, rectal carcinoma management

1. MULTIDISCIPLINARY APPROACH
TO RECTAL CARCINOMA
Rajendra
Moderators: Dr. Dhritiman

2. Definition
• Biopsy proven malignant
lesion in the rectum,
• Within 15 cm from anal
verge (on sigmoidoscopy)
• Below a virtual line from
the sacral promontory to
the upper edge of pubic
symphysis (on MRI)
• Upto 5 cm: low rectal Ca
• 5-10 cm: middle rectal Ca
• 10-15 cm: high rectal Ca

3. Incidence and Mortality
• Colorectal cancer – 3rd most common malignancy worldwide
• 3rd MC in males
• 2nd in females,
• Estimated 704,376 new cases and 310,394 deaths occurring in 2018
due to rectal cancer.(Global cancer statistics 2018)
• Rates higher in men than in women

4. Epidemiology-India
• PBCR 2012, 9th and 10th leading
cancer
• Males: Aizawl District AAR (6.8)
🡪Mizoram PBCR (5.4)
• Females: Aizawl District AAR
(5.4), 🡪Kamrup Urban District
(4.3)

5. Should be managed by
• Radiologist
• Endoscopist
• Pathologist
• Radiation oncologist
• Medical oncologist
• Surgeon

6. Presentation
• Asymptomatic
• Bleeding per rectum
• Change in bowel habit (change in
frequency, tenesmus, narrow stool,
incomplete evacuation)
• Abdominal discomfort
• Weight loss, tiredness
• Acute presentation
• Obstruction
• Perforation
• Massive bleeding
Signs
• Pallor
• Rectal mass
• Abdominal lump
• Icterus
• Ascites

7. Prognostic factors
Good prognostic
factors
• Old age
• Gender(F>M)
• Asymptomatic pts
• Polypoidal lesions
• Diploid
Poor prognostic
factors
•Obstruction
•Perforation
•Ulcerative lesion
•Adjacent structures
•involvement
•Positive margins
•LVSI
•Signet cell carcinoma
•High CEA
•Tethered and fixed cancer

8. Work up
CLINICAL
• History
• Clinical examination
• DRE +/- rigid proctoscopy
• Colonoscopy + biopsy
• Performance status assessment
INVESTIGATIONS
• CBC, Routine chemistry
• CEA
• CT Chest and Abdomen
• Pelvic MRI with contrast
• ERUS if the above C/I
• Stoma Site marking

9. Diagnostic Work Up
•

10. Role of Endoscopist
• Colonoscopy
• Patients with CRC identified on screening colonoscopy
• Early stage of disease
• Can be treated with local excision
• Better outcome
• Rigid rectoscopy and preoperative colonoscopy to caecal
pole required
• Obstruction: virtual colonoscopy
• exclude synchronous colonic tumours

11. • If no preoperative complete colonoscopy
• completion colonoscopy within 6 months of
surgery
• Screening colonoscopy: every 10 years
• individuals of average risk
• age of 50 years
• Till 10 y of life expectancy
• Earlier age
• Personal history of CRC/adenomatous polyp
• Genetic syndrome predisposing to CRC (HNPCC
,FAP)
• First-degree relative with CRC or advanced
adenoma
• IBD (long standing active disease)
• Abdominal radiation therapy

12. Polypectomy
• Goals
• Completely remove all neoplastic
tissue
• Tissue sample for histological
evaluation
• Characteristics s/o malignancy
• Firm consistency
• Adherence
• Ulceration
• Friability

13. • <5 mm
• Biopsy forceps/snare polypectomy
• 5-10 mm
• Snare excision
• >10 mm
• Large pedunculated :snare
removal
• Flat/sessile: Endoscopic mucosal
resection (EMR)
• Large polyps: consider TEM/TAMIS

