1 to 3 rectal cancer with Dr.
Laurence Sands, professor of surgery and chief of colorectal surgery at the University of Miami.
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Dr. Laurence Sands credentials:
Certifications
American
Board of Surgery
American
Board of Colon
& Rectal Surgery
Specialties
Surgery
Colon & Rectal
Surgery
Roles
Professor and Chief, Division of Colon and Rectal Surgery
