Rectal Cancer International Perspectives on Multimodality
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Current Clinical Oncology
Maurie Markman, MD, Series Editor
For other titles published in this series, go to
www.springer.com/series/7631
Rectal Cancer
International
Perspectives on
Multimodality
Management
Edited by
Brian G. Czito
Department of Radiation Oncology,
Duke University Medical Center, Durham, NC, USA
Christopher G. Willett
Department of Radiation Oncology,
Duke University Medical Center, Durham, NC, USA
Editors
Brian G. Czito Christopher G. Willett
Department of Radiation Oncology Department of Radiation Oncology
Duke University Medical Center Duke University Medical Center
Durham, NC Durham, NC
USA USA
[email protected] [email protected]
ISBN: 978-1-60761-566-8 e-ISBN: 978-1-60761-567-5
DOI: 10.1007/978-1-60761-567-5
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2010931685
© Springer Science+Business Media, LLC 2010
All rights reserved. This work may not be translated or copied in whole or in part without the written
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Preface
Rectal Cancer: International Perspectives on Multimodality Management is a timely
analysis of the diagnosis, staging, pathology, and therapy of cancer of the rectum. This book
is intended as a useful resource for physicians, scientists, medical students, and allied health
personnel in the disciplines of radiology, gastroenterology, surgical oncology, medical oncol-
ogy, radiation oncology, and pathology. Renowned contributors from different medical dis-
ciplines have written their chapters in a thoughtful, provocative, and visual fashion.
Importantly, these chapters highlight the controversies in the diagnostic, staging, and thera-
peutic management of patients with rectal cancer while providing practical management
recommendations.
This book is divided into 18 chapters. Early chapters address the diagnosis and staging of
rectal cancer, highlighting the critical role of contemporary imaging in guiding treatment.
The remaining chapters focus on the multimodality management of rectal cancer from the
vantage points of surgery, pathology, chemotherapy, and radiation therapy. The major devel-
opments in surgery are reviewed first, including contemporary roles of local excision, total
mesorectal excision, lateral pelvic lymph node dissection, organ preservation approaches, as
well as the management of advanced, recurrent, and metastatic disease. Following is a chap-
ter describing the pathologic evaluation of rectal cancer specimens, with emphasis on proper
methodology and its clinical relevance to overall disease management. The final chapters
review the contemporary roles of chemotherapy (including with radiation therapy, adjuvant
and neoadjuvant settings without radiation therapy, as well as in metastatic disease) as well
as radiation therapy (including adjuvant and neoadjuvant approaches, short vs. long course
treatments, brachytherapy and contact therapy, nonoperative approaches utilizing definitive
chemoradiotherapy, and technical innovations).
We would like to thank the authors for their outstanding contributions which will aid us
in the understanding of this malignancy as well as the care of our patients. We would also
express thanks to the patients whose willingness has allowed continued therapeutic advances
to be made in this disease over the past three decades. We hope you enjoy reviewing this
work as much as we have.
