Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes

Bhangu, Aneel; Beynon, J.; Brown, Gina; Chang, George J.; Das, Prajnan; Desai, Avni M.; Frizelle, Frank; Glynne‐Jones, Robert; Goldin, Robert D.; Hawkins, M.; Heriot, Alexander G.; Laurberg, Søren; Mirnezami, Alex H.; Moran, Brendan; Nicholls, R. J.; Sagar, P. M.; Tekkis, Paris; Vuong, T.; Wilson, Malcolm S; Ali, Simak; Antoniou, Anthony; Bose, P.; Boyle, K.; Branagan, Graham; Burling, David; Clark, Sue; Colquhoun, Patrick; Crane, Christopher H.; Darzi, Ara; Davies, M; Delaney, Conor P.; Dietz, David W.; Dozois, Eric J.; Duff, M. J.; Dziki, Adam; Faria, Julio; Fitzgerald, J Edward; Georgiou, Panagiotis; George, Bruce; George, Mark; Gupta, Alok; Guy, Richard; Harji, Deena; Harris, Dean; Herzig, Daniel O.; Holm, Torbjörn; Hompes, Roel; Jeys, Lee; Jenkins, John T.; Kiran, Ravi P.; Koh, Cherry; Law, Wai Lun; Liberman, Alexander; Marshall, MJ; McArthur, D. Ray; Mortensen, N J; Myers, E.; O'Connell, P. R.; O’Dwyer, S T; Oliver, Alex; Pallan, Arvind; Patel, Prashant; Patel, Uday; Radley, Simon; Ramsey, Kelvin; Rasmussen, P.; Richard, Carole; Rutten, H.J.T.; Sebag‐Montefiore, David; Solomon, Michael J.; Stocchi, Luca; Swallow, Carol J.; Tait, D.; Tan, Ek Khoon; As, Nicholas van; Wiggers, Theo; Wilt, Johannes H. W. de; Winter, D. C.; Woodhouse, Christopher

doi:10.1002/bjs.9192_1

Cited by 145 publications

(26 citation statements)

References 148 publications

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“…TME surgery can be possible when the tumour has been downsized sufficiently. In patients with advanced and recurrent rectal cancer, surgery should aim for complete resection and conventional surgical planes may not be adhered to 185 . In some patients, a clinical complete response can be achieved after chemoradiation alone.…”

Section: Managementmentioning

confidence: 99%

Colorectal cancer

Kuipers

Grady

Lieberman

et al. 2015

Nat Rev Dis Primers

1,303

1,062

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Colorectal cancer had a low incidence several decades ago. However, it has become a predominant cancer and now accounts for approximately 10% of cancer-related mortality in western countries. The ‘rise’ of colorectal cancer in developed countries can be attributed to the increasingly ageing population, unfavourable modern dietary habits and an increase in risk factors such as smoking, low physical exercise and obesity. New treatments for primary and metastatic colorectal cancer have emerged, providing additional options for patients; these treatments include laparoscopic surgery for primary disease, more-aggressive resection of metastatic disease (such as liver and pulmonary metastases), radiotherapy for rectal cancer and neoadjuvant and palliative chemotherapies. However, these new treatment options have had limited impact on cure rates and long-term survival. For these reasons, and the recognition that colorectal cancer is long preceded by a polypoid precursor, screening programmes have gained momentum. This Primer provides an overview of the current state of art knowledge on the epidemiology and mechanisms of colorectal cancer, as well as on diagnosis and treatment.

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Section: Managementmentioning

confidence: 99%

Colorectal cancer

Kuipers

Grady

Lieberman

et al. 2015

Nat Rev Dis Primers

1,303

1,062

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“…The current consensus is to plan treatment for rectal cancer using baseline MRI staging [ 7 ]. However, this position is changing and some authors believe that there is a moral imperative to inform patients if they have had a cCR following CRT, with a view to offering these patients deferral of surgery [ 39 , 40 ].…”

Section: Discussionmentioning

confidence: 99%

“…The need for a validated means of assessing response to treatment is widely accepted [ 6 ] but there has been no reliable method of assessing this response in the pre-operative setting to date. Therefore, the current consensus is that the baseline MRI staging should be the standard of care that is used to define the plane of surgery, regardless of any assessment of treatment response [ 7 ]. Recently, a 5-point MRI tumour regression grade (mrTRG), which most closely resembles the Mandard pTRG system [ 8 ], has been developed [ 9 ].…”

Section: Introductionmentioning

confidence: 99%

A rectal cancer feasibility study with an embedded phase III trial design assessing magnetic resonance tumour regression grade (mrTRG) as a novel biomarker to stratify management by good and poor response to chemoradiotherapy (TRIGGER): study protocol for a randomised controlled trial

