Multidisciplinary Treatment Of Rectal Cancer Research Articles

Roles of MRI evaluation of pelvic recurrence in patients with rectal cancer

Abstract Developments in the multidisciplinary treatment of rectal cancer with advances in preoperative magnetic resonance imaging (MRI), surgical techniques, neoadjuvant chemoradiotherapy, and adjuvant chemotherapy have had a significant impact on patient outcomes, increasing the rates of curative surgeries and reducing pelvic recurrence. Patients with pelvic recurrence have worse prognoses, with an impact on morbidity and mortality. Although local recurrence is more frequent within 2 years of surgical resection of the primary tumor, late recurrence may occur. Clinical manifestations can vary from asymptomatic, nonspecific symptoms, to pelvic pain, bleeding, and fistulas. Synchronous metastatic disease occurs in approximately 50% of patients diagnosed with local recurrence. MRI plays a crucial role in posttreatment follow-up, whether by identifying viable neoplastic tissues or acting as a tool for therapeutic planning and assessing the resectability of these lesions. Locally recurrent tissues usually have a higher signal intensity than muscle on T2-weighted imaging. Thus, attention is required for focal heterogeneous lesions, marked contrast enhancement, early invasive behavior, and asymmetric appearance, which are suspicious for local recurrence. However, postsurgical inflammatory changes related to radiotherapy and fibrosis make it difficult to detect initial lesions. This study therefore aimed to review the main imaging patterns of pelvic recurrence and their implications for the surgical decision-making process. Critical relevance statement MRI plays a crucial role in the posttreatment follow-up of rectal cancer, whether by identifying viable neoplastic tissues or by acting as a tool for therapeutic planning. This study reviewed the main imaging patterns of pelvic recurrence. Key Points MRI aids in surgical planning and the detection of pelvic recurrence and postoperative complications. Being familiar with surgical techniques enables radiologists to identify expected MRI findings. Patterns of rectal cancer recurrence have been categorized by pelvic compartments. Neoplastic tissue may mimic postsurgical and postradiotherapy changes. Resectability of pelvic recurrence is highly related to lesion location. Graphical Abstract

Prognostic importance of circumferential resection margin in the era of evolving surgical and multidisciplinary treatment of rectal cancer: A systematic review and meta-analysis

BackgroundCircumferential resection margin is considered an important prognostic parameter after rectal cancer surgery, but its impact might have changed because of improved surgical quality and tailored multimodality treatment. The aim of this systematic review was to determine the prognostic importance of circumferential resection margin involvement based on the most recent literature. MethodsA systematic literature search of MEDLINE, Embase, and the Cochrane Library was performed for studies published between January 2006 and May 2019. Studies were included if 3- or 5-year oncological outcomes were reported depending on circumferential resection margin status. Outcome parameters were local recurrence, overall survival, disease-free survival, and distant metastasis rate. The Newcastle Ottawa Scale and Jadad score were used for quality assessment of the studies. Meta-analysis was performed using a random effects model and reported as a pooled odds ratio or hazard ratio with 95% confidence interval. ResultsSeventy-five studies were included, comprising a total of 85,048 rectal cancer patients. Significant associations between circumferential resection margin involvement and all long-term outcome parameters were uniformly found, with varying odds ratios and hazard ratios depending on circumferential resection margin definition (<1 mm, ≤1 mm, otherwise), neoadjuvant treatment, study period, and geographical origin of the studies. ConclusionCircumferential resection margin involvement has remained an independent, poor prognostic factor for local recurrence and survival in most recent literature, indicating that circumferential resection margin status can still be used as a short-term surrogate endpoint.

Residents entering Complex General Surgical Oncology fellowship lack confidence with pelvic MRI for rectal cancer: Results of a needs assessment survey

BackgroundMagnetic resonance imaging (MRI) is essential for the multidisciplinary treatment of rectal cancer. However, baseline experience of surgical residents with MRI is unknown. Therefore, a needs assessment survey was conducted to examine confidence with pelvic MRI for residents entering Complex General Surgical Oncology (CSGO) fellowships. MethodsA multi-institutional survey evaluated incoming CGSO fellows’ experience with pelvic MRI for rectal cancer in residency. Additionally, confidence was assessed for essential components of pelvic MRI including T- and N-stage, circumferential resection margin (CRM), extramural venous invasion (EMVI), and pelvic anatomy. ResultsOf the twenty-four incoming fellows who completed the survey (response rate = 44%), 20 reported frequent use of pelvic MRI for rectal cancer in residency, but 16 reported rarely/never interpreting images themselves for staging or operative planning. Most respondents reported low confidence for T-stage, N-stage, CRM, EMVI, as well as pelvic anatomy, particularly for lateral and posterior pelvis. ConclusionsThe development of a pelvic MRI curriculum for residents entering CGSO fellowships could enhance their clinical training in the multidisciplinary management of patients with rectal cancer.