Durham, NC Brian G. Czito
Christopher G. Willett
v
Contents
Preface............................................................................................................................. v
Contributors.................................................................................................................... ix
1 Clinical Staging: Endoscopic Techniques............................................................... 1
Hueylan Chern and W. Douglas Wong
2 Clinical Staging: CT and MRI................................................................................ 21
Gina Brown, Shwetal Dighe, and Fiona Taylor
3 Local Excision........................................................................................................ 37
Y. Nancy You and Heidi Nelson
4 Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection................. 53
Miranda Kusters, Yoshihiro Moriya, Harm J.T. Rutten,
and Cornelis J.H. van de Velde
5 Abdominoperineal Resection, Low Anterior Resection,
and Beyond............................................................................................................. 79
Kirk Ludwig, Lauren Kosinski, and Timothy Ridolfi
6 T4 and Recurrent Rectal Cancer............................................................................. 109
Jason Park and Jose Guillem
7 Surgical Management of Pulmonary Metastases.................................................... 123
Loretta Erhunmwunsee and Thomas A. D’Amico
8 Surgical and Ablative Management of Liver Metastases........................................ 131
Srinevas K. Reddy and Bryan M. Clary
9 Surgical Pathology.................................................................................................. 151
Nicholas P. West and Philip Quirke
10 Chemotherapy: Concurrent Delivery with Radiation Therapy............................... 165
Jean-François Bosset, Christophe Borg, Philippe Maingon,
Gilles Crehange, Stéphanie Servagi-Vernat, and Mathieu Bosset
11 Chemotherapy: Adjuvant and Neoadjuvant Approaches........................................ 175
Rachel Wong, David Cunningham, and Ian Chua
12 Chemotherapy: Metastatic Disease......................................................................... 189
Kathryn M. Field and John R. Zalcberg
13 Radiation Therapy: Adjuvant vs. Neoadjuvant Therapy......................................... 223
Rolf Sauer and Claus Rödel
14 Radiation Therapy: Short Versus Long Course...................................................... 235
Krzysztof Bujko and Magdalena Bujko
vii
viii Contents
15 Chemoradiation Therapy: Nonoperative Approaches............................................. 249
Angelita Habr-Gama, Rodrigo Perez, Igor Proscurshim,
and Joaquim Gama-Rodrigues
16 Contact X-Ray Therapy.......................................................................................... 267
Jean-Pierre Gérard, Robert Myerson, and A. Sun Myint
17 High-Dose-Rate Preoperative Endorectal Brachytherapy
for Patients with Rectal Cancer............................................................................... 277
Té Vuong, Slobodan Devic, and Ervin Podgorsak
18 Radiation Therapy: Technical Innovations............................................................. 289
Brian G. Czito and Christopher G. Willett
Index................................................................................................................. 307
Contributors
Christophe Borg, MD, PhD • Medical Oncology Department,
Besançon University Hospital, Besançon, France
Jean-François Bosset, MD • Radiotherapy-Oncology Department,
Besançon University Hospital, Besançon, France
Mathieu Bosset, MD • Radiotherapy-Oncology Department,
Besançon University Hospital, Besançon, France
Gina Brown, MD • Royal Marsden Hospital, Sutton, Surrey, UK
Krzysztof Bujko, MD • Department of Radiotherapy, Maria Sklodowska-Curie Memorial
Cancer Centre and Institute of Oncology, Warsaw, Poland
Magdalena Bujko, MD • Department of Radiotherapy, Maria Sklodowska-Curie Memorial
Cancer Centre and Institute of Oncology, Warsaw, Poland
Ian Chua, MD • Department of Medicine, Royal Marsden Hospital, Sutton, Surrey, UK
Hueylan Chern, MD • Department of Surgery, Memorial Sloan-Kettering Cancer Center,
New York, NY, USA
Bryan M. Clary, MD • Department of Surgery, Division of General Surgery,
Duke University Medical Center, Durham, NC, USA
Gilles Crehange, MD • Radiotherapy Department, Georges François Leclerc Center,
Dijon, France
