Adjuvant Management of Rectal Cancer: The More We Learn, the Less We Know

Abstract

Two decades ago, the adjuvant management of rectal cancer was less complex and far less controversial. Patients in the United States underwent surgery, commonly by blunt dissection, and if there was pT3 and/or pN1-2 disease, they received 6 months of postoperative fluouracil (FU)-based chemotherapy with pelvic radiation during months 3 and 4 (combined-modality therapy). Subsequent randomized and nonrandomized trials have taught us manynewlessons.Amongthesearetotalmesorectalexcisionasthe preferred surgical technique 1 ; at least 12 examined nodes to accurately determine the nodal stage 2 ; the relationship of local failure notonlytostagebutalsotothelocationofthetumorintherectum and the presence of a positive circumferential margin 3 ; and the subsets of patients with pT3N0 of pT1-2N1 disease who may not require postoperative radiation. 4 Furthermore, for patients with cT3 and or N disease, the German trial confirmed that preoperative combined-modality therapy has significantly improved local control, caused less acute short and long-term toxicity, and increased sphincter preservation compared with postoperative combined-modality therapy. 5