Impact of Recurrence and Salvage Surgery on Survival After Multidisciplinary Treatment of Rectal Cancer.

Purpose After preoperative chemoradiotherapy followed by total mesorectal excision for locally advanced rectal cancer, patients who experience local or systemic relapse of disease may be eligible for curative salvage surgery, but the benefit of this surgery has not been fully investigated. The purpose of this study was to characterize recurrence patterns and investigate the impact of salvage surgery on survival in patients with rectal cancer after receiving multidisciplinary treatment. Patients and Methods Patients with locally advanced (cT3-4 or cN+) rectal cancer who were treated with preoperative chemoradiotherapy followed by total mesorectal excision at our institution during 1993 to 2008 were identified. We examined patterns of recurrence location, time to recurrence, treatment factors, and survival. Results A total of 735 patients were included. Tumors were mostly midrectal to lower rectal cancer, with a median distance from the anal verge of 5.0 cm. The most common recurrence site was the lung followed by the liver. Median time to recurrence was shorter in liver-only recurrence (11.2 months) than in lung-only recurrence (18.2 months) or locoregional-only recurrence (24.7 months; P = .001). Salvage surgery was performed in 57% of patients with single-site recurrence and was associated with longer survival after recurrence in patients with lung-only and liver-only recurrence ( P < .001) but not in those with locoregional-only recurrence ( P = .353). Conclusion We found a predilection for lung recurrence in patients with rectal cancer after multidisciplinary treatment. Salvage surgery was associated with prolonged survival in patients with lung-only and liver-only recurrence, but not in those with locoregional recurrence, which demonstrates a need for careful consideration of the indications for resection.

Update on advances and controversy in rectal cancer treatment.

Changes in the multidisciplinary treatment of rectal cancer have been recently proposed. We performed a comprehensive review of the current data on neoadjuvant and adjuvant treatment of rectal cancer, focussing on chemoradiotherapy treatment and timing of surgery. Six components were proposed as the framework for the treatment of rectal cancer: neoadjuvant therapy and changing patterns in patient selection, long- or short-course radiotherapy, adverse effects of radiotherapy, timing of surgery, non-operative management of rectal cancer and postoperative adjuvant therapy. Lack of a consistent difference in terms of local recurrence has been observed between short-course radiotherapy and long-course chemoradiotherapy. Indications for preoperative radiotherapy have been reconsidered in the last years. An interval of 10-11 weeks seemed to be the optimal timing, with no impact on patient safety. Since assessment criteria of clinical complete response are not well defined, and the basis for non-operative management of rectal cancer is still not clear, further investigations are required. There is controversy about standard treatments for patients with locally advanced rectal cancer that are being analyzed by ongoing studies. Tailored treatments could avoid over-treatment for a large number of patients without any impairment of the oncologic results.

