Rectal Cancer Clinical Practice Guidelines in OncologyNCCN Categories of Evidence and ConsensusCategory 1: The recommendation is based on high-level evidence (e.g., randomized controlled trials) and there is uniform NCCN consensus.Category 2A: The recommendation is based on lower-level evidence and there is uniform NCCN consensus.Category 2B: The recommendation is based on lower-level evidence and there is nonuniform NCCN consensus (but no major disagreement).Category 3: The recommendation is based on any level of evidence but reflects major disagreement.All recommendations are category 2A unless otherwise noted.Clinical trials: The NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.OverviewIn 2009 an estimated 40,870 new cases of rectal cancer will occur in the United States (23,580 cases in men; 17,290 cases in women). During the same year, an estimated 49,920 people will die from rectal and colon cancers.1 Although colorectal cancer is ranked as the fourth most frequently diagnosed cancer and the second leading cause of cancer death in the United States, mortality from colorectal cancer has decreased during the past 30 years. This decrease may be due to earlier diagnosis through screening and better treatment modalities.The recommendations in these clinical practice guidelines are classified as category 2A except where noted, meaning that there is uniform NCCN consensus, based on lower-level evidence (including...
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ComptonCC. Updated protocol for the examination of specimens from patients with carcinomas of the colon and rectum, excluding carcinoid tumors, lymphomas, sarcomas, and tumors of the vermiform appendix: a basis for checklists. Cancer Committee. Arch Pathol Lab Med2000;124:1016–1025.
NagtegaalIDMarijnenCAKranenbargEK. Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit. Am J Surg Pathol2002;26:350–357.
Glynne-JonesRMawdsleySNovellJR. The clinical significance of the circumferential resection margin following preoperative pelvic chemo-radiotherapy in rectal cancer: why we need a common language. Colorectal Dis2006;8:800–807.
MawdsleySGlynne-JonesRGraingerJ. Can histopathologic assessment of circumferential margin after preoperative pelvic chemoradiotherapy for T3-T4 rectal cancer predict for 3-year disease-free survival?Int J Radiat Oncol Biol Phys2005;63:745–752.
PocardMPanisYMalassagneB. Assessing the effectiveness of mesorectal excision in rectal cancer: prognostic value of the number of lymph nodes found in resected specimens. Dis Colon Rectum1998;41:839–845.
MeyersMOHollisDRMayerRJ. Ratio of metastatic to examined lymph nodes is a powerful predictor of overall survival in rectal cancer: an analysis of Intergroup 0114 [abstract]. J Clin Oncol2007;25(Suppl 1):Abstract 4008.
Khambata-FordSGarrettCRMeropolNJ. Expression of epiregulin and amphiregulin and K-ras mutation status predict disease control in metastatic colorectal cancer patients treated with cetuximab. J Clin Oncol2007;25:3230–3237.
De RoockWPiessevauxHDe SchutterJ. KRAS wild-type state predicts survival and is associated to early radiological response in metastatic colorectal cancer treated with cetuximab. Ann Oncol2008;19:508–515.
PuntCJTolJRodenburgCJ. Randomized phase III study of capecitabine, oxaliplatin, and bevacizumab with or without cetuximab in advanced colorectal cancer, the CAIRO2 study of the Dutch Colorectal Cancer Group [abstract]. J Clin Oncol2008;26(Suppl 1):Abstract LBA 4011.
TejparSPeetersMHumbletY. Relationship of efficacy with KRAS status (wild type versus mutant) in patients with irinotecan-refractory metastatic colorectal cancer, treated with irinotecan and escalating doses of cetuximab: the EVEREST experience (preliminary data) [abstract]. J Clin Oncol2008;26(Suppl 1):Abstract 4001.
LahayeMJEngelenSMNelemansPJ. Imaging for predicting the risk factors—the circumferential resection margin and nodal disease—of local recurrence in rectal cancer: a meta-analysis. Semin Ultrasound CT MR2005;26:259–268.
YouYNBaxterNNStewartANelsonH. Is the increasing rate of local excision for stage I rectal cancer in the United States justified?: a nationwide cohort study from the National Cancer Database. Ann Surg2007;245:726–733.
den DulkMPutterHColletteL. The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer. Eur J Cancer2009;45:1175–1183.
Sebag-MontefioreDStephensRJSteeleR. Prooperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial. Lancet2009;373:811–820.
ColletteLBossetJFden DulkM. Patients with curative resection of cT3-4 rectal cancer after preoperative radiotherapy or radiochemotherapy: does anybody benefit from adjuvant fluorouracil-based chemotherapy? A trial of the EORTC Group. J Clin Oncol2007;25:4379–4386.
BujkoKKepkaLMichalskiWNowackiMP. Does rectal cancer shrinkage induced by preoperative radio(chemo)therapy increase the likelihood of anterior resection? A systematic review of randomised trials. Radiother Oncol2006;80:4–12.
