Contemporary management of rectal cancer.An overview

Abstract

Surgery does not cure more than 50% of “curable” rectal cancers. Local, regional, and disseminated cancers unremoved and untreated by surgery and other modalities account for this unrelenting mortality for the past 20 years. The results and promise of current investigations in multimodality approaches are discussed. Studies on lymph node histopathology seem to offer reliable prognostic significance in local or regionally confined disease. The use of adjuvant preoperative radiation foretells increased curability rates by decreasing the pathologic staging and local recurrence rates. Trials are under way potentiating the effects of radiation on tumor cells by combining it with various methods of hyperthermia or radiosensitizing compounds. Recent reports on the use of anticoagulation therapy at the time of surgery to prevent tumor cell implantation in fibrin networks indicate that this therapy is reasonable and worthy of more trial. The use of localized treatment in carefully selected patients is reviewed, including excision with electrocoagulation and contact x-ray therapy popularized in France by Papillon. Our early results of treatment by an interstitial iridium 192 rectal template afterloading technique are impressive. While chemotherapy for rectal cancer has, in general, been of no benefit, the combination of methyl-CCNU, vincristine and 5-FU seems to offer a reasonable response rate. The most exciting modality at present is immunotherapy. We believe that the adequate destruction of local and regional disease by radiation and surgery, the prevention of recurrent local and regional disease by radiation and surgery, the prevention of its local extension and implantation of metastases by anticoagulation and chemotherapy, with the stimulation of the hosts' immune response or prevention of immunosuppression by immunotherapy, are the indicated multimodalities of contemporary treatment.