Food for thought: re-evaluating dietary advice

Gastrointestinal NursingVol. 13, No. 6 CommentFood for thought: re-evaluating dietary adviceMelanie BakerMelanie BakerSearch for more papers by this authorMelanie BakerPublished Online:14 Jul 2015https://doi.org/10.12968/gasn.2015.13.6.14AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Culkin A, Gabe SM, Madden AM (2009) Improving clinical outcome in patients with intestinal failure using individualised nutritional advice. J Human Nutr Diet 22(4): 290–8. doi: https://doi.org/10.1111/j.1365-277X.2009.00954.x Crossref, Google ScholarGlasgow MA, Shields K, Vogel RI, Teoh D, Argenta PA (2014) Postoperative readmissions following ileostomy formation among patients with a gynecologic malignancy. Gynecol Oncol 134(3): 561–5. doi: https://doi.org/10.1016/j.ygyno.2014.06.005 Crossref, Google ScholarHayden DM, Pinzon MC, Francescatti AB et al. (2013) Hospital readmission for fluid and electrolyte abnormalities following ileostomy construction: preventable or unpredictable? J Gastrointest Surg 17(2): 298–303. doi: https://doi.org/10.1007/s11605-012-2073-5 Crossref, Google ScholarMorris A, Leach B (2009) An exploration of dietary advice for individuals with an ileostomy and Crohn's disease. J Hum Nutr Diet 22(3): 271–272. doi: https://doi.org/10.1111/j.1365-277X.2009.00952_21.x Google ScholarMcDonald PJ, Fazio VW (1988) What can Crohn's patients eat? Eur J Clin Nutr 42(8): 703–8 Google ScholarNg DH, Pither CA, Wootton SA, Stroud MA (2013) The ‘not so short-bowel syndrome’: potential health problems in patients with an ileostomy. Colorectal Dis 15(9): 1154–61. doi: https://doi.org/10.1111/codi.12252 Google ScholarPersson E, Gustavsson B, Hellström AL, Lappas G, Hultén L (2005) Ostomy patients' perceptions of quality of care. J Adv Nurs 49(1): 51–8 Crossref, Google ScholarPhatak UR, Kao LS, You YN et al. (2014) Impact of ileostomy-related complications on the multidisciplinary treatment of rectal cancer. Ann Surg Oncol 21(2): 507–12. doi: https://doi.org/10.1245/s10434-013-3287-9 Crossref, Google ScholarSun V, Grant M, McMullen CK et al. (2013) Surviving colorectal cancer: long-term, persistent ostomy-specific concerns and adaptations. J Wound Ostomy Continence Nurs 40(1): 61–72. doi: https://doi.org/10.1097/WON.0b013e3182750143 Crossref, Google ScholarThomson TJ, Runcie J, Khan A (1970) The effect of diet on ileostomy function. Gut 11(6): 482–5 Crossref, Google Scholar FiguresReferencesRelatedDetailsCited byDietary management for people with an ileostomy: a scoping review1 September 2021 | JBI Evidence Synthesis, Vol. 19, No. 9Provision of dietary advice for people with an ileostomy: a survey in the UK and Ireland9 August 2020 | Colorectal Disease, Vol. 22, No. 12Older ostomates and diet management in careJennie Burch9 April 2020 | Nursing and Residential Care, Vol. 22, No. 5 2 July 2015Volume 13Issue 6ISSN (print): 1479-5248ISSN (online): 2052-2835 Metrics History Published online 14 July 2015 Published in print 2 July 2015 Information© MA Healthcare LimitedAcknowledgementsThe author would like to thank Health Education East Midlands for its support in this researchPDF download

Lokalna ponovitev bolezni pri bolnikih operiranih zaradi nemetastatskega raka danke, zbolelih v obdobju 2003 - 2005

Background: In the last decades outcomes of rectal cancer treatment are improving due to better understanding of tumor biology, neoadjuvant and adjuvant treatment and precise surgical technique, considering pathologic anatomical lines. Proportion of rectal cancer local recurrence (LR) has been substantially decreasing. Objectives of this study are, first, to find out whether two groups, with and without rectal local recurrence, are statistically important different in certain risk factors and, second, to define prognostic factors of rectal local recurrence.Methods: Total of 787 nonmetastatisc rectal cancer patients, diagnosed between 2003 and 2005, treated with surgery in all Slovenian hospitals, were enrolled retrospectively. The recurrence-free survival rates were calculated with Kaplan-Meier method. For statistical comparison of survival of two groups according to prognostic factors log-rank test was used. The adjusted hazard ratios for significant survival prognostic factors were calculated using Cox multivariate analysis.Results: Patients with LR had more tumors in the lower third of rectum (p=0,045), more abdominoperineal, Hartmann's and local excisions (p=0,000) and less radical operations (p=0,005), more of them were operated in hospitals with lesser caseload of patients (p=0,000), more often were treated only surgically (p=0,048), had more colon defects after excision of tumors (p=0,025) and had more distant disease recurrences (p=0,000). In follow up period of 5,3 years LR occurred in 13,1% and in 54% of those in 1,9 years after surgery. In the multivariate analysis, the statistically significant prognostic factors for recurrence-free survival were tumor's rectal position, regional lymph nodes status and the hospital of surgery.Conclusions: Proportion of LR is an appropriate indicator of optimal multidisciplinary rectal cancer treatment.

Multidisciplinary treatment of rectal cancer in 2014: where are we going?