14. Imaging: Principles
• CT chest and abdomen/ MRI Abdomen (with contrast)
• Evaluate local extent of tumor or infiltration into surrounding structures
• Assess for distant metastases
• MRI Pelvis
• T and N stage of the primary rectal tumor.
• May not be required if tumor known to be definite T1
• Patient not a candidate for primary tumor resection
• Endorectal MRI
• PET/CT is not routinely indicated
• evaluate an equivocal finding
• strong contraindications to IV contrast administration
• potentially surgically curable M1 disease

15. Pelvic Imaging
• Pelvic MRI:
• Depth of tumor penetration
• Presence of local lymph nodal
metastases
• Involvement of mesorectum
• CRM : closest distance of the tumor
to the mesorectal fascia
• > 1 mm from mesorectal fascia and
levator muscles and not invading
into the intersphincteric plane

16. • 5 year follow up of MERCURY trial :
• high-resolution MRI can
accurately assess the CRM
preoperatively, differentiating
patients with low-risk and high-
risk disease (Taylor FG et al, J
Clin Oncol 2014)
• Accurate for the prediction of T
and N stage (Faletti R et al,
Minerva Chir 2018)

17. • CECT Pelvis
• Locoregionally confined disease
• Need for adjacent organ
resection
• Poor sensitivity for the prediction
of CRM status (Wolberink SV et
al, Dig Dis 2007 )
• CT has lower sensitivity and
specificity for the prediction of
lymph node involvement than
MRI (CT, 55% and 74%; MRI, 66%
and 76%)
• Pelvic CT is not recommended for
rectal staging

18. Endoluminal Ultrasonography
• 2004 meta-analysis : EUS and MRI have
similar sensitivities and specificities for
evaluation of lymph nodes (EUS, 67%
and 78%; MRI, 66% and 76%)
• New Evidence: EUS is not very accurate
for rectal cancer staging (Ashraf S, et al.
Colorectal Dis 2012)
• ERUS performed in 165 of 494 patients who
underwent TEM for rectal cancer in UK
• inaccurately staged 44.8% of tumours:
• 32.7% understaged
• 12.1% overstaged
• No significant difference in the depth of TEM
excision or R1 rate between the patients who
underwent ERUS before TEM and those who
did no (P = 0.73)

19. • Problem areas: high or bulky
rectal tumors
• regions beyond immediate
area of the primary tumor (eg,
tumor deposits, vascular
invasion)
• high degree of operator
dependence.
• Current guideline: EUS should
only be used to evaluate the
pelvis if MRI is contraindicated

20. Imaging for Distant Metastases
• Chest CT (with or without contrast)
• CT/MRI Abdomen with contrast
• PET scan: not indicated
• evaluate an equivocal finding
• strong contraindications to IV contrast
administration
• potentially surgically curable M1 disease

21. Role of CEA
• Prognostic utility
• CEA >5 ng/mL : worse prognosis, stage for stage, than those with
lower levels
• Persistence of high levels post-surgery s/o residual disease, needs
further evaluation

22. STAGING (AJCC 8th/e)
T stage
• TX: primary tumor cannot be assessed
• T0: no evidence of primary tumor
• Tis: carcinoma in situ, intramucosal carcinoma
(involvement of lamina propria with no extension
through muscularis mucosae)
• T1: tumor invades submucosa (through the muscularis
mucosa but not into the muscularis propria)
• T2: tumor invades muscularis propria
• T3: tumor invades through the muscularis propria into
the pericolorectal tissues
• T4:
• T4a: tumor invades through the visceral peritoneum
(including gross perforation of the bowel through tumor
and continuous invasion of tumor through areas of
inflammation to the surface of the visceral peritoneum)
• T4b: tumor directly invades or adheres to other adjacent
organs or structures

