The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer

Diseases of the Colon & Rectum, Journal Year: 2020, Volume and Issue: 63(9), P. 1191 - 1222

Published: Aug. 13, 2020

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, management disorders diseases colon, rectum, anus. Clinical Practice Guidelines Committee composed society members who are chosen because they have demonstrated expertise in specialty colon rectal surgery. This committee was created lead international efforts defining quality for conditions related anus develop clinical practice guidelines based on best available evidence. Although not proscriptive, these provide information which decisions can be made do dictate a specific form treatment. These intended use all practitioners, health workers, patients desire about addressed topics covered guidelines. should deemed inclusive proper methods nor exclusive reasonably directed toward obtaining same results. ultimate judgment regarding propriety any procedure must physician light circumstances presented individual patient. STATEMENT OF THE PROBLEM Colorectal cancer remains third most common both men women, second leading cause cancer-related deaths United States annually. It projected that 145,600 new colorectal cases will been diagnosed an estimated 51,020 from occurred 2019.1 difficult estimate statistics attributable specifically because, historically, much reporting has combined with as single disease entity "colorectal cancer."1 Overall, incidence declined over past decades, largely risk factor modification screening.2 However, 18- 50-year age group represents unique cohort whom increasing. In contrast overall trends, increased 1.8% annually younger adults between 1990 2013.1 effort ensure receive appropriate using multidisciplinary approach, ASCRS collaborated multispecialty National Accreditation Program Cancer create educational modules set standards focusing program management, services, improvement cancer.3,4 Because involves multiple disciplines working conjunction one another, surgical here viewed within context represent only portion treatment necessary optimal cancer. screening, bowel preparation, enhanced recovery pathways, surveillance after curative treatment, prevention thromboembolic disease, while relevant cancer, beyond scope other guidelines.5–9 A guideline surgery frailty forthcoming. METHODOLOGY last Parameters Management published 2013.10 systematic search MEDLINE, PubMed, Embase, Cochrane Database Collected Reviews performed January 1, 2013 through 15, 2020. Individual literature searches were conducted each different sections (Fig. 1). An additional limitation core journals applied if initial word combination returned more than 500 articles. Directed embedded references primary articles selected circumstances. 1812 screened evaluated their level evidence, favoring trials, meta-analysis/systematic reviews, comparative studies, large registry retrospective studies institutional series, peer-reviewed, observational studies. Additional identified sources well or consensus statements societies also reviewed. final list 361 methodologic quality, evidence base examined, formulated subcommittee this guideline. grade recommendation statement determined Grades Recommendation, Assessment, Development, Evaluation system (Table When agreement incomplete guideline, chair, vice 2 assigned reviewers outcome. Members worked joint production inception publication. Recommendations reviewed entire Committee. Final recommendations approved Executive Council. general, Guideline updated every 5 years. No funding received preparing authors declared no competing interests material. conforms Appraisal Research (AGREE) checklist.TABLE 1.: GRADE system: grading recommendationsFIGURE PRISMA flow sheet. CPG = Guideline.Defining Rectum lower limit rectum usually defined anorectal ring, anatomic landmark palpable physical examination visible radiographically upper border anal sphincter puborectalis muscles.11 variably splaying teniae coli, sacral promontory, proximal valve Houston, peritoneal reflection. recent conference point sigmoid take-off (ie, junction mesocolon mesorectum) seen cross-sectional imaging rectum.12 Given correlation among landmarks imperfect presence 3 valves Houston inconsistent, perspective, somewhat elusive. practice, location commonly assessed distance its distal margin verge, beginning hair-bearing skin. Tumors 