In the present review we discuss the recent developments and future directions in the multimodal treatment of locally advanced rectal cancer, with respect to staging and re-staging modalities, to the current role of neoadjuvant chemo-radiation and to the conservative and more limited surgical approaches based on tumour response after neoadjuvant combined therapy. When initial tumor staging is considered a high accuracy has been reported for T pre-treatment staging, while preoperative lymph node mapping is still suboptimal. With respect to tumour re-staging, all the current available modalities still present a limited accuracy, in particular in defining a complete response. The role of short vs long-course radiotherapy regimens as well as the optimal time of surgery are still unclear and under investigation by means of ongoing randomized trials. Observational management or local excision following tumour complete response are promising alternatives to total mesorectal excision, but need further evaluation, and their use outside of a clinical trial is not recommended. The preoperative selection of patients who will benefit from neoadjuvant radiotherapy or not, as well as the proper identification of a clinical complete tumour response after combined treatment modalities,will influence the future directions in the treatment of locally advanced rectal cancer.

Impact of Ileostomy-Related Complications on the Multidisciplinary Treatment of Rectal Cancer

Radical resection is the primary treatment for rectal cancer. When anastomosis is possible, a temporary ileostomy is used to decrease morbidity from a poorly healed anastomosis. However, ileostomies are associated with complications, dehydration, and need for a second operation. We sought to evaluate the impact of ileostomy-related complications on the treatment of rectal cancer. We conducted a retrospective study of patients who underwent sphincter-preserving surgery between January 2005 and December 2010 at a tertiary cancer center. The primary outcome was the overall rate of ileostomy-related complications. Secondary outcomes included complications related to ileostomy status, ileostomy closure, anastomotic complications at primary resection, rate of stoma closure, and completion of adjuvant chemotherapy assessed by multivariate logistic regression. Of 294 patients analyzed, 32% (n = 95) were women. Two hundred seventy-one (92%) received neoadjuvant chemoradiation. The median tumor distance from the anal verge was 7 cm (interquartile range 5-10 cm). Two hundred eighty-one (96%) underwent stoma closure at a median of 7 months (interquartile range 5.4-8.3 months). The most common complication related to readmission was dehydration (n = 32-11%). Readmission within 60 days of primary resection was associated with delay in initiating adjuvant chemotherapy (odds ratio 3.01, 95% confidence interval 1.42-6.38, p = 0.004). Diverting ileostomies created during surgical treatment of rectal cancers are associated with morbidity; however, this is balanced against the risk of anastomosis-related morbidity at rectal resection. Given the potential benefit of fecal diversion, patient-oriented interventions to improve ostomy management, particularly during adjuvant chemotherapy, can be expected to yield marked benefits.