PeetersKCvan de VeldeCJLeerJW. Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients—a Dutch colorectal cancer group study. J Clin Oncol2005;23:6199–6206.
MeyerJCzitoBYinFFWillettC. Advanced radiation therapy technologies in the treatment of rectal and anal cancer: intensity-modulated photon therapy and proton therapy. Clin Colorectal Cancer2007;6:348–356.
American College of Radiology. Practice Guideline for Intensity-modulated radiation therapy (IMRT) 2007; Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/ro/imrt.aspx. Accessed July 2009
Habr-GamaAPerezROProscurshimI. Interval between surgery and neoadjuvant chemoradiation therapy for distal rectal cancer: does delayed surgery have an impact on outcome?Int J Radiat Oncol Biol Phys2008;71:1181–1188.
TulchinskyHShmuellEGigerA. An interval > 7 weeks between neoadjuvant theapy and surgery improves pathologic complete response and disease-free survival in patients with locally advanced rectal cancer. Ann Surg Oncol2008;15:2661–2667.
WolmarkNWieandHSHyamsDM. Randomized trial of postoperative adjuvant chemotherapy with or without radiotherapy for carcinoma of the rectum: National Surgical Adjuvant Breast and Bowel Project Protocol R-02. J Natl Cancer Inst2000;92:388–396.
BensonABIII. New approaches to assessing and treating early-stage colon and rectal cancers: cooperative group strategies for assessing optimal approaches in early-stage disease. Clin Cancer Res2007;13:6913s–6920s.
AlbertsSRHorvathWLSternfeldWC. Oxaliplatin, fluorouracil, and leucovorin for patients with unresectable liver-only metastases from colorectal cancer: a North Central Cancer Treatment Group phase II study. J Clin Oncol2005;23:9243–9249.
PoultsidesGAServaisELSaltzLB. Outcome of primary tumor in patients with synchronous stage IV colorectal cancer receiving combination chemotherapy without surgery as initial treatment. J Clin Oncol2009;27:3379–3384.
RivoireMDe CianFMeeusP. Combination of neoadjuvant chemotherapy with cryotherapy and surgical resection for the treatment of unresectable liver metastases from colorectal carcinoma. Cancer2002;95:2283–2292.
EliasDLiberaleGVernereyD. Hepatic and extrahepatic colorectal metastases: when resectable, their localization does not matter, but their total number has a prognostic effect. Ann Surg Oncol2005;12:900–909.
NordlingerBSorbyeHGlimeliusB. Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983): a randomized controlled trial. Lancet2008;37:1007–1016.
TanBRZubalBHawkinsw. Preoperative FOLFOX plus cetuximab or panitumumab therapy for patients with potentially resectable hepatic colorectal metastases [abstract]. Prestented at the 2009 ASCO Gastrointestinal Cancers Symposium; January 15–17, 2009; San Francisco, California. Abstract 497.
FolprechtGGruenbergerTHartmannJT. Cetuximab plus FOLFOX6 or cetuximab plus FOLFIRI as neoadjuvant treatment of nonresectable colorectal liver metastases: A randomized multicenter study (CELIM-study) [abstract]. Presented at the 2009 ASCO Gastrointestinal Cancers Symposium; January 15–17 2009; San Francisco, California. Abstract 296.
SouglakosJAndroulakisNSyrigosK. FOLFOXIRI vs FOLFIRI as first-line treatment in metastatic colorectal cancer: a multicentre randomised phase III trial from the Hellenic Oncology Research Group. Br J Cancer2006;94:798–805.
FalconeARicciSBrunettiI. Phase III trial of infusional fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFOXIRI) compared with infusional fluorouracil, leucovorin, and irinotecan (FOLFIRI) as first-line treatment for metastatic colorectal cancer: the Gruppo Oncologico Nord Ovest. J Clin Oncol2007;25:1670–1676.
ReddySKMorseMAHurwitzHI. Addition of bevacizumab to irinotecan- and oxaliplatin-based preoperative chemotherapy regimens does not increase morbidity after resection of colorectal liver metastases. J Am Coll Surg2008;206:96–106.
LowyAMRichTASkibberJM. Preoperative infusional chemoradiation, selective intraoperative radiation, and resection for locally advanced pelvic recurrence of colorectal adenocarcinoma. Ann Surg1996;223:177–185.
DresenRCGosensMJMartijnH. Radical resection after IORT-containing multimodality treatment is the most important determinant of outcome in patients with locally recurrent rectal cancer. Ann Surg Oncol2008;15:1937–1947.
YanTDBlackDSavadyRSugarbakerPH. Systemic review on the efficacy of cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis from colorectal carcinoma. J Clin Oncol2006;24:4011–4019.
EsquivelJSticcaRSugarbakerP. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin: a consensus statement. Society of Surgical Oncology. Ann Surg Oncol2007;14:128–133.