Significance of surgery in the multimodality treatment of rectal cancer

Since the NIH recommendations in 1990 the majority of patients with rectal cancer are treated by a multimodality approach. The last decade has seen considerable improvements in the overall management of rectal cancer, therefore a certain reorientation seems justified. Although many questions remain to be answered, some general recommendations for the treatment of rectal cancer focussed on the small pelvis can be given. Surgery with total mesorectal excision is the standard therapy for cancers of the middle and low rectum in stages T1/2 N0. Adjuvant radiochemotherapy and shortterm pre-operative radiotherapy are both feasible approaches for the treatment of stage II and stage III rectal carcinomas. The superiority of either concept awaits clarifying randomised trials. Patients with T4 rectal cancers should undergo long-term neoadjuvant radiochemotherapy with consecutive oncological resection. The exact mode of the neoadjuvant regimen combining high remission rates with low treatment-associated morbidity needs further refinements. Local excision should be restricted to patients with well-differentiated, less than semi-circumferential T1 carcinomas. Tumours with less favourable histologies should not be treated locally unless general patient conditions forbid oncological resections. In these instances, additional radiochemotherapy appears able to reduce the risk of local recurrence.