Multidisciplinary Treatment of Rectal Cancer

Russell et al1 have addedmore information to thedebate over the treatment of rectal cancer in institutions focused on the treatment of rectal cancer. Although the treatment of patients with rectal cancer in higher-volume academic centers with neoadjuvant protocols does not guarantee good surgical outcomes, it seems to help. Because no type of hospital (even a high-volume academic hospital) was immune to high outlier status for circumferentialmargins positive for cancer, the need for quality assurance and improvement in processes is extremely important for anyhospital/institution that treatspatients with rectal cancer. TheAmericanSocietyofColonandRectalSurgeons, inconjunctionwith the Society of Surgical Oncology, the American College of Surgeons, the Society for Surgery of the Alimentary Tract, and the Society of American Gastrointestinal and EndoscopicSurgeons,has initiated a project to optimize treatment of rectal cancer; OSTRiCh (Optimizing Surgical Treatment of Rectal Cancer) is a group of interested institutionsand individuals attempting todevelopaprogramin the United States similar to that in the United Kingdom, Scandinavia, and Europe. Out of this effort, a set of criteria for centers of excellence should become available. Rather than focusing solely on surgeon credentialing, the OSTRiCh group is embracing the institution with a multidisciplinary approach to rectal cancer. Someof the criteria includeddedicatedhighvolumesurgeonsusing totalmesorectal excisionof rectal cancer; radiologists experienced in magnetic resonance imaging stagingof rectal cancer;medical and radiationoncologistswho understand the nuances of neoadjuvant chemoradiation and adjuvant chemotherapy for rectal cancer; pathologists focused on macroscopic specimen grading, circumferential radial margin reporting, and whole-specimen processing for cross-sectionmounts; gastroenterologistswithhigh-level endoscopic intervention skills; and genetic counselors, asmembers of a multidisciplinary team, whomanage, evaluate, and assesseseverypatient treatedwithcolorectal cancer.Thesecriteria should improve the outcomes of patients treated for rectal cancer. Russell et al1 havealso shownus that apatient’s awareness of theappropriate treatmentof rectal cancer is important.Older individuals and those without private insurance had a higher likelihood of choosing low-volume, nonteaching hospitals, which have a greater likelihood of high outlier status for radial margins positive for cancer. As patients become more aware and/or educated about rectal cancer, this trend should change. This study1 has some issues that may never be resolved, even with the use of a database as sophisticated as the NationalCancerDataBase.Thepatientpopulation includedyoung patientswhomust,bydefinition,beconsideredhighrisk forhereditary cancer, which behaves differently from sporadic cancer. The inclusionof rectosigmoid cancers, simplybecause the patients underwent irradiation, may bias or negatively influence the outcomes because only the most advanced rectosigmoid cancers would require neoadjuvant therapy. The change in the awareness of the requirements for the pathologicevaluationofa rectal cancerspecimenbegan in2007 and seems to be associatedwith the increase in circumferentialmarginpositivity. Similarly, surgeonsaremoreawareof the need for total mesorectal excision and the avoidance of circumferential radial margin positivity. The use of a 9% to 10% baseline level of circumferential radial positivity and a 100% complete total mesorectal specimen can become an objectivemeasureof surgicalquality forhospitals treating rectal cancer.On thewhole,Russell et al1 are tobecongratulated for their superb effort to improve the surgical procedure for and the treatment of rectal cancer.

Modern multidisciplinary treatment of rectal cancer based on staging with magnetic resonance imaging leads to excellent local control, but distant control remains a challenge

AimThe purpose of this multicenter cohort study was to evaluate whether a differentiated treatment of primary rectal cancer based on magnetic resonance imaging (MRI) can reduce the number of incomplete resections and local recurrences and improve recurrence-free and overall survival. MethodsFrom February 2003 until January 2008, 296 patients with rectal cancer underwent preoperative MRI using a lymph node specific contrast agent to predict circumferential resection margin (CRM), T- and N-stage. Based on expert reading of the MRI, patients were stratified in: (a) low risk for local recurrence (CRM>2mm and N0 status), (b) intermediate risk and (c) high risk (close/involved CRM, N2 status or distal tumours). Mainly based on this MRI risk assessment patients were treated with (a) surgery only (TME or local excision), (b) preoperative 5×5Gy+TME and (c) a long course of chemoradiation therapy followed by surgery after a 6–8week interval. ResultsOverall 228 patients underwent treatment with curative intent: 49 with surgery only, 86 with 5×5Gy and surgery and 93 with chemoradiation and surgery. The number of complete resections (margin>1mm) was 218 (95.6%). At a median follow-up of 41months the three-year local recurrence rate, disease-free survival rate and overall survival rate is 2.2%, 80% and 84.5%, respectively. ConclusionWith a differentiated multimodality treatment based on dedicated preoperative MR imaging, local recurrence is no longer the main problem in rectal cancer treatment. The new challenges are early diagnosis and treatment, reducing morbidity of treatment and preferably prevention of metastatic disease.

État des lieux du traitement multidisciplinaire du cancer du rectum

In the last 10 years, a number of important European randomized published studies investigated the optimal management of rectal cancer. In order to define an evidence-based approach of the clinical practice based, an international consensus conference was organized in Italy under the endorsement of European Society of Medical Oncology (ESMO), European Society of Surgical Oncology (ESSO) and European Society of Therapeutic Radiation Oncology (ESTRO). The aim of this article is to present highlights of multidisciplinary rectal cancer management and to compare the conclusions of the international conference on ‘Multidisciplinary Rectal Cancer Treatment: looking for an European Consensus’ (EURECA-CC2) with the new National Comprehensive Cancer Network (NCCN) guidelines.

Assimilation of evidence-based medicine into clinical practice: Adjuvant radiotherapy in the multidisciplinary treatment of rectal cancer.

