Rectal Cancer (eBook)

Preface 6
Contents 8
Contributors 10
1: Clinical Staging: Endoscopic Techniques 14
Introduction 14
Staging of Rectal Cancer 15
Staging Accuracy of Digital Rectal Exam (DRE) 16
Staging Accuracy of CT, MRI, ERUS 16
Staging with CT 16
Staging with MRI 17
Staging with ERUS 17
ERUS Technique 17
Normal ERUS Anatomy 19
Interpreting ERUS 19
uT0 Disease 20
uT1 Disease 22
uT2 Disease 22
uT3 Disease 24
uT4 Disease 24
Nodal Metastasis 26
Evaluating Distal Rectal Cancer with Endoanal Ultrasound 26
3D Endorectal Ultrasound 28
ERUS Following Neoadjuvant Chemoradiation 30
ERUS in Postoperative Follow-Up 30
Conclusion 30
References 30
2: Clinical Staging: CT and MRI 33
Introduction 33
Anatomy and Surgical Implications 34
Prognostic Factors 34
Circumferential Margin 34
Nodes 35
Extramural Venous Invasion 35
Peritoneal Involvement 35
Staging 35
CT Staging 35
T-Stage 37
Lymph Nodes 37
Extramural Venous Invasion (EMVI) 38
MRI Staging 38
T-Stage 38
Margins 40
Mesorectal Lymph Nodes 41
Extramural Vascular Invasion (EMVI) 42
Pelvic Sidewall Lymph Nodes 42
Post Chemoradiotherapy Images and Low-Lying Rectal Cancer 43
References 44
3: Local Excision 48
Introduction 48
Historical Perspective and Relevance to Clinical Practice Today 48
Current Controversies Surrounding LE 49
Technical Aspects of LE 50
Preoperative Preparation 50
Conventional Transanal Excision 50
Transanal Endoscopic Microsurgery 50
Outcomes of LE for Early-Stage Rectal Cancer 52
Studies Containing Tumors of Differing T Stages 52
Consecutive and Nonconsecutive Case Series 52
T1 Tumors 52
Consecutive Case Series 52
Population-Based Case Series 52
Nonrandomized Controlled Clinical Trials 55
Nonblinded Randomized Controlled Clinical Trials 55
Summary 55
T2 Tumors 55
Outcomes of LE Alone for T2 Tumors 55
Outcomes of LE and Postoperative Chemotherapy and/or RT for T2 Tumors 57
Outcomes of Preoperative Chemoradiation Followed by LE for T2 Tumors 57
Summary 59
Conclusions 59
References 59
4: Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection 63
Total Mesorectal Excision 63
Introduction 63
History 64
Anatomical Considerations 65
Technique 65
Nerve-Sparing Surgery 67
Urinary Function 67
Sexual Function 67
Defecation Function 68
Anastomotic Leakage 68
Possible Causes of Local Recurrence: The Dutch TME Trial 70
Advanced Disease 71
Low Anterior Resection 71
Abdominoperineal Resection 72
Lateral Disease 72
Future Perspectives 73
Lateral Lymph Node Dissection 73
History 73
West 74
East 75
West vs. East 76
Technique 76
Nerve-Sparing Surgery and LLND 77
Patterns of Local Recurrence 79
Current Practice in Japan 81
Lymphoscintigraphy 81
Locally Advanced Disease: (Chemo)Radiation or LLND? 82
References 83
5: Abdominoperineal Resection, Low Anterior Resection, and Beyond 89
Introduction 89
Total Mesorectal Excision 90
The Holy Plane 90
Toward Use of Sphincter Sparing Resections 92
Technical Advances 93
Margins 93
Changing Concepts in Sphincter-Preserving Rectal Cancer Resection 94
Sphincter Sparing Resections 95
Basic Technical Concepts 95
Low Anterior Resection 95
Standard LAR for Upper Rectal Cancer 95
LAR for Mid- and Low-Rectal Cancer 96
Hand-Sewn LAR with Colonic Pouch to Anal Anastomosis 97
Intersphincteric Proctectomy with Colonic Pouch to Anal Anastomosis 97
Results with LAR and Intersphincteric Proctectomy 99
Reconstruction After LAR and Coloanal Anastomosis 100
Temporary Diversion After Coloanal Anastomosis 101
Abdominoperineal Resection 103
Oncologic Adequacy of the Standard APR 103
Perineal Wound Healing After APR 106
Frequency of APR Utilization 107
Quality of Life After APR 107
