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39 Rectal Conditions: Rectal Cancer—Adjuvant andNeoadjuvant Therapy
Table 39.1 AJCC staging system for colorectal cancer (8th Edition)
Primary tumour (T)
Tx Primary tumour cannot be assessed
T0 No evidence of primary tumour
Tis Carcinoma in situ: intramucosal carcinoma
T1 Tumour invades submucosa
T2 Tumour invades muscularis propria
T3 Tumour invades through muscularis propria into pericolorectal tissue
T4a Tumour penetrates to the surface of the visceral peritoneum (including gross perforation of the bowel
through tumour and continuous invasion of tumour through areas of inammation to the surface of the
visceral peritoneum)
T4b Tumour directly invades or is adherent to other organs or structures
Regional lymph nodes (N)
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 One to three regional lymph nodes are positive (tumour in lymph nodes measuring –/> 0.2mm), or any
number of tumour deposits are present and all identiable lymph nodes are negative
N1a One regional lymph node is positive
N1b Two or three regional lymph nodes are positive
N1c No regional lymph nodes are positive, but there are tumour deposits in the subserosa, mesentery, or
nonperitonealized pericolic, or perirectal/mesorectal tissues
N2 Four or more regional lymph nodes are positive
N2a Four to six regional lymph nodes are positive
N2b Seven or more regional lymph nodes are positive
Distant metastasis (M)
M0 No distant metastasis by imaging, etc.: no evidence of tumour in distant sites or organs
M1 Metastasis to one or more distant sites or organs or peritoneal metastasis is identied
M1a Metastasis to one organ or site is identied without peritoneal metastasis
M1b Metastasis to two or more sites or organs is identied without peritoneal metastasis
M1c Metastasis to the peritoneal surface is identied alone or with other site or organ metastases
305
disease. These issues have led many practitioners to adopt more selective use of radiotherapy based on MRI stage, with particular focus
on the status of the CRM.With improvement
in the quality of surgery and obtaining a high
quality total mesorectal excision (TME) in the
mesorectal specimen, neoadjuvant chemoradiotherapy may be of limited benet in patients
with T3N0 disease and a clear CRM, when
weighed against the short- and long-term risks
of radiation, as well as the extended treatment
time for the patient with rectal cancer. High
quality surgery with a complete TME has been
shown to have the greatest impact on local
recurrence, with rates well below 10% seen
regardless of the use of neoadjuvant therapy.
High quality MRI reporting in conjunction
with high quality surgery is essential. With
accurate preoperative staging, it has been
shown by the MERCURY Study Group and
others that a clear CRM is likely more important in predicting local recurrence then are T
and N staging. The role of accurate staging in
order to select patients for neoadjuvant chemoradiotherapy cannot be over stated, as understaged disease may result in the need to
consider chemoradiotherapy in the postoperative setting, putting patients at risk of anastomotic leak, stricture, anterior resection
syndrome, and perineal wound complications.
Early studies of rectal cancer outcomes
found locoregional recurrence rates of
30–40%. The addition of adjuvant radiotherapy attempted to lower local recurrence rates.
The benets of total mesorectal excision were
demonstrated by Dr. R.J. Heald who showed
that surgical resection in the proper mesorectal plane to achieve a negative CRM could
306
T. Zwiep et al.
drop the rate of locoregional recurrence to
5–7%. The role of adjuvant radiotherapy was
subsequently questioned, especially for upper
rectal lesions and early stage disease. Later
studies found that even with a good surgical
TME, radiotherapy, particularly in the neoadjuvant setting, could still signicantly impact
upon the positive CRM and locoregional
recurrence rates.
The German Rectal Cancer Study, published in 2004, provided the evidence to move
chemoradiotherapy from the adjuvant to neoadjuvant setting. Results showed that there
was a signicantly lower local recurrence rate
with neoadjuvant therapy, but overall survival
and disease free survival rates were similar.
Given the potential negative impacts of
exposing a low anastomosis or perineal
wound to postoperative radiation, this signicantly changed the algorithm for rectal cancer
management in locally advanced disease.
Currently, neoadjuvant therapy continues to
attract much interest and research in determining the optimal delivery. Standard neoadjuvant therapy involves delivering 1.8Gy per
day, ve fractions per week, for a total of
50.4Gy, consistent with the German Rectal
Cancer Study.