552 Background: Implementation of evidence based standards is recognized to be problematic. Level 1 evidence supports the superiority of neoadjuvant therapy for stage II/III rectal cancer. The purpose of this study was to determine to what extent evidence based medicine has impacted clinical practice. Methods: Stage II/III rectal cancer patients undergoing surgery from 1998-2007 were identified in the SEER tumor registry using SEER*Stat 6.2. Variables were extracted and analyzed in SPSS; trends were evaluated with regression models and survival with log rank test. Results: A total of 25,129 patients were identified, 15,769 (63%) were treated with adjuvant radiotherapy. A majority were &gt; 60 years old (56%), white (82.8%), male (60.9%), had stage III cancers (59.2%) and treated with neoadjuvant radiotherapy (54.5%). Significant changes in timing of adjuvant radiotherapy were noted over the study period. In 1998 28.1% of patients were treated neoadjuvantly, this increased to 74% in 2007, a 263% increase. Scatter plot best fit lines intersect in approximately year 2002, p value of trend &lt;0.001. On univarate analysis race (p=0.018), sex (p&lt;0.001), year of diagnosis (p&lt;0.001), age (p&lt;0.001), and stage (p&lt;0.001) were associated increased likelihood of neoadjuvant radiotherapy. Logistic regression found male sex (OR 1.14, p&lt;0.001), year (OR 1.223, p&lt;0.001) and stage II (OR 1.39, p&lt;0.001) were predictors of neoadjuvant therapy. Significant increases in preoperative radiotherapy were observed for all races and cancer stages (p&lt;0.001). There was a significant survival advantage for those treated with adjuvant radiotherapy, median survival 39 vs. 93 months p&lt;0.0001. There, however, was no survival advantage to neoadjuvant vs. postoperative radiotherapy, median survival 94 vs. 93 months, p=0.749. Conclusions: When adjuvant radiotherapy is utilized, there has been rapid adoption of evidence based standards for Stage II/III rectal cancer. However, substantial numbers of patients are not receiving care recognized to improve outcomes.

Strategies of multidisciplinary treatment of rectal cancer

The incidence of rectal cancer has been increasing over past decades in China, making it the third most common malignant tumor. Multidisciplinary treatment plays a fundamental role in the successful treatment of rectal cancer.Total mesorectal excision has been wildly accepted as the standard technique, however, this procedure has not been standardized in China. Neoadjuvant radiation has been accepted as a standard regimen for patients with an advanced rectal cancer at a higher risk of local recurrence, even though controversies remain, such as the selection of patients for preoperative radiation and the optimum regimen for radiation. Combination of chemotherapeutic agents and targeted therapies is recommended according to updated results of randomized controlled trials (RCTs). In the future, multidisciplinary treatment should be adjusted according to the socioeconomic status of China and RCTs results in Chinese population. Standardization of surgery and surgery quality control also continue to play a core role in improving treatment results of rectal cancer in China. Key words: Rectal neoplasms; Multidisciplinary treatment; Neoadjuvant treatment

Rectal cancer radiotherapy: Towards European consensus

Background and purpose. During the first decade of the 21st century several important European randomized studies in rectal cancer have been published. In order to help shape clinical practice based on best scientific evidence, the International Conference on ‘Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus’ (EURECA-CC2) was organized. This article summarizes the consensus about imaging and radiotherapy of rectal cancer and gives an update until May 2010. Methods. Consensus was achieved using the Delphi method. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by topic, and a series of statements were developed. Each committee member commented and voted, sentence by sentence three times. Sentences which did not reach agreement after voting round # 2 were openly debated during the Conference in Perugia (Italy) December 2008. The Executive Committee scored percentage consensus based on three categories: “large consensus”, “moderate consensus”, “minimum consensus”. Results. The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only three (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of members. All chapters were voted on by at least 75% of the members, and the majority was voted on by >85%. Considerable progress has been made in staging and treatment, including radiation treatment of rectal cancer. Conclusions. This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe. In spite of substantial progress, many research challenges remain.

Evidence and research perspectives for surgeons in the European Rectal Cancer Consensus Conference (EURECA-CC2)

Although surgery remains the most important treatment of rectal cancer, the management of this disease has evolved to become more multidisciplinary to offer the best clinical outcome. The International Conference on Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus' (EURECA-CC2) had the duty to identify the degree of consensus that could be achieved across a wide range of topics relating to the management of rectal cancer helping shape future programs, investigational protocols and guidelines for staging and treatment throughout Europe. Consensus was achieved using the Delphi method. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by topic, and a series of statements were developed. Each committee member commented and voted, sentence by sentence three times. Sentences which did not reach agreement after voting round #2 were openly debated during the Conference in Perugia (Italy) December 2008. The Executive Committee scored percentage consensus based on three categories: "large consensus", "moderate consensus", "minimum consensus". The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only 3 (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of members. All chapters were voted on by at least 75% of the members, and the majority was voted on by 85%. This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe. In spite of substantial progress, many research challenges remain.