15 cm verge typically classified cancers, although total length vary body habitus sex.11 PREOPERATIVE ASSESSMENT 1. cancer-specific history obtained eliciting disease-specific symptoms, associated family history, perioperative medical risk. Routine laboratory values, including CEA level, evaluated, indicated. Grade recommendation: Strong moderate-quality 1B. cornerstone preoperative evaluation. Bleeding, pain, symptoms obstruction help determine urgency sequence evaluation intervention; consideration particularly when neoadjuvant therapy being considered. Urinary, sexual, function indicative malignant fistulas severe radiating pain may alert surgeon locally advanced involving adjacent pelvic organs. patient's fitness undergo multimodality guide planning management. thorough discussion stratification guideline.13–15 document premalignant lesions cancers details like at diagnosis lineage affected first- second-degree relatives. Patients asked known predisposing hereditary syndromes, prior genetic testing, ancestry ethnicity relevant.16 findings suggestive inherited susceptibility referred counseling. previously published.17,18 bloodwork part baseline before initiating elective prognostic long-term survival used reference during posttherapy surveillance.19 levels time points correlate response, does reliably predict pathologic response therapy.20–23 There insufficient support routine tumor markers such CA19-9 cancer.24 2. As complete examination, extent cancer's relation complex assessed. low-quality 1C. Assessment relationship lesion ring top complex) essential evaluating candidacy preservation ideally therapy, regression lesion. digital endoscopically (rigid proctoscopy accurate measurement flexible sigmoidoscopy). Endoscopic tattooing purposes anticipated intraoperative localization facilitate mucosal event helpful.25–29 3. Before histological invasive adenocarcinoma confirmed, full colonic so plan address synchronous pathology, needed. important confirm setting, neoplasms histologies amenable nonresectional options.30 endoscopic biopsy nondiagnostic incongruent impression sampling error, repeat operative biopsies required establish planning. Operative excisional unless it done curative-intent transanal full-thickness excision adequate radial margins discussed detail later. newly low, range 1% 3%, adenomas polyps high 30%.31–34 Colonoscopy preferred method offers therapeutic platform treat polyps.35,36 where colonoscopy completed, instance, due obstructing CT colonography used.37–40 Computed tomography shown superior diagnostic study compared double-contrast barium enema detect lesions.41 receiving reattempted there sufficient permit passage colonoscope. If performed, urgent intervention needed lesions, planned postoperatively. Staging staged according Joint TNM except emergent required. system, Cancer, describes depth local invasion (T stage), regional lymph node involvement (N distant metastasis (M stage).42,43 Updated 8th edition staging definitions categorize nodes harboring micrometastasis (clusters 20 cells metastases measuring >0.2 mm <2 diameter) N1 deposits (N1c disease) stage III regardless status nodes, M1c disease.42,43 described (cTNM), guides decisions, (pTNM), information.42 further prefixed designate modality used, u ultrasound, mr MRI, ct scan. For treated reported ypTNM.44,45 protocol MRI locoregional staging. Endorectal ultrasound (EUS) considered differentiating early T stages T1 versus T2 tumors) contraindicated. Magnetic resonance standardized technical protocols templates, assesses penetration, nodal metastases, (tumor and/or nodes) mesorectum mesorectal fascia.46,47 Thus, clearance circumferential resection (CRM), shortest fascia.47–49 positive CRM 1 mm50,51 fascia levator ani muscle; Comprehensive Network currently defines mm.52 recurrence decreased (5-year recurrence: HR 3.50; 95% CI, 1.53–8.00; p < 0.05; 5-year survival: 1.97; 1.27–3.04; 0.01).53–55 Primary features T4 status, extramural vascular invasion, mm, least high-risk features.56,57 factors critical vital Multidisciplinary Treatment Planning. complementary useful tumors).57 contraindicated certain implantable devices present metallic implants, MR incompatible pacemakers).58,59 Disadvantages EUS include operator dependency, limited accuracy assessing bulky discomfort, inability evaluate stenotic preclude transducer.58,59 Accurately potentially involved (including