23. N STAGE
• Regional lymph nodes (pN)
• NX: regional lymph nodes cannot be
assessed
• N0: no regional lymph node metastasis
• N1: metastasis in 1 - 3 regional lymph nodes
• N1a: metastasis in 1 regional lymph node
• N1b: metastasis in 2 - 3 regional lymph nodes
• N1c: no regional lymph nodes are positive but
there are tumor deposits in the subserosa,
mesentery or nonperitonealized pericolic or
perirectal / mesorectal tissues
• N2: metastasis in 4 or more regional lymph
nodes
• N2a: metastasis in 4 - 6 regional lymph nodes
• N2b: metastasis in 7 or more regional lymph
nodes
M STAGE
• M0: no distant metastasis by imaging; no
evidence of tumor in other sites or organs
(this category is NOT assigned by
pathologists)
• M1: distant metastasis
• M1a: metastasis confined to 1 organ or site
without peritoneal metastasis
• M1b: metastasis to 2 or more sites or organs
is identified without peritoneal metastasis
• M1c: metastasis to the peritoneal surface is
identified alone or with other site or organ
metastases

24. STAGE GROUPING

25. ROLE OF SURGEON
• Cornerstone of curative treatment
for rectal cancer
• a wide resection of tumour :
histologically negative margins
• total mesorectal excision (TME)
-resection of local lymph nodes with
transabdominal procedures

26. SURGICAL APPROACHES
• LOCAL PROCEDURES (T1)
• Polypectomy
• Transanal local excision
• Transanal Endoscopic Microsuregry (TEM)
• Transanal minimally invasive surgery (TAMIS)
• TRANSABDOMINAL RESECTIONS WITH TME (Open/ Laparoscopic)
• LAR (upper and middle rectal tumours)
• APR (lower rectal tumours)

27. Transanal Endoscopic Microsuregry
• selected T1, N0 early- stage cancers
• Small (<3 cm), well to moderately
differentiated tumors
• within 8 cm of the anal verge
• limited to less than 30% of the rectal
circumference
• no evidence of nodal involvement
• Willett CG et al, Cancer 1994

28. • TEM may achieve superior oncologic
outcomes compared with transanal local
excision (Clancy et al. a systematic review
and meta-analysis. Dis Colon Rectum 2015 )
• prospective, single-blinded, randomized trial
compared laparoscopic surgery with
laparoscopy combined with TEM in 60
patients
• shorter operation times
• hospital stays
• no local nor distant recurrences (28 months)

29. • LAR
• extended 4 to 5 cm below the distal
edge
• creation of a colorectal anastomosis
• APR
• tumor directly involves the anal
sphincter or the levator muscles
• R0 resection would result in loss of anal
sphincter function and incontinence
• extralevator APR : lower rates of
intraoperative perforation, CRM
involvement, and local recurrence
(Negoi et al. ,A systematic review and
meta-analysis. Am J Surg 2016 )

30. Resected Margins
• Proximal: minimum 5 cm (gross margins)
• Distal
• above distal mesorectal margin: 2 cm + TME
• At or below the distal mesorectal margin: 1-cm negative distal margin
acceptable (if received neoadj CTRT)
• Circumferential Radial Margin—minimum 1 mm (microscopic margins)
• Upper rectal cancers: tumor-specific mesorectal excision with perpendicular
transection of the mesorectum leaving a 5-cm distal margin distal to the tumor
• meta-analysis of sphincter-sparing rectal cancer surgery with TME +/- RT, patients whose distal margins
were negative but less than 1 cm did not have higher local recurrence rates than those with greater distal
margins
• Patients not receiving TME or RT had higher local recurrence rates if distal margins were less than 1 cm
• More prospective data needed

31. Total Mesorectal Excision
• precise, sharp dissection between the
visceral and parietal layers of the endopelvic
fascia
• en bloc removal of the perirectal areolar tissue,
including lateral and circumferential margins of
mesorectal envelope, lymphatics,
and vascular/perineural tumor deposits with
primary rectal cancer.
• Preserves the autonomic nerves
• Reduces the risk of presacral bleeding
• Up to the plane between the mesorectum
and the presacral fascia (Heald's "holy
plane")