Neoadjuvant short course radiotherapy
(SCRT) was developed in the 1990s and is
currently used in many institutions in the
place of standard long course neoadjuvant
chemoradiotherapy in select patients. SCRT
involves a higher daily dose of radiation, but
over a shorter time frame (25Gy in 5 fractions over only 5days) and without chemotherapy. Comparative studies of SCRT,
including the Swedish Rectal Cancer Trial,
Dutch TME Trial, and the MRC Trial, have
shown that SCRT is more effective than surgery alone in terms of local recurrence rates.
The Polish study and the TROG trial have
shown it to be equivalent to standard long
course chemoradiotherapy in terms of local
recurrence, overall survival, distant metastases, and late toxicity. SCRT is not used for
downstaging, and subsequently less pathological complete response is seen. It is therefore not recommended by NCCN for T4
tumours. Downstaging may be an important
consideration in the surgical management of
rectal cancer in patients with borderline
resectable disease, T4b disease, and very
bulky tumors. If downstaging is a potential
goal in such patients, long course chemoradiotherapy should be chosen over short
course radiotherapy. In addition, some
patients may not be able to tolerate standard
long course neoadjuvant chemoradiotherapy
due to confounders such as medical comorbidities, symptoms related to the rectal cancer
such as bleeding or impending obstruction,
anticipated toxicity or side effects of radiosensitizing chemotherapy, or travel distance
to the closest center providing radiotherapy. It
may be more appropriate to consider such
patients for SCRT as well. These decisions
require discussion with the patient and input
from multidisciplinary tumor boards. It is
most important to recognize the roles, risks,
and benets of both SCRT and long course
chemoradiotherapy and consider both modalities of delivering neoadjuvant treatment to
the individual patient.
Neoadjuvant chemotherapy regimens
administered during radiotherapy have not
been as standardized as radiotherapy. A commonly used regimen involves the use of infusional uorouracil (FU) during the rst and
fth week of radiation therapy. Other regimens that have been suggested include bolus
5-uorouracil (5-FU) with leucovorin and oral
capecitabine. Bolus 5-FU with leucovorin has
been shown to be effective, but may result in
greater toxicity and infusional 5-FU has been
shown to be more effective in the adjuvant setting. Capecitabine is an oral prodrug of uorouracil. It is metabolized in the liver into
uorouracil and is taken twice per day, 5days
per week during radiation therapy. The ease of
administration, avoidance of intravenous
lines, and lower toxicity has made it the standard neoadjuvant chemotherapy in rectal cancer. The efcacy of capecitabine has been
shown in randomized trials (NASBP trial
R-04) to have similar local recurrence, overall
survival, and downstaging rates as infusional
5-FU.Some caution is required in the use of
39 Rectal Conditions: Rectal Cancer—Adjuvant andNeoadjuvant Therapy
307
capecitabine as it may be metabolized differently between individuals, but we otherwise
recommend its use over infusional 5-FU in the
neoadjuvant setting. Various trials have experimented with administering infusional oxaliplatin with FU or capecitabine, but the benet
of concurrent use is still unclear. Oxaliplatin
increases the toxicity of the chemotherapy
regimen and does not appear to affect overall
survival when used for a short course in the
neoadjuvant setting. NCCN guidelines currently recommend either infusional FU or
capecitabine and not bolus FU with leucovorin or the addition of oxaliplatin to chemotherapy regimens.
D. Total Neoadjuvant Therapy
Recently, the concept of total neoadjuvant
therapy has been introduced. With long
course neoadjuvant chemoradiotherapy,
patients often wait 5 months or longer from
their diagnosis before they receive full dose
systemic chemotherapy in the adjuvant setting. This wait can be even longer if any surgical or radiation related complications occur.
Additionally, up to 50% of patients may not
complete adjuvant chemotherapy after neoadjuvant chemoradiotherapy and surgery.
This may be the result of patient choice or
failure to complete proposed adjuvant therapy due to side effects, complications, or
treatment fatigue. Total neoadjuvant therapy
has been proposed to improve the pathological complete response rate and ensure that all
patients who would benet from systemic
chemotherapy receive it in a timely fashion
and at a time when they would be most likely
to complete the recommended cycles.
