Locally advanced rectal cancer: management challenges

Abstract

Between 5% and 10% of patients with rectal cancer present with locally advanced rectal cancer (LARC), and 10% of rectal cancers recur after surgery, of which half are limited to locoregional disease only (locally recurrent rectal cancer). Exenterative surgery offers the best long-term outcomes for patients with LARC and locally recurrent rectal cancer so long as a complete (R0) resection is achieved. Accurate preoperative multimodal staging is crucial in assessing the potential operability of advanced rectal tumors, and resectability may be enhanced with neoadjuvant therapies. Unfortunately, surgical options are limited when the tumor involves the lateral pelvic sidewall or high sacrum due to the technical challenges of achieving histological clearance, and must be balanced against the high morbidity associated with resection of the bony pelvis and significant lymphovascular structures. This group of patients is usually treated palliatively and subsequently survival is poor, which has led surgeons to seek innovative new solutions, as well as revisit previously discarded radical approaches. A small number of centers are pioneering new techniques for resection of beyond-total mesorectal excision tumors, including en bloc resections of the sciatic notch and composite resections of the first two sacral vertebrae. Despite limited experience, these new techniques offer the potential for radical treatment of previously inoperable tumors. This narrative review sets out the challenges facing the management of LARCs and discusses evolving management options.

Prognostic factors and patterns of failure after surgery for T4 rectal cancer in the beyond total mesorectal excision era

“…There are 43 000 new cases of rectal cancer annually in the USA, with up to 30 per cent being locally advanced at presentation. Although neoadjuvant therapy may downstage the cancer to enable conventional TME for complete surgical resection, approximately 5–10 per cent of rectal cancers still breach the mesorectal plane and invade adjacent structures. The Beyond TME Collaborative defined these tumours as rectal cancers predicted by MRI staging to require an extended surgical resection beyond the TME plane to achieve a pathological R0 resection.…”

Meta-analysis of the prognostic value of CpG island methylator phenotype in rectal cancer

“…Colorectal cancer (CRC) is a significant health problem due to high prevalence and mortality, representing the third most common cause of cancer death in the USA [ 1 ]. Rectal cancer (RC) as a sub-population of approximately 30% of CRC poses additional significant mortality, morbidity, and management challenges, due to the anatomical confines of the bony pelvis and proximity of significant neurovascular structures and other organ systems [ 2 ]. The management of rectal cancers is currently undergoing a paradigm shift; previously inoperable locally advanced and locally recurrent rectal cancers are increasingly rendered operable due to improved operative techniques and the judicious use of neoadjuvant chemoradiation (nCRT) [ 3 ].…”

Lateral pelvic lymphadenectomy for low rectal cancer: a META-analysis of recurrence rates

“…However, 5-10% of patients still present with locally advanced disease [3,4]. The management of locally advanced rectal cancer (LARC) poses unique challenges to both clinicians and patients regard-ing aggressiveness of treatment and the impact to long-term functional and cancer-specific outcomes [5][6][7].…”