32. Techniques of TME
• Standard transabdominal TME
• Open, laparoscopic, or robotic
• Standard treatment
• Transanal TME (TaTME)
• Distal rectal tumors in obese male patients with a narrow pelvis
• Distal margin assessed precisely from beginning of the procedure
• Studies with follow-up of up to 29 months showed that TaTME had a
comparable LR and OS to standard TME
• Long-term oncologic outcomes are still awaited
• High-volume centers by experienced surgeons
Tuech JJ et al, Ann Surg. 2015 Feb; Muratore A et al, Eur J Surg Oncol. 2015 Apr

33. Laparoscopic versus open approach
COLOR II COREAN AlaCaRT ACOSOG Z6051
Comparison Laparoscopic vs
open surgery (2:1)
Preop CTRT+
lap/open Sx
Lap vs Open Sx Preop CTRT+
lap/open Sx
Macroscopic
negative margin
88 vs 92% Similar
+ve CRM 10 vs 10% Similar
Median distal
margin
3 vs 3 cm
28 day morbidity Similar Similar
Mortality Similar
DFS 3 Y: 72.5 % vs 79.2% FAILED NONINFERIORITY CRITERIA
• experienced surgeon
• abdominal exploration
• limited to lower-risk tumors
Long term oncological outcomes awaited

34. NeoAdjuvant Therapy
• Resectable, non-metastatic disease (stage II, stage III)
• Clinically staged T3 or T4, or node-positive tumors.
• Distal tumors, even if cT2N0, for which tumor regression may allow successful
conversion of a planned APR to a sphincter-sparing surgical procedure
• preoperative staging evaluation: invasion of MRF or threatened CRM
• Combined-modality therapy consisting of surgery, concurrent
fluoropyrimidine-based chemotherapy with ionizing radiation to the
pelvis (chemoRT), and chemotherapy.
• The total duration of perioperative therapy, including chemoRT and
chemotherapy, should not exceed 6 months.

35. Pre-Op Vs Post-Op RT
German Rectal Cancer
Trial 3(Phase III)
NSABP R 03 Trial 4(Phase
III)
Design Pre op CTRT + TME (50.4
Gy / 5-FU) Vs TME + PO
CTRT (55.8 Gy / 5-FU)
Pre Op CTRT(50.4 Gy / 5-
FU/ Cap) f/b TME vs TME
f/b PO CTRT (50.4 Gy / 5-
FU/ Cap)
N 421 Vs 402 267
OS 76 vs 74% [p=0.8] 74 vs 66% [p=0.14]
DFS 68 vs 65% 64 vs 53%
LR 6 vs 13% [p=0.006] 5 vs 9% [p=0.5]
Gd 3/4 acute toxicity 27 vs 40 % (P=0.001)
Long term Toxic effects 14 vs 24% (P=0.01)
SS 39 vs 19% 34 vs 24%
German CAO/ARO/AIO-
94 randomized phase III trial
Results of 11-year follow up
OS 59.6 vs 59.9 (P=0.85)
LR 7.1 vs 10.1% (P = .048)
METS 29.8% vs 29.6%; (P = .9)

36. Advantages of Pre-op RT
• Reduction in tumor volume: facilitate resection, increase chance of a
sphincter-sparing procedure
• Irradiation of surgery-naïve tissue (better oxygenated) may result in
increased sensitivity to RT
• Avoid occurrence of radiation-induced injury to small bowel trapped
in the pelvis by post-surgical adhesions.
• Includes structures that will be resected: increases chance of an
anastomosis with healthy colon

37. Disadvantages
• Possibility of over- treating early-stage tumors
• Recommendation:
• Preoperative chemoRT : stage II/III rectal cancer.
• Postoperative chemoRT: stage I rectal cancer is upstaged to stage II or III after
pathologic review of the surgical specimen

38. Technical Aspects of Radiation Therapy
• Multiple RT fields should include the tumor or tumor bed with a 2- to
5- cm margin, presacral nodes, and the internal iliac nodes.
• External iliac nodes should also be included for T4 tumors involving
anterior structures
• Inguinal nodes for tumors invading into the distal anal canal.
• 45 to 50 Gy in 25 to 28 fractions to the pelvis using 3 or 4 fields.