Beyond: Laparoscopic Rectal Cancer Resection 108
References 110
6: T4 and Recurrent Rectal Cancer 118
Introduction 118
Classification and Nomenclature 118
T4 Rectal Cancer 118
Locally Recurrent Rectal Cancer 119
Evaluation 120
Clinical Evaluation 120
Imaging 121
Management of T4 or Pelvic Recurrence of Rectal Cancer 121
Category I: Resectable, Isolated Pelvic Disease 121
Category II: Unresectable, Isolated Pelvic Disease 124
Category III: Asymptomatic Local Disease in the Setting of Distant Metastasis 124
Category IV: Symptomatic Local Disease in the Setting of Distant Metastasis 125
Surgical Considerations 125
Preoperative Preparation 125
Conduct of Operation 126
Surgical Management Based on Location of Disease 127
Anterior Disease 127
Posterior Disease 127
Lateral Disease 128
Axial Disease 128
Radiation and Chemotherapy 128
Intraoperative Radiation Therapy 128
Reconstruction for Perineal Defects 129
Summary 129
References 129
7: Surgical Management of Pulmonary Metastases 131
Introduction 131
Patient Evaluation 131
Outcomes 132
Prognostic Factors 132
Controversial Issues 135
Conclusion 135
References 136
8: Surgical and Ablative Management of Liver Metastases 138
Introduction 138
Resectability of Colorectal Liver Metastases 138
Criteria for Resectability 138
Resection Margin 141
Extrahepatic Metastatic Disease 142
Injury from Prehepatectomy Chemotherapy to the Nontumor Bearing Liver 143
Use of Chemotherapy to Downsize Unresectable to Resectable Liver Disease 146
Prehepatectomy Portal Venous Occlusion 147
Two-Stage Hepatectomy 148
Long-Term Outcomes 148
Resection 148
Ablation 150
Conclusion 151
References 151
9: Surgical Pathology 158
Introduction 158
The Role of the Pathologist in the Modern Multidisciplinary Team 158
Interaction with Surgeons 159
Interaction with Medical and Radiation Oncologists 159
Interaction with Radiologists 159
Other Roles of the Pathologist 160
Histopathological Reporting of Rectal Cancer 160
Macroscopic Dissection of the Rectal Cancer Resection Specimen 160
Histological Reporting of the Rectal Cancer Resection Specimen 164
Reporting Rectal Cancer Resections Following Neoadjuvant Therapy 164
Reporting Low Rectal Cancer Resection Specimens 165
The Future of Pathological Reporting in the Modern Digital Age 167
References 168
10: Chemotherapy: Concurrent Delivery with Radiation Therapy 172
References 178
11: Chemotherapy: Adjuvant and Neoadjuvant Approaches 182
Who Should Receive Adjuvant Chemotherapy? 182
What Is the Evidence for Adjuvant Chemotherapy in Rectal Cancer Patients? 183
What Are the Optimal Drugs to Use? 188
What Is the Role of Neoadjuvant Chemotherapy? 189
Current Evidence for the Role of Neoadjuvant Chemotherapy 190
Conclusion 192
References 192
12: Chemotherapy: Metastatic Disease 195
Background and Epidemiology 195
Chemotherapy for CRC: A Historical Perspective 196
Chemotherapy Drugs with Efficacy in Metastatic Disease 198
5-Fluorouracil 198
Oral Fluoropyrimidines 200
Oxaliplatin 200
Irinotecan (CPT11) 202
Mitomycin C 203
Regional Chemotherapy: Hepatic Arterial Infusion Chemotherapy 203
Approach to Chemotherapy Scheduling (Table 4, Fig. 2) 204
FOLFOX vs. FOLFIRI 205
Sequential vs. Combination Therapy 206
Duration of Chemotherapy 208
Chemotherapy in Potentially Resectable Metastatic Disease 209
When Should Chemotherapy Be Given to Asymptomatic Patients? 212
Targeted Therapies in Current Clinical Use 213
Translational Research in Action 213
Drugs in Routine Clinical Use 213
Bevacizumab 213
Cetuximab 214
Panitumumab 215
Combining Targeted Therapies: Lessons Learned 216
Molecular Differences Between Colon and Rectal Cancer 217
What Lies Ahead? 218