The addition of neoadjuvant chemotherapy after chemoradiation was studied in the
Timing of Rectal Cancer Response to
Chemoradiation trial. The pathological complete response rate was 18% for standard long
course chemoradiation therapy alone, 25%
for long course chemoradiation therapy followed by 2 cycles of 5-FU, leucovorin, and
oxaliplatin (FOLFOX), 30% for long course
chemoradiation therapy followed by 4 cycles
of FOLFOX, and 38% for long course chemo-
radiation therapy followed by 6 cycles of
FOLFOX. Additionally, better compliance
was seen in patients receiving neoadjuvant
rather than adjuvant chemotherapy. Long
term data showed improved disease free survival rates, but no difference in overall survival with the addition of neoadjuvant
chemotherapy. These ndings are similar to
other published studies showing an improvement in pathological complete response and
compliance with chemotherapy. Currently,
the randomized phase II/III PROSPECT trial
is in progress and will assess the time to local
recurrence and disease free survival of
patients randomized to either neoadjuvant
chemotherapy or neoadjuvant chemotherapy
with or without neoadjuvant chemoradiation
therapy (dependent on tumour response on
imaging to chemotherapy).
Total neoadjuvant therapy appears to be a
feasible option for the management of rectal
cancer and has been included in the NCCN
guidelines as a possible treatment strategy.
With improved pathological complete
response rates and compliance with chemotherapy, this has the potential to improve survival in patients with rectal cancer.
E. Complete Clinical Response to Neoadjuvant
Chemoradiotherapy
Neoadjuvant therapy may lead to complete
pathological response in 16–27% of cases
submitted to surgery. Although surgical
resection for rectal cancer remains the standard of care, the phenomenon of complete
response has led to the so-called “watch and
wait” approach in select patients with distal
rectal cancers who achieve a complete clinical response with neoadjuvant chemoradiotherapy (Fig. 39.1). This approach may be
appealing to many patients, especially those
who may not tolerate surgery or those who
would require an abdominal perineal resection to obtain appropriate margins and wish
to avoid a permanent colostomy. A complete
clinical response is considered when there is
no clinical, endoscopic, or radiographic evidence of residual tumour after completion of
neoadjuvant therapy. Unfortunately, a com-
308
T. Zwiep et al.
plete clinical response is not always indicative of a complete pathologic response. Up to
33% of patients with a complete clinical
response will have cancer present in the surgical specimen upon proctectomy or biopsies
of the residual scar endoscopically. HabrGama and her group were the rst to report
on their experience with the watch and wait
approach in selected patients who had a complete clinical response after neoadjuvant long
course chemoradiotherapy and published
promising results with a complete clinical
response rate of 49%. Five-year follow up
data showed a local regrowth rate of 31%,
correlating well with the reported rate of persistent disease of 33% in other trials. Other
groups have published varying data on the
watch and wait approach. The variability in
results can be attributed to heterogeneity in
patient selection, variable follow up in terms
of time frame and imaging modalities, and
different denitions of complete clinical
response. Given the regrowth rate and poor
correlation of complete clinical response with
complete pathologic response, more data are
required to both properly select appropriate
patients and to optimally monitor those
patients in the long term who have chosen the
watch and wait approach. A standardized surveillance regimen has not been established.