39. Timing of surgery
• One NCDB analysis: interval of >8 weeks a/w increased odds of pCR
• Other analyses: Interval >56 or 60 days (8–8.5 weeks) a/w higher
rates of positive margins, lower rates of sphincter preservation,
and/or shorter survival
• Recommendation: 5 to 12 weeks following completion of full-dose
5.5-week chemoRT
• To allow patient recuperation from chemoRT-associated toxicities

40. Short-course Radiation
• 25 Gy over 5 days
• Effective local control
• Same OS as conventional RT
• Appropriate option for T3N0 or T1-3N1-2
• Need for downstaging and possibility of long-term toxicity
• Not recommended for T4 disease at this time.

41. Short-course Radiation
Bujko et al - Polish Trial 7 (Phase III) TROG 01.04 Trial 8(Phase III)
Design Preop short course radiotherapy (25 Gy) +
surgery vs.
Preop CTRT (50.4 Gy) + Surgery
Preop short course radiotherapy (25 Gy) +
surgery vs. preop CTRT(50.4 Gy) + surgery
N 316 326
OS 66 vs 64% [p = 0.055] 70 vs 74% [p = 0.62]
DFS 55 vs 58% [p = 0.74] -
LR 14 vs 9% [p = 0.82] 4 vs 8% [p= .24]
pCR 1% vs 16% -
CRM+ve 13% vs 4%
7.Bujko K, Nowacki MP, Nasierowska-Guttmejer A, Michalski W, Bebenek M, Kryj M. Long term results of a randomized
trial comparing preoperative short course radiotherapy with preoperative conventionally fractionated chemoradiation for
rectal cancer. Br J Surg 2006;93:1215
8. Ngan SY, Burmeister B, Fisher RJ, Solomon M, Goldstein D, Joseph D, et al. Randomized trial of short course
radiotherapy versus long course chemoradiation comparing rates of local recurrence in patients with T3 rectal cancer:
TransTasman Radiation Oncology Group trial 01.04. J Clin Oncol 2012;30: 3827.

42. Concurrent Chemotherapy with Radiation
• Local RT sensitization
• Eradication of micrometastases
• Increase rates of pathologic complete response
• Sphincter preservation

43. Preoperative radiotherapy with or without
concurrent fluorouracil and leucovorin in T3-
4 rectal cancers: results of FFCD 9203
Pre op CTRT (45 Gy/ 5-FU, LV) Pre op RT alone (45 Gy/ 5)
Grade 3 or 4 acute toxicity 14.6% 2.7% (P < .05)
pCR 11.4% 3.6% (P < .05)
LR 8.1% 16.5% (P < .05)
OS 65% 66% (p=0.68)
• Resectable T3-4, Nx, M0 rectal adenocarcinoma
• N=733

44. Enhanced tumorocidal effect of chemotherapy
with preoperative radiotherapy for rectal cancer:
preliminary results--EORTC 22921
• Arm 1: preop RT 45 Gy in 5 weeks;
• Arm 2: preop RT plus two 5-day CT
courses (fluorouracil 350 mg/m2/d
and leucovorin 20 mg/m2/d) in the
first and fifth week of RT;
• Arm 3: preop RT plus four
postoperative CT courses
• Arm 4, preop RT and CT plus
postoperative CT
CT+RT Only RT
N 473 476
pCR 13.7% 5.3%(P < .0001)
LR 8.1% 16.5% (P < .05)
OS 68% 67% (p=0.84)
Addition of CT to preop RT induces down-sizing, downstaging,
and significant changes in histologic characteristics

