Current Options for the Management of Rectal Cancer |
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Authors: | Bert H O’Neil Joel E Tepper |
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Institution: | (1) UNC Lineberger Comprehensive Cancer Center, 101 Manning Dr., 3009 Old Clinic Bldg, CB #7305, Chapel Hill, NC 27599, USA;(2) Department of Radiation Oncology, UNC Lineberger Comprehensive Cancer Center, NC Clinical Cancer Center, Rm 1043, 101 Manning Drive, Campus Box No. 7512, Chapel Hill, NC 27599-7512, USA |
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Abstract: | Opinion statement Patients diagnosed with rectal cancer should undergo locoregional staging with transrectal endoscopic ultrasound (EUS) or
surface coil array MRI of the pelvis if that technique is available. Patients thought to have more than very early stage (T1
or T2) disease should undergo abdominal imaging as well by CT or MRI, and chest imaging with either CXR or preferably CT.
The care of rectal cancer patients should be coordinated amongst an experienced multidisciplinary team to maximize the chance
of cure and to minimize both local recurrence and complications of therapy. For patients with very early stage disease (T1N0
or T2N0), local resection with or without chemoradiation may be adequate therapy, but these patients must be selected carefully
and should be without any poor prognostic factors. For the majority of patients with T3N0 or greater rectal cancer, standard
therapy consists of neoadjuvant continuous 5-FU and radiation followed by surgery and further chemotherapy (either with 5-FU,
capecitabine, or FOLFOX). The use of capecitabine, irinotecan, and oxaliplatin during radiotherapy shows promise, but remains
investigational pending results of phase III studies. Neoadjuvant therapy is preferred because it decreases local recurrence
and appears to result in improved postoperative bowel function in comparison with postoperative therapy. Select patients with
high (>10 cm from the anal verge) uT3N0 tumors may be at sufficiently low risk of local recurrence to justify omission of
radiotherapy. Patients who experience pathologic complete response to radiotherapy should still receive postoperative adjuvant
chemotherapy to reduce systemic recurrence risk until data demonstrate that this is not necessary. Patients with stage IV
rectal cancer may still require local therapy with radiation, surgery, or both; however, care should be taken in these patients
that chemotherapy is not excessively delayed as this is the one modality in this case that can result in improved survival. |
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