One suggested surveillance program includes
assessment of the tumour 8weeks following
the completion of neoadjuvant therapy with
clinical exam, endoscopic assessment with
biopsies of suspicious areas, CEA level, and
MRI of the rectum (Fig.39.1). If a complete
clinical response is demonstrated, close surveillance of the area should be initiated and
should include clinical examination, endoscopic assessment, and CEA levels every
3months for the rst year. MRI should also
be used to assess for residual tumour or
regrowth and it has been suggested that imaging should be performed every 3months for
the rst year as well and then at longer intervals thereafter. Patients must understand and
commit to this very close surveillance
program. Most failures of the watch and wait
approach are detected within the rst year,
and so experts suggest that the surveillance
intervals can be lengthened to similar surveillance guidelines that follow standard surgical
resection for rectal cancer after 1 to 2 years. If
there is a concerning nodule or lesion detected
that does not prove to be adenocarcinoma on
biopsy, the patient may be taken to the operating room for a local, full thickness excision to
determine if the area is indeed tumor
regrowth. If so, the patient likely should
undergo a proctectomy with a complete
TME.The watch and wait approach is relatively new and there are outstanding issues
that will be standardized in the future, including the denition of a complete clinical
response, time from neoadjuvant therapy to
rst assessment, appropriate surveillance regimen, and the use of consolidation chemotherapy in the wait and watch patient
population. There may also be some benet
to providing combination chemotherapy
upfront with radiation therapy in patients who
are being considered for the watch and wait
approach. As there are many ongoing trials to
address these issues, patients who are considered potential candidates for the watch and
wait approach must be properly counseled on
standards of care in rectal cancer treatment
algorithms and our current knowledge gaps in
the literature on the long-term outcomes.
F. Timing of Surgery Following Neoadjuvant
Chemoradiotherapy
The optimal timing of surgery following neoadjuvant therapy has not been determined.
For SCRT, surgery is usually performed
within 1week as was outlined in the Swedish
Rectal Cancer Trial. However, the recently
published Stockholm III trial suggests that
SCRT with a delay of 4–8 weeks or longer
results in similar oncologic results as SCRT
with immediate surgery or long course
chemoradiotherapy and reduces postoperative complications. For standard long course
chemoradiotherapy therapy, the interval
between nishing neoadjuvant therapy and
surgery continues to be investigated, as there
can be signicant tumour regression following the completion of neoadjuvant therapy.
This interval was originally established at
39 Rectal Conditions: Rectal Cancer—Adjuvant andNeoadjuvant Therapy
309
4–6weeks, as this time period was shown to
lead to a higher number of pathological complete responses than patients which had surgery after 2weeks. This interval is now being
extended up to 12weeks following the completion of neoadjuvant therapy. An interval of
9–12 weeks has been shown to affect the
pathological complete response rate for
locally advanced rectal cancers, but not early
tumours (T1-3 N0). However, an improvement in overall survival has not been demonstrated with a longer time interval. Certainly,
waiting longer may allow for neoadjuvant
therapy to continue to induce further cellular
response, but comes at the expense of balancing resolution of radiotherapy- induced
inammation and tissue friability against pelvic scarring and surgical dissection difculty.
The authors wait approximately 10–12weeks
from the completion of radiotherapy to surgical resection date, but there is clear variability
among centers and surgeons.
G. Adjuvant Chemotherapy
Following surgical resection, adjuvant chemotherapy is indicated in all patients who
have received neoadjuvant chemoradiotherapy. In the past, all chemotherapy was administered in the adjuvant setting, until the
German Rectal Cancer Study provided denitive evidence to support neoadjuvant treatment in appropriate patients. Commonly,
only 5-FU is used in the neoadjuvant setting
as a radiosensitizer, rather than additional
combination chemotherapy, again highlighting one of the goals of neoadjuvant chemoradiotherapy to reduce local recurrence, but not
improve survival. Therefore, after neoadjuvant chemoradiotherapy and surgery, patients
are usually considered for 3–6 months of
adjuvant combination chemotherapy. The
evidence for 5-FU based chemotherapy, with
or without oxaliplatin, in the adjuvant setting
when neoadjuvant chemoradiotherapy has
been administered has been questioned and
the evidence is sparse. Despite this dilemma,
adjuvant chemotherapy continues to be the
standard recommendation inlocally advanced
rectal cancer. Combination chemotherapy
usually consists of 5-FU, leucovorin, and
oxaliplatin (FOLFOX). Regimens involving
irinotecan have also been investigated and
there is no strong evidence for its use.
Bevacizumab, cetuximab, and panitumumab
have not been shown to be benecial in the
adjuvant setting unless there is hepatic metastatic disease. There may be signicant downstaging with neoadjuvant chemoradiotherapy
and the post treatment pathological stage may
not reect the pre-treatment stage. This staging discordance may subject some patients to
combination chemotherapy who otherwise
would not have received it and highlights the
need for continued improvements in the accuracy of preoperative staging. Further studies
are needed to address the use of adjuvant chemotherapy and clarify which patients will
benet most from its use.