45. • Significantly increased grade III and IV acute toxicity (OR 1.68-10, P = 0.002)
• Marginally affected postoperative overall morbidity (OR 0.67-1.00, P = 0.05)
• Increased rate of complete pathological response (OR 2.12-5.84, P < 0.00001)
• Did not lead to higher sphincter preservation rate (OR 0.92-1.30, P = 0.32)
• Local recurrence at five years significantly lower in the CRT group (OR 0.39-0.72,
P < 0.001)
• No statistically significant differences were observed in DFS (OR 0.92-1.34, P =
0.27) or OS (OR 0.79-1.14, P = 0.58) at five years

46. Replacement of 5-FU with Capecitabine
• median follow-up of 52 months Capecitabine 5-FU
N 197 195
5 yr OS 76% 67% (P = .0004)
3 yr DFS 75% 67% (P = .07)
LR 6% 7% (p=0.67)
DM 19% 28% (p=0.04)
Capecitabine with RT an acceptable
alternative to infusional 5-FU in those
patients who are able to manage the
responsibilities inherent in self-
administered, oral chemotherapy.

47. Treatment Intensification with Oxaliplatin
STAR Trial15
(Phase III)
ACCORD 12
Trial16 (Phase
III)
NSABP R0417
(Phase III)
PETACC 618
(Phase III)
CAO/ARO/AI
O-04 19
(Phase III)
N 747 598 1608 1094 1236
OS 70.6 vs 74.2 % 88 vs 87% 79.9 vs 80.8% 80 VS 83%
DFS 70.6 vs 74.2% 72 vs 67% 66.4 vs 67.7% 70 VS 71% 76 vs 71 %
[p=0·03]
LR - 4.4 vs 6% 11.2 vs 11.8% - -
SS - - - 65 vs 70%
[p=0.09]
-
15.Aschele C, Cionini L, Lonardi S, Pinto C, Cordio S, Rosati G, et al. Primary tumor response to preoperative chemoradiation with or without oxaliplatin in locally advanced rectal
cancer:
pathologic results of the STAR01 randomized phase III trial. J Clin Oncol 2011;10:29
16.Ge´rard JP, Azria D, Gourgou-Bourgade S, Martel-Laffay I, Hennequin C, Etienne PL, et al. Comparison of two neoadjuvant chemoradiotherapy regimens for locally advanced
rectal cancer: results of the phase III trial ACCORD 12/ 0405Prodige 2. J Clin Oncol 2010;28:1638
17.Allegra Carmen Joseph, Yothers Greg, O’Connell Michael J, Roh Mark S, Beart Robert W, Nicholas J, et al. Neoadjuvant therapy for rectal cancer. Mature results from NSABP R04
(abstract). J Clin Oncol 2014;32(Suppl. 3):3
18.Schmoll H-J, Haustermans K, Price TJ, Nordlinger B,Hofhneinz R, aisne J-F. Preoperative chemoradiotherapy and postoperative chemotherapy with capecitabine and oxaliplatin
versus capecitabine alone in locally advanced rectal cancer: first results of the PETACC-6 randomized phase III trial. Abstr 3531, 31 ed. 2013.
19.Rödel, Claus et al. “Oxaliplatin Added to Fluorouracil-Based Preoperative Chemoradiotherapy and Postoperative Chemotherapy of Locally Advanced Rectal Cancer (the German
CAO/ARO/AIO-04 Study): Final Results of the Multicentre, Open-Label, Randomised, Phase 3 Trial.” The Lancet Oncology 16.8 (2015): 979–989. Crossref. Web.
The addition of oxaliplatin to neoadjuvant chemoRT is not recommended
at this time