David Cunningham, MD, FRCP • Department of Medicine, Royal Marsden Hospital,
Sutton, Surrey, UK
Brian G. Czito, MD • Department of Radiation Oncology, Duke University Medical
Center, Durham, NC, USA
Thomas A. D’Amico, MD • Department of Surgery, Division of General Surgery,
Duke University Medical Center, Durham, NC, USA
Slobodan Devic, PhD • Department of Medical Physics, McGill University,
Montreal, QC, Canada
Shwetal Dighe, MS (Mum), DNB, MRCS • Mayday University Hospital, Croydon, UK
Loretta Erhunmwunsee, MD • Department of Surgery, Division of General Surgery,
Duke University Medical Center, Durham, NC, USA
Kathryn M. Field, MBBS Hons, MD • Royal Melbourne Hospital, Victoria, Australia
Joaquim Gama-Rodrigues, MD, PhD • Department of Gastroenterology,
University of Sao Paulo, Sao Paulo, Brazil
ix
x Contributors
Jean-Pierre Gérard, MD • Department of Radiation Oncology, Centre Antoine
Lacassagne, Nice, France
Jose Guillem, MD, MPH • Department of Surgery, Memorial Sloan-Kettering Cancer
Center, New York, NY, USA
Angelita Habr-Gama, MD, PhD • Department of Gastroenterology, University
of Sao Paulo, Sao Paulo, Brazil
Lauren Kosinski, MD • Section of Colorectal Surgery, Department of Surgery,
Medical College of Wisconsin, Milwaukee, WI, USA
Miranda Kusters, MSc • Department of Surgery, Leiden University Medical Center,
Leiden, The Netherlands
Kirk Ludwig, MD • MCW/Froedtert Cancer Center and Department of Surgery,
Medical College of Wisconsin, Milwaukee, WI, USA
Philippe Maingon, MD, PhD • Radiotherapy Department, Georges François Leclerc
Center, Dijon, France
Yoshihiro Moriya, MD • Department of Colorectal Surgery, National Cancer Center
Hospital, Tokyo, Japan
Robert Myerson, MD, PhD • Department of Radiation Oncology, Washington University
of Medicine, St, Louis, MO, USA
A. Sun Myint, FRCP, FRCR • Clatterbridge Centre for Oncology, NHS Foundation Trust,
Wirral, UK
Heidi Nelson, MD • Division of Colon and Rectal Surgery, Mayo Clinic
College of Medicine, Rochester, MN, USA
Jason Park, MD, MEd • Department of Surgery, Memorial Sloan-Kettering
Cancer Center, New York, NY, USA
Rodrigo Perez, MD • Department of Gastroenterology, University of Sao Paulo,
Sao Paulo, Brazil
Ervin Podgorsak, PhD • Department of Medical Physics, McGill University, Montreal,
QC, Canada
Igor Proscurshim, MD • Department of Gastroenterology, University of Sao Paulo,
Sao Paulo, Brazil
Philip Quirke, PhD • Department of Pathology and Tumour Biology, Leeds Institute
of Molecular Medicine, University of Leeds, Leeds, UK
Srinevas K. Reddy, MD • Department of Surgery, Division of General Surgery,
Duke University Medical Center, Durham, NC, USA
Timothy Ridolfi, MD • Department of Surgery, Medical College of Wisconsin,
Milwaukee, WI, USA
Claus Rödel, MD • Department of Radiation Therapy and Oncology, University
of Frankfurt, Germany
Harm J.T. Rutten, PhD • Department of Surgery, Catherina Hospital, Eindhoven,
The Netherlands
Contributors xi
Rolf Sauer, MD • Department of Radiation Therapy, University of Erlangen, Germany
Stéphanie Servagi-Vernat, MD • Radiotherapy-Oncology Department,
Besançon University Hospital, Besançon, France
Fiona Taylor, MBBS, MRCS • Mayday University Hospital, Croydon, UK
Cornelis J.H. van de Velde, MD, PhD • Department of Surgery, Leiden University
Medical Center, Leiden, The Netherlands
Té Vuong, MD, FRCPC • Department of Radiation Oncology, McGill University,
Montreal, QC, Canada
Nicholas P. West, MB, ChB • Department of Pathology and Tumour Biology,
Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK
Christopher G. Willett, MD • Department of Radiation Oncology,
Duke University Medical Center, Durham, NC, USA
W. Douglas Wong, MD • Department of Surgery, Memorial Sloan-Kettering
Cancer Center, New York, NY, USA
Rachel Wong, MD • Department of Medicine, Royal Marsden Hospital,
Sutton, Surrey, UK
Y. Nancy You, MD, MHSc • Division of Colorectal Surgery, Department of Surgery,
Mayo Clinic, Rochester, MN, USA
John R. Zalcberg, MD, PhD • Division of Hematology and Medical Oncology and
Department of Medicine, Peter MacCallum Cancer Centre, University of Melbourne,
Melbourne, Australia
1 Clinical Staging: Endoscopic
Techniques
Hueylan Chern and W. Douglas Wong
Introduction
The treatment of rectal cancer has advanced tremendously in the last decade, leading to
a decrease in local recurrence and an increase in sphincter-sparing rates. The importance of
preoperative staging in improving rectal cancer treatment cannot be overemphasized.