Advances in multidisciplinary treatment of rectal cancer

To summarize the advances in the multidisciplinary treatment of rectal cancer and to analyze the existing problems and development prospects. The full text database retrieval system of MEDLINE and the periodicals of CHKD were searched. The words “rectal cancer, diagnosis, surgery, chemotherapy, radiotherapy, targeted therapy, analysis” were used as key words for retrieval of literature concerning the values and clinical significance of rectal cancer multidisciplinary treatment from January, 2000 to December, 2007. Thirty papers were selected, of which 26 were used in analysis at last. Accurate preoperative staging of rectal cancer is a key factor in the multidisciplinary and comprehensive treatment of patients. A new therapy which is combined with radical operation can reduce the rate of local recurrence, prolong survival time, and particularly, promote the rate of sphincter preservation. Radical surgery combined with adjuvant therapy is still recognized as standard treatment modality for the patients with rectal cancer in stage II-III. Total removal of resectable metastases followed by prompt standard adjuvant therapy may extend survival time. The introduction of new chemical drugs, drugs of targeting therapy, and a regimen of combination therapy may improve outcomes in treatment for rectal cancer patients. A treatment standard for rectal cancer patients needs to be actively pursued. Compared with colon cancer patients, there has not been sufficient evidence to confirm that the total survival rate of rectal cancer patients after multidisciplinary and comprehensive treatments has been improved; therefore, it needs to be further studied.

Multidisciplinary Rectal Cancer Management: 2nd European Rectal Cancer Consensus Conference (EURECA-CC2)

Background and purpose During the first decade of the 21st century a number of important European randomized studies were published. In order to help shape clinical practice based on best scientific evidence from the literature, the International Conference on ‘Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus’ (EURECA-CC2) was organized in Italy under the endorsement of European Society of Medical Oncology (ESMO), European Society of Surgical Oncology (ESSO), and European Society of Therapeutic Radiation Oncology (ESTRO). Methods Consensus was achieved using the Delphi method. The document was available to all Committee members as a web-based document customized for the consensus process. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by a topic, and a series of statements were developed. Each member commented and voted, sentence by sentence thrice. Sentences upon which an agreement was not reached after voting round # 2 were openly debated during a Consensus Conference in Perugia (Italy) from 11 December to 13 December 2008. A hand-held televoting system collected the opinions of both the Committee members and the audience after each debate. The Executive Committee scored percentage consensus based on three categories: “large consensus”, “moderate consensus”, and “minimum consensus”. Results The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only 3 (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of the members. All chapters were voted on by at least 75% of the members, and the majority was voted on by >85%. Conclusions This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe.

Multidisciplinary treatment of rectal cancer: medical oncology

The management of rectal cancer requires a multidisciplinary approach with individual treatment based on a careful assessment of tumour location, stage and resectability. Early identification of the patients that are candidates for combined modality treatment is crucial. After showing less acute and long-term toxicity along with an improved local control in a randomized study, pre-operative combined chemoradiation has in fact recently replaced post-operative radiochemotherapy as standard treatment for locally advanced rectal cancer [1]. Multimodality treatment and the optimization of single treatment components [surgery in particular with the introduction of total mesorectal excision (TME)] have concurred and improved the prognosis of locally advanced rectal cancer with local recurrences decreasing from 40 to 80% in the 2000s [3]. Of note, the substantial improvement in local control has not been paralleled by a similar decrease in distant metastases that represent the site of failure for up to 30% of patients, despite optimal surgery and preor post-operative radiation with concomitant, radiosensitizing, and sequential, adjuvant, 5-fluorouracil (FU)-based chemotherapy (Figure 1) [1, 4, 5]. The role and limits of the chemotherapy regimens used in the standard combined-modality treatment programs for rectal cancer and the ongoing research to improve these regimens will be reviewed in this article in the light of the specific aims and current indications of adjuvant/neoadjuvant treatment.

The multidisciplinary treatment of rectal cancer: pathology

The multidisciplinary treatment of rectal cancer: pathology