Conclusion 219
References 220
13: Radiation Therapy: Adjuvant vs. Neoadjuvant Therapy 229
Introduction 229
Randomized Trials of Postoperative RCT 229
Randomized Trials to Optimize 5-FU-Based Postoperative RCT 231
Preoperative Radiation 232
Randomized Trials to Optimize the Sequence 233
Concomitant Chemotherapy with Preoperative Radiation Therapy? 233
Integrating Novel Chemotherapeutic Agents into Preoperative Combined Modality Treatment 236
Future Challenges for Combined Modality Rectal Cancer Treatment 236
References 239
14: Radiation Therapy: Short Versus Long Course 241
Introduction 241
Rationale for Using Short-Course Radiation Therapy 241
The Evidence of Local Efficacy of Short-Course Radiation Therapy 243
Early Adverse Effects and Compliance of Short-Course Radiation Therapy 243
Postoperative Complications Following Short-Course Preoperative Radiation Therapy 246
Late Adverse Effects of Short-Course Radiation Therapy 246
Randomized Trials Comparing Preoperative Short-Course Radiation Therapy Versus Preoperative Chemoradiation Therapy in Resectab 247
Preoperative Short-Course Radiation Therapy Alone or Combined with Consolidation Chemotherapy in Unresectable Rectal Cancer, wi 248
Short-Course Radiation Therapy Prior to Full-Thickness Local Excision 249
References 251
15: Chemoradiation Therapy: Nonoperative Approaches 254
Tumor Response to Radiation Therapy and Surgery 254
Definition of Complete Clinical Response 255
Timing of Response Assessment 255
Tools in Assessment of Tumor Response 257
The Effects of Radiation Therapy on Nodal Status 259
Follow-Up Algorithm 261
Patient Selection 263
Long-Term Results 263
Survival and Recurrences 265
Salvage Therapy 266
Perspectives 267
References 267
16: Contact X-Ray Therapy 271
Definition 271
Brief Historical Background 271
Technical Description 271
Treatment Protocols 272
T1 N0 Disease: CXRT Alone for Cure 272
Adjuvant CXRT After Local Excision for T1 N0 Disease 273
T2–3 N0 Disease: CXRT Combined with EBRT 273
Other Protocols 274
Toxicity 274
Early Toxicity 274
Late Toxicity 275
Primary Advantages of CXRT 275
Clinical Results 275
Present Perspectives 277
CXRT After Local Excision for T1 N0 Lesions 277
Elderly Patients 277
T2 N0 Disease: Neoadjuvant CXRT.±.EBRT Followed by TLE 277
The Papillon 50® Machine and the CONTEM Trial 278
Conclusion 278
References 278
17: High-Dose-Rate Preoperative Endorectal Brachytherapy for Patients with Rectal Cancer 280
Introduction 280
Clinical Study of HDREBT 280
Pretreatment Imaging 281
HDREBT Equipment 281
3D Treatment Planning 283
Differential Source Positioning Technique 283
Daily Image Guidance 284
Clinical Applications of HDREBT 285
Neoadjuvant Treatment for Patients with Operable Rectal Cancer 285
HDREBT as a Boost Treatment After External Beam Radiation for Patients with Medically Inoperable, Localized T2–3 Tumors 288
HDREBT as a Neoadjuvant Modality to Promote SPS for Patients with Low-Lying Rectal Cancer 289
HDREBT as a Neoadjuvant Treatment for Patients with Previous Pelvic Radiation Therapy for Other Malignancies (Prostate, Gynecol 290
Conclusion 290
References 290
18: Radiation Therapy: Technical Innovations 292
Introduction 292
Radiation Therapy Planning and IMRT 293
Dose Escalation 296
Dose–Response Relationship in Rectal Cancer 296
Normal Tissue Toxicity 298
Femur 298
Experience with IMRT 299
Small Bowel 299
Experience with IMRT 299
Skin and External Genitalia 300
Experience with IMRT 300
Bladder 300
Experience with IMRT 301
Bone Marrow 301
Experience with IMRT 301
Disease-Related Outcomes and Future 302
Particle Radiotherapy 302
Conclusion 304
References 305
Index 309