Accurate preoperative staging guides important management decisions, such as identifica-
tion of patients who will benefit from neoadjuvant therapy as well as those amenable to local
excision or sphincter-sparing surgery rather than abdominoperineal resection.
In randomized controlled trials, preoperative chemoradiation therapy for T3, T4, or N1
rectal cancers has been shown to result in lower toxicity and improved local control com-
pared with postoperative chemoradiotherapy (2). Local excision may be considered for some
T1 rectal cancers. However, local excision for T2 or more advanced lesions (including those
with positive. lymph nodes) is not generally recommended (3). Thus, it is of utmost impor-
tance that initial staging of rectal cancer be accurate and complete, in order to determine
individual T stage as well as nodal status.
Contemporary modalities used for preoperative staging of rectal cancer include digital
rectal exam (DRE), computed tomography (CT), magnetic resonance imaging (MRI), and
endorectal ultrasound (ERUS). The ideal staging modality should be relatively easy to per-
form, accurate, and cost-effective. This chapter focuses on ERUS, which is the authors’
initial staging method of choice.
For “Rectal Cancer: International Perspectives on Multimodality Management”, Brian G.
Czito, MD and Christopher G. Willett, MD, editors (Humana Press)
From: Current Clinical Oncology: Rectal Cancer,
Edited by: B.G. Czito and C.G. Willett, DOI: 10.1007/978-1-60761-567-5_1,
© Springer Science+Business Media, LLC 2010
1
2 H. Chern and W.D. Wong
Staging of Rectal Cancer
Many classification systems have been used for the staging of rectal cancer. In the
United States, the standard and most commonly used system is the tumor, node, metastasis
(TNM) staging system (4) (Table 1). Addition of the prefix “u” to a TNM classification
indicates that staging has been performed by ultrasound (5). At Memorial Sloan Kettering
Cancer Center (MSKCC), a modified ultrasound staging system has been proposed to
assist in clinical decision-making (Table 2). In this modified, treatment-oriented ultra-
Table 1
TNM staging system for rectal cancer
Primary tumor (T)
Tis Carcinoma in situ
T1 Tumor invades the submucosa
T2 Tumor invades the muscularis propria
T3 Tumor invades the perirectal fat
T4 Tumor directly invades adjacent organs and structures,
and/or perforates visceral peritoneum
Regional lymph nodes (N)
Nx Tumor cannot be assessed
N0 No regional metastases
N1 Metastases in one to three nodes
N2 Metastases in four or more regional nodes
Distant metastases (M)
Mx Distant metastases cannot be assessed
M0 No distant metastases
M1 Distant metastases
Staging
Stage 0 Tis N0 M0
Stage I T1-2 N0 M0
Stage IIA T3 N0 M0
Stage IIB T4 N0 M0
Stage IIIA T1-2 N1 M0
Stage IIIB T3-4 N1 M0
Stage IIIC Any T N2 M0
Stage IV Any T Any N M1
Table 2
MSKCC modified ERUS staging system
Stage Description
uTw uT0/T1 Amenable to local excision
uTy uT2/superficial uT3 Recommend radical surgery, may require neoadjuvant
therapy, pathologic features and nodal status helpful
in determining need for neoadjuvant therapy
uTz Deep uT3/any uT4 Recommend neoadjuvant therapy followed by radical resection
uN1 Probable or definite Recommend neoadjuvant therapy
uN1 Equivocal Base treatment on tumor stage and pathologic features