Battersby

Dattani

et al. 2017

Trials

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A rectal cancer feasibility study with an embedded phase III trial design assessing magnetic resonance tumour regression grade (mrTRG) as a novel biomarker to stratify management by good and poor response to chemoradiotherapy (TRIGGER): study protocol for a randomised controlled trial AbstractBackground: Pre-operative chemoradiotherapy (CRT) for MRI-defined, locally advanced rectal cancer is primarily intended to reduce local recurrence rates by downstaging tumours, enabling an improved likelihood of curative resection. However, in a subset of patients complete tumour regression occurs implying that no viable tumour is present within the surgical specimen. This raises the possibility that surgery may have been avoided. It is also recognised that response to CRT is a key determinant of prognosis. Recent radiological advances enable this response to be assessed pre-operatively using the MRI tumour regression grade (mrTRG). Potentially, this allows modification of the baseline MRI-derived treatment strategy. Hence, in a 'good' mrTRG responder, with little or no evidence of tumour, surgery may be deferred. Conversely, a 'poor response' identifies an adverse prognostic group which may benefit from additional pre-operative therapy. Methods/design: TRIGGER is a multicentre, open, interventional, randomised control feasibility study with an embedded phase III design. Patients with MRI-defined, locally advanced rectal adenocarcinoma deemed to require CRT will be eligible for recruitment. During CRT, patients will be randomised (1:2) between conventional management, according to baseline MRI, versus mrTRG-directed management. The primary endpoint of the feasibility phase is to assess the rate of patient recruitment and randomisation. Secondary endpoints include the rate of unit recruitment, acute drug toxicity, reproducibility of mrTRG reporting, surgical morbidity, pathological circumferential resection margin involvement, pathology regression grade, residual tumour cell density and surgical/specimen quality rates. The phase III trial will focus on long-term safety, regrowth rates, oncological survival analysis, quality of life and health economics analysis.Discussion: The TRIGGER trial aims to determine whether patients with locally advanced rectal cancer can be recruited and subsequently randomised into a control trial that offers MRI-directed patient management according to radiological response to CRT (mrTRG). The feasibility study will inform a phase III trial design investigating stratified treatment of good and poor responders according to 3-year disease-free survival, colostomy-free survival as well as an increase in cases managed without a major resection.Trial registration: ClinicalTrials.gov, ID: NCT02704520. Registered on 5 February 2016.

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“…Preoperative chemotherapy is administered to facilitate tumor downstaging and thus enhancing the chance of a complete resection. Complete resections are the most important prognostic factor for overall survival, and it is hypothesized achieving wider resection margins may improve outcome [ 6 , 20 ]. The results of the current study contradict the potential downstaging effect of chemotherapy in previously irradiated patients.…”

Section: Discussionmentioning

confidence: 99%

Response to chemotherapy in patients with recurrent rectal cancer in previously irradiated area

Alberda

Haberkorn

Morshuis

et al. 2015

Int J Colorectal Dis

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BackgroundTumor lesions in previously irradiated area may have a less favorable response to chemotherapy compared to tumor sites outside the radiation field. The aim of the present study was to evaluate the response to chemotherapy of locally recurrent rectal cancer (LRRC) within the previous radiation field compared to the response of distant metastases outside the radiation field.Patients and methodsAll patients with LRRC referred between 2000 and 2012 to our tertiary university hospital were reviewed. The response to chemotherapy of LRRC within previously irradiated area was compared to the response of synchronous distant metastases outside the radiation field according to the Response Evaluation Criteria in Solid Tumors (RECIST).ResultsOut of 363 cases with LRRC, 29 previously irradiated patients with distant metastases were treated with chemotherapy and eligible for analysis. Twenty-six patients (89 %) suffered a first recurrence and three patients (11 %) a second recurrence. These patients were followed with a median of 22 months (IQR, 9–40 months) and had a median survival of 33 months (IQR, 14–42). In 23 patients (79 %), the local recurrence showed stable disease, but the overall response rate of the local recurrences in the previously irradiated area was significantly lower than the response rate of distant metastases outside the radiation field (10 vs. 41 %,p = 0.034).ConclusionsPreviously irradiated patients with LRRC have a lower response rate to chemotherapy of the local recurrence within the radiation field compared to the response rate of distant metastases outside the radiation field. This suggests that chemotherapy for local palliation may not have the desired effect.

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Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes

Abstract: The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.

Cited by 145 publications

References 148 publications

Colorectal cancer

Colorectal cancer

A rectal cancer feasibility study with an embedded phase III trial design assessing magnetic resonance tumour regression grade (mrTRG) as a novel biomarker to stratify management by good and poor response to chemoradiotherapy (TRIGGER): study protocol for a randomised controlled trial

Response to chemotherapy in patients with recurrent rectal cancer in previously irradiated area

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