Patients with stage II and III disease who had
not received neoadjuvant chemoradiotherapy
prior to surgery likely should receive adjuvant
radiotherapy and combination chemotherapy
following surgical resection to help prevent
locoregional recurrence and distant disease.
This therapeutic schema includes patients in
whom the tumour was upstaged upon pathologic assessment, those who underwent an
emergency operation without the possibility of
receiving neoadjuvant therapy, and those who
underwent a local excision and do not wish to
proceed with denitive surgery for T2 or T3
lesions. Radiotherapy should be combined with
a radio-sensitizer such as capecitabine or infusional 5-FU. Combination chemotherapy
should be 5-FU based, such as FOLFOX.The
optimal sequencing of treatments has not been
established in this situation. Postoperative radiation therapy may lead to problems with anastomotic strictures, radiation proctitis or enteritis,
and perineal wound breakdown in the event of
an abdominoperineal resection, and thus should
be carefully considered. It is important to ensure
that small bowel is kept out of the radiation
elds where possible.
H. Metastatic Rectal Cancer
Stage IV colorectal cancer was historically
approached with a palliative intent.
Metastasectomy for single organ metastases
such as from the liver or lung, however, has
310
Fig. 39.2 Treatment options in stage IV rectal cancer with resectable disease. Additional less common treatment
sequences not shown here may be potential options in appropriate patients
T. Zwiep et al.
been shown to be with both an overall survival
and disease-free survival advantage in many
patients. The indications for more aggressive
surgical approaches to metastatic disease continue to expand. Extensive liver resections,
multiple site resections (for example, lung and
liver resections in patients with metastatic disease), and cytoreductive surgery with intraoperative chemotherapy for peritoneal
carcinomatosis, have radically changed the
approach to patients with stage IV disease.
While this group still has an overall poor prognosis, long term overall survival and diseasefree survival have been reported to be
approximately 25 percent in patients who are
carefully selected for multimodality
approaches where the metastatic disease is
limited and amenable to surgical resection.
Neoadjuvant chemoradiotherapy and adjuvant
chemotherapy play important roles in the management of stage IV rectal cancer and the timing of therapy is on ongoing area of research.
In the event of stage IV rectal cancer and
resectable metastatic disease, the sequence of
treatments may signicantly vary between
patients based on the nuances of the location
and burden of disease at the primary and metastatic sites, symptoms, and patient comorbidities; thus, the input from a multidisciplinary
tumor board and a team-based approach to
patients are essential. Possible pathways for
patients with liver metastases are summarized
in Fig.39.2 and include the following:
1. Synchronous resection of the rectum and
liver followed by adjuvant chemotherapy.
This sequence is used in patients who do
not require downstaging of disease at either
site and are well. In unwell patients, a
staged resection should be performed and
may start with the liver or rectum.
2. Standard neoadjuvant chemoradiotherapy
for the primary rectal cancer followed by
synchronous resection of the rectum and
liver and then adjuvant chemotherapy. This
sequence is used in patients who require
downstaging of the primary rectal cancer.
This sequence can be altered by performing
a staged resection with the liver resection
preceding the neoadjuvant chemoradiotherapy. In unwell patients, a staged resection
39 Rectal Conditions: Rectal Cancer—Adjuvant andNeoadjuvant Therapy
311
should be performed after neoadjuvant
chemoradiotherapy.
3. Liver directed neoadjuvant chemotherapy followed by short course radiotherapy for the primary rectal cancer and
then synchronous resection of the liver
and rectum. This sequence is used in
patient who require downstaging of the
liver disease. In unwell patients, a staged
resection should be performed with the
liver rst and then followed by the
rectum.
4. Standard neoadjuvant chemoradiotherapy
or short course radiotherapy followed by
liver directed neoadjuvant chemotherapy
followed by reappraisal and synchronous
resection if determined to be resectable.
This sequence is used in patients with
potentially resectable disease who need
downstaging of both the rectum and liver.
In patients who are unwell, this sequence
may be altered by starting with liver
directed neoadjuvant chemotherapy followed by reappraisal and resection of the
liver if resectable, followed by chemoradiotherapy for the primary rectal cancer
and resection of the rectum.