48. Addition of targeted agents
• Randomized phase II EXPERT-C trial assessed complete response rate with the addition of
cetuximab to radiation treatment in 165 patients,
• significant improvement in OS seen in patients with KRAS exon 2/3 wild-type tumors with
cetuximab
• But the primary endpoint of complete response rate was not met
• Phase II SAKK 41/07 trial evaluated the addition of panitumumab to preoperative
capecitabine-based chemoRT in patients with locally advanced, KRAS wild-type rectal cancer
• increased rates of grade 3 or greater toxicity
• pCR in 53% vs 32%
• Phase II study of 57 patients with resectable T3/T4 rectal cancer evaluated addition of
bevacizumab to pre-op CTRT, followed by surgery 8 weeks later and adjuvant
FOLFOX/bevacizumab . Primary endpoint of pCR not met, significant toxicities seen, and
compliance with adjuvant therapy was low
At this time, use of bevacizumab, cetuximab, panitumumab, irinotecan,
or oxaliplatin with concurrent radiotherapy is not recommended

50. Adjuvant Chemotherapy
• Role not well defined.
• Guidelines
• NCCN: Recommended for all patients with stage II/III rectal cancer
following neoadjuvant chemoRT and surgery if they did not receive
neoadjuvant CT, regardless pathology results
• ESMO: stage III and "high-risk" yp stage II patients, evidence limited
to DFS, not OS.
• European rectal cancer conference: insufficient evidence on benefit
of adjuvant chemotherapy after preoperative chemoradiotherapy to
recommend its use.

52. Trials on adjuvant chemotherapy
Glynne et al Trial 20 (Phase III) PROCTOR SCRIPT
Trial 21 (Phase III)
EORTC 22921 22
(Phase III)
N 113 437 1011
OS 89 vs 88% 80 vs 79% 51 vs 48% [p=0·32]
DFS 78 vs 71% 62 vs 55% 47 vs 43% [p=0·38]
LR 22 vs 27% 7.8 vs 7.8% 14 vs 12%
[p=0·0017]
20.Glynne-Jones R, Counsell N, Quirke P, Mortensen N,Maraveyas A, Meadows HM, et al. Chronicle: results of a randomised phase III trial in
locally advanced rectal cancer after
neoadjuvant chemoradiation randomising postoperative adjuvantcapecitabine plus oxaliplatin (XELOX) versus control. Ann
Oncol2014;25(7):1356–62.
21.Breugom AJ, van Gijn W, Muller EW, Berglund A ˚ , van den Broek CB, Fokstuen T, et al. Adjuvant chemotherapy for rectal cancer patients
treated with preoperative (chemo)radiotherapy
and total mesorectal excision: a Dutch Colorectal Cancer Group (DCCG) randomized phase III trial. Ann Oncol 2015;26(4): 696–701.
22.Bosset JF, Calais G, Mineur L, Maingon P, Stojanovic-Rundic S, Bensadoun RJ, et al. Fluorouracil-based adjuvant chemotherapy after
preoperative chemoradiotherapy in rectal cancer: long-term results of the EORTC 22921 randomised study. Lancet Oncol 2014;15:184–90

53. Can surgery be avoided?
• Watch-and-Wait Nonoperative Approach
for Clinical Complete Responders !!
• No randomized trials
• Careful endoscopic, clinical, and
radiographic evaluation : identify patients
with good likelihood of local tumor
control and may not need surgery
• Larger numbers of patients, and well-
designed prospective randomized trials
needed to validate this approach
Habr-Gama
et al
OnCoRe
study
71(cCR) vs
22 (cPR)
129
OS 100% vs 88% 96% vs 87%
DFS 92% vs 83% 88% vs 78%

56. SURVEILLANCE
• Screening for rectal recurrence and metachronous colorectal
neoplasm
• 60- 80% recurrence in 24 months, 90% in 48 months
• Each visit DRE + sigmoidoscopy + CEA
• CT scan : 1 year post resection and then annually till 3 years

57. SURVEILLANCE
• Postoperative at 2 weeks and then every 3 months for 2 years
• After 2 years every 6 months for 5 years
• If no recurrence, then colonoscopy every 3-5 years
• Close observation for high risk patients

58. THANK YOU