New Frontiers in Management of Early and Advanced Rectal Cancer

Abstract

It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a “watch and wait” non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.

Current Surgical Methods in Local Rectal Excision

“…One of the main indications for transanal surgery is early rectal cancer (ERC), which includes a variety of precancerous polyps and malignant lesions such as carcinoma in situ and T1 rectal carcinoma. The main characteristic of T1 lesions is that malignant cells spread into the submucosa (sm1) but not beyond it [ 18 ].…”

“…Local methods or TME resection are recommended upon accurately determining the tumour stage and the nature of the tumour (size, grade, possible invasion of lymphatic and/or blood vessels, invasion of sm1 according to Haggitt/Kikuchi classification). The indication for the utilisation of transanal surgery relies on a discussion with a multidisciplinary team and a detailed discussion with the patient regarding the risks and benefits of offering LE without lymphadenectomy [ 18 , 27 ]. According to the ESMO and ASCRS Clinical Practice Guidelines, transanal LE is indicated for early stage, low-risk cT1N0 rectal cancer, offering curative resection with good oncological outcomes while avoiding morbidity and poor functional outcomes of the TME.…”

“…Tumour budding (bd1–bd3) is becoming an increasingly important feature, as studies have found a positive correlation between the severity of the tumour budding and positive lymph nodes, and this factor should be considered in future treatment decisions [ 30 ]. If poor histological features are present on preoperative staging (lymphatic/vascular/perineural invasion, poor differentiation, tumour budding) or deeper invasion (sm2 or sm3), the patient should be managed as having a T2 lesion [ 18 , 24 ].…”

Robotic Rectal Resection for Rectal Cancer: State of the Art

“…Early-stage rectal cancer, which does not spread further than the mucosa, can be treated by curative endoluminal resection. When rectal tumor spreads beyond the mucosa and the submucosa into the perirectal tissue, the transanal endoscopic resection is not curative and a multimodal approach with systemic and local therapies associated with surgical resection is required [1]. The initially proposed regimen was combined chemo-radiotherapy following surgical resection, as adjuvant therapy [2].…”

Special Issue “Current Management of Early and Advanced Rectal Cancer”

“…Another major point of this Special Issue is the confirmation that rectal cancer treatment is multimodal, with various actors (medical and radiation oncologists, liver surgeons, and reconstructive surgeons) playing roles at different stages of the disease, from early to locally advanced and/or metastatic rectal cancer, as discussed by Wlodarczyk and Lee [6]. As reported by Meldolesi and colleagues [7], treatment of rectal cancer could involve radiation oncologists not only for standard neoadjuvant chemoradiotherapy, but also to deliver a radiotherapy boost on lateral pelvic nodes in cases of clinical involvement at baseline, ensuring improved disease control without surgical excision.…”