These pathways may also be used for
patients with pulmonary metastases and
require the input from multidisciplinary
teams involving thoracic surgeons.
The resection of the primary rectal cancer and the metastatic disease may occur in
staged or synchronous fashions. Staged
resections have traditionally involved
resecting the primary rectal cancer rst followed by the metastatic disease, but resection of metastases rst may be an effective
approach and can be performed, especially
if the metastatic disease is resectable at presentation but relatively high burden.
Synchronous resection allows for the
patient to undergo one combined operation
and then proceed on to adjuvant chemotherapy sooner, but clearly adds to the complexity and potential complications of that large
combined operation. Up front combination
chemotherapy may provide the best chance
to control and eradicate distant and micro-
scopic disease and may covert borderline
and unresectable metastases into resectable
metastases. It will also identify patients
who respond well to chemotherapy as well
as those who will have progression of disease despite being treated. This sequence
might allow one to avoid unnecessary
aggressive surgical interventions for the
primary cancer and metastatic disease and
their potential complications in patients
whose poor tumor response to chemotherapy declare these patients to be poor candidates for curative intent while on
chemotherapy. It is important to remember
that stage IV disease is not curable most of
the time, and each patient must be carefully
considered with input from medical oncology, radiation oncology, colorectal surgery,
and hepatobiliary or thoracic surgery to
properly navigate these very complicated
treatment sequencing options.
Combination chemotherapy in patients
with stage IV disease should be 5-FU
based, as is used for adjuvant chemotherapy
and described earlier. FOLFOX or FOLFIRI
can be used. The addition of irinotecan to
FOLFOX (FOLFOXIRI) has shown some
benet in converting upfront unresectable
liver disease into resectable. Vascular endothelial growth factor (VEGF) and epidermal growth factor receptor (EGRF)
inhibitors also have potential roles in the
management of stage IV disease by medical
oncology. These monoclonal antibodies
have not been shown to be useful in stage
I-III colorectal cancer, but do confer both
an overall survival and progression free survival advantage for patients with stage IV
disease. Bevacizumab is a VEGF inhibitor
and can be used either pre- operatively or
post-operatively. If such an agent is preoperatively used, surgery should be delayed
for at least 5 weeks after completion to
avoid the known complications of VEGF
inhibitors. These complications include
intestinal perforation, bleeding, impaired
wound healing, and arterial thromboembolic disease. Cetuximab and panitumumab
are EGFR inhibitors and are also useful in
312
T. Zwiep et al.
stage IV disease. Unlike bevacizumab,
however, the EGFR inhibitors are known to
be effective only in patients who are wild
type KRAS. There may even be some harm
with the use of cetuximab in patients who
have KRAS mutations. Patients with potentially resectable disease who are undergoing up front combination chemotherapy
should be re- imaged every 2 months to
assess response of the metastatic disease
and the primary tumor (if in situ) and discussed at multidisciplinary tumour boards
as necessary to re- evaluate the efcacy of
the treatment pathway.
In patients with unresectable metastatic
disease, surgery, chemotherapy and radiotherapy all have potential important indications. Management of symptomatic primary
lesions can occur through the use of colonic
stents, diversion with colostomy or ileostomy, radiotherapy, or rarely, palliative
resection. Chemotherapy is used for a progression free survival benet in symptomatic
patients and once again should be 5-FU
based (FOLFOX or FOLFIRI) with the addition of bevacizumab or an EGFR inhibitor
where appropriate. The risk of perforation is
minimal and this should not prevent the use
of bevacizumab in patients that have not
undergone resection of the primary rectal
cancer. Patients should be re-evaluated after
2months of therapy to assess the response
and determine if they are potentially resectable. Other agents have become available for
patients with unresectable disease who have
had progression of disease despite treatment
with standard chemotherapy regimens, or
are intolerant to them. These drugs include
regorafenib, an angiogenic tyrosine kinase
inhibitor, and triuridine-tipiracil, which
combines a nucleoside analogue and a thymidine phosphorylase inhibitor. Both of
these agents have shown marginal benets.
