Keynote Lecture - Rectal Cancer 2005

Lars Pahlman, University Hospital Uppsala, Sweden

Powerpoint File

The most important part in rectal cancer surgery is the preoperative staging including a check for distant metastases and appropriate local staging. Regarding local staging, it is dependant upon the rectal exam. Tumours, which might be suitable for local excision (T1-T2 tumours) should be staged with ultrasound (1) and larger tumours (T2 or more) where there is a risk for cancer growth outside the bowel wall, should be staged with MRI (2).

If local excision is considered data do support that it should be under optimal vision using the TEM technique (3). On the other hand, if an open procedure is planned, the gold standard today is to do a Total Mesorectal Excision following the embryological planes without damaging mesorectum. Only in tumours situated in the upper third of rectum a resection of mesorectum 5 cm distal to the tumour can be accepted. Otherwise a Total Mesorectal Excision should be done (4-6).

Lot's of data support special training in rectal cancer surgery and rectal cancer surgery should be concentrated to few well-trained surgeons at each hospital (7-9).

Adjuvant radiotherapy has been tested during 20 years and all data support that, if radiotherapy should be given it should be give preoperatively (10-11). Two randomised trials testing pre- vs postoperative radiotherapy have shown that preoperative is the best (12-13). The main question is whether radiotherapy should be given to all patients or in selective cases. Based upon the MRI staging there are data supporting that it is possible to identify tumours growing out to the rectal fascia, i.e the circumferential margin could be invaded (2). In all cases, where the surgical margin is threatened based upon MRI examination, preoperative radiotherapy should be considered. Moreover, in very tricky cases, like obese male patients an abdominal perineal excision, radiotherapy must be considered.

No strong evidence support adjuvant chemotherapy in rectal cancer. There are some data from American trials indicating that chemotherapy is beneficial (14-15), but two large studies in Europe have not confirmed this (ref 16-17). Therefore adjuvant chemotherapy in rectal cancer should preferably be studied in more trials with new drugs.

Summary: Preoperative staging in rectal cancer is crucial to give the patient the best treatment. Radiotherapy must be considered in most cases of advanced cancer and chemotherapy should still be tested. The important thing is that all patients with a rectal cancer should be evaluated in a MDT conference, where surgeons, radiotherapists, oncologists and pathologists meet.

References:

1) Akbari RP & Wong WD (2003) Endorectal ultrasound and the preoperative staging of rectal cancer Scan J Surg 92: 25-34.

2) Beets-Tan RG, Reets GL, Vliegen RFK et al (2001) Accuracy of magnetic resonance imaging in prediction of tumour-free resection margin in rectal cancer surgery. Lancet 357: 497-504.

3) Buess GF (1996) Local procedures including endoscopic resection. In Williams NS (ed) Colorectal Cancer. Edinburgh: Churchill Livingstone.

4) MacFarlane JK, Ryall RD & Heald RJ (1993) Mesorectal excision for rectal cancer. Lancet 341: 457-460.

5) Enker WE, Thaler HT, Cranor ML & Polyak T (1995). Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg 18: 335-346

6) Moriya Y, Hojo K, Sawada T & Koyama Y (1989) Significance of lateral lymph node dissection for advanced rectal carcinoma at or below the peritoneal reflection. Dis Colon Rectum 32: 307-315.

7) Dahlberg M, Glimelius B, Påhlman L 1999 Changing strategy for rectal cancer is associated with improved outcome. Br J Surg 86: 379-84.

8) Martling AL, Holm T, Rutquist LE et al (2000) Effect of a surgical training programme on the outcome of rectal cancer in the County of Stockholm. Lancet 356: 93-96.

9) Wibe A, Møller B, Norstein J et al (2002a) A national strategy change in treatment policy for rectal cancer - Implementation of total mesorectal excision as routine treatment in Norway. A national audit. Dis Colon Rectm 45: 857-866.

10) Colorectal Cancer Collaborative Group (2001) Adjuvant radiotherapy for rectal cancer: a systematic overview of 8,507 patients from 22 randomised trials. Lancet 358: 1291-304

11) Glimelius B, Grönberg H, Järhult J, Wallgren A, Cavallin-Ståhl E (2003). A systematic overview of radiation therapy in rectal cancer. Acta Oncologica 42: 476-492

12) Påhlman L & Glimelius B (1990) Pre- or postoperative radiotherapy in rectal and rectosigmoid carcinoma: report from a randomized multicenter trial. Ann Surg 211: 187-195.

13) Sauer R, Becker H, Hohenberger W et al (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer New Engl J Med 351: 1731-1740

14) GITSG (Gastrointestinal Tumor Study Group) (1985) A controlled trial of adjuvant chemotherapy, radiation therapy or combined chemoradiation therapy following curative resection for rectal carcinoma. N Engl J Med 312: 1465-1472.

15) Fisher B, Wolmark N, Rockette H et al (1988) Postoperative adjuvant chemotherapy or radiation therapy for rectal cancer: results of NSABP Protocol R-01. J Natl Cancer Inst 80: 21-29.

16) Glimelius B, Cedermark B, Dakl O et al (2003) Adjuvant chemotherapy in colorectal cancer: Joint analyses of randomised trials by the Nordic Gastrointestinal Tumour Adjuvant Therapy Group Eur J Cancer Supplement 1, ECCO 12, abstract 1066.

17)Taal BG, Van Tinteren H, Zoetmulder FA et al 2001 Adjuvant 5-FU plus levamisole in colonic or rectal cancer: improved survival in stage II or III. Br J Cancer 85: 1437-1443.