I. Ileostomy Reversal
Diverting ileostomies have been shown to be
effective in reducing clinically important anastomotic leaks as well as mortality in patients
who have undergone a proctectomy with a low
colorectal or coloanal anastomosis and those
who have received neoadjuvant radiation.
Following the completion of adjuvant chemotherapy, patients should be considered for
reversal of diverting ileostomies. The length of
time to reversal has been studied and there is
evidence that delaying the reversal past
6 months increases complications such as
anastomotic leak and length of hospital stay.
Factors that may lead to delayed reversal
include adjuvant chemotherapy and anastomotic leak or stricture. The EASY trial was
developed to assess the benets of closing
temporary ileostomies at 8–13days instead of
waiting at least 12weeks or until after adjuvant
chemotherapy. The primary outcome being
studied in this trial was the rate of complications and it was shown that it is safe to close
diverting ileostomies at this early stage in
patient who do not have any evidence of an
anastomotic leak. Other trials on early ileostomy closure are still ongoing and the timing
of ileostomy closure may shorten signicantly
in the future. Some patients who have had temporary diverting ileostomies performed may
never undergo reversal due to anastomotic
complications, morbidities following systemic
chemotherapy, or patient preference. Prior to
reversal, it is important to inspect the anastomosis endoscopically to ensure patency and
rule out any obvious early recurrence or anastomotic leak. We also recommend standard use
of a water soluble contrast enema to rule out
any small anastomotic leak which may precipitate after stoma closure.
J. Multidisciplinary Tumor (MDT) Boards
MDTs have been widely implemented to
allow for a thorough discussion of patients with
rectal cancer in order to follow an evidencebased multidisciplinary approach to their care.
The management of rectal cancer has changed
signicantly over the years and is still undergoing many changes, as highlighted early in the
chapter. Surgeons, radiologists, oncologists,
and pathologists commonly comprise these
tumor boards and should advocate for each
patient to ensure that they receive the best care
possible. Each specialty has a role to play in the
39 Rectal Conditions: Rectal Cancer—Adjuvant andNeoadjuvant Therapy
313
discussion and review of the staging and possible treatments. In the United Kingdom and
many other European countries, it is mandatory
that rectal cancer be treated at a center of excellence and that each patient with rectal cancer is
discussed at a multidisciplinary tumor board
meeting. This process has led to higher rates of
TME and more standardized care. The National
Accreditation Program for Rectal Cancer
(NAPRC) is a quality program of the American
College of Surgeons (ACS) that developed
through collaboration between the OSTRiCh
Consortium (Optimizing the Surgical Treatment
of Rectal Cancer) and the Commission on
Cancer (CoC) in the United States. This North
American group advocates for multidisciplinary discussion of rectal cancer patients and
individualized treatment pathways. Their goal,
once again, is to provide more standardized and
evidence-based care to all patients with rectal
cancer, not just those living close to a “center of
excellence”, in order to improve cancer outcomes and standards of care. MDTs are a large
part of achieving this goal of standardization of
care and have also been shown to lead to
improved patient outcomes in many other types
of cancer such as breast and head and neck cancers. Clearly, the treatment of rectal cancer is
complex, especially when one considers the
nuances of local stage, distant disease, roles of
chemotherapy and radiotherapy, and sequencing of treatments. Multidisciplinary involvement is essential to improving care and
optimizing outcomes for all patients with rectal
cancer. One of the accreditation standards of
the ACS CoC NAPRC is that every patient’s
particulars are discussed at MDT prior to and
after treatment in accredited centers and
beyond.
Suggested Reading
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Berho M, Narang R, Van Koughnett JA, Wexner SD.
Modern multidisciplinary perioperative management
of rectal cancer. JAMA Surg. 2015;150(3):260.
Danielsen AK, Park J, Jansen JE, Bock D, Skullman S,
Wedin A, etal. Early closure of a temporary ileostomy
in patients with rectal cancer: a multicenter randomized controlled trial. Ann Surg. 2017;265(2):284–90.
Dietz DW.Multidisciplinary management of rectal cancer:
the OSTRICH.J Gastrointest Surg. 2013;17(10):1863.
Fernandez-Martos C, Noque M, Cejas P, Moreno-Garcia
V, Machancoses AH, Feliu J.The role of capecitabine
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