mesorectal, lateral pelvic, inguinal compartments) challenge modalities.60 Sensitivity specificity 55% 74% CT, 67% 78% EUS, 66% 76% MRI.48,61 Nodal improved incorporating criteria spiculated mixed signal intensity MRI.57,62,63 metastatic completed influences plan. Swedish Registry, sites liver (70%), lung (47%), bone (12%), nervous (8%).64 contrast-enhanced scan chest, abdomen, pelvis. Pulmonary sensitivity better ability arbitrate otherwise indeterminate time, recommended rather chest x-ray.65,66 without intravenous followed triphasic (arterial, venous, portal) generally choice detecting characterizing hepatic lesions.67–69 smaller background fatty changes, multidetector positron emission (PET). PET/CT alone cancer.60 suspected excluding IV surgery, supporting added value limited.70,71 Positron /CT role equivocal CT.72,73 4. Restaging consisting assessment particular, would influence need alter concern interval development disease. Importantly, restaging evaluates possible (cCR) adjust expectations. Some change strategy 11% 15% patients, identification but others benefit restaging.74,75 repeating initially, challenging N setting.76–79 Advanced functional diffusion-weighted MRI) improve response.70,80 Planning incorporate team board discussion. Optimal requires input coordination clinicians radiology, radiation, oncology, ancillary members. staging, modify individualize aspects review demonstrate potential impact disease-free (OS).81–83 either temporary permanent ostomy considered, education stoma site marking performed. Consultation enterostomal therapist whose involve creation. Preoperative proficiency decrease ostomy-related complications.84–86 published.87,88 TREATMENT Surgical Techniques Considerations Local Excision carefully cT1N0 features. acceptable highly favorable Transanal cT medically unfit radical Whereas advantages minimizing sequelae, adequately remove pathologically nodes. occult ranges 6% greater SM3 poor differentiation, budding, lymphovascular perineural invasion.89,90 Accurate careful selection contemplating excision. Distinguishing Tis, T1, T2) utilized tool situations. small (<3 cm) adenocarcinomas <30% circumference, moderately differentiated, budding tissue biopsy, involvement, accessible transanally excision.52 our current understanding applicability excision, changed 2B 1B.10 Technically, ≥10 grossly normal down perirectal fat providing minimum 2-mm-deep margin.52 orient specimen assessment, tangential, piecemeal, fragmented avoided, possible. conventional microsurgery (TEMS) minimally (TAMIS). While paucity well-designed randomized, controlled suggest TEMS visualization access TAMIS appear comparable.91–93 submucosal dissection, colonoscopic procedure, very superficial approach remain controversial.94 rate following varies 7% 21% consistently higher resection.95–97 appreciate reveals significant deeper stage, inadequate margins, deep (SM3) subsequent recommended. oncologically cT2 26% 47%, tumors elevated disease.98 Radical under refuse prioritize preservation, adjuvant chemoradiation pT1/T2 removed those went (n 405) underwent 130). Despite data bias, weighted average rates 10% (95% 4–21) 3–15) pT1 11–21) 4–22) pT2 lesions.99 resection, salvageable recurrence.100 select T1/T2 lesions. studied trials.101–104 Two prospective trials randomly 50104 47103 standard resection. Long-term statistically differences survival. pooled analysis morbidity (22.3%), postoperative suture line dehiscence (9.7% each).105,106 require counseling outcomes, safety efficacy unestablished practice. Resection exploration operation. cavity abdominal organs rule out (eg, metastasis, carcinomatosis), fixation organs), coexisting pathology.107 Unexpected decision proceed operation should, ideally, discovered ligating pedicle committing tumor-specific low anterior (LAR) divided, below tumor. middle thirds (TME) ultralow abdominoperineal (APR). 2-cm mural TME. 1-cm located margin. 1A. Appropriate technique integral optimizing oncological outcomes morbidity, follow principles planes Dissection visceral parietal layers endopelvic facilitates en bloc removal mesentery, lymphatics, deposits. Mesorectal preserve autonomic nerves reduce bleeding recurrence.108 Among registered Medical Council (MRC) CR07 NCIC-CTG CO16 trial, 3-year 4% good mesorectal) plane dissection 13% muscularis propria) (p 0.003).109 spread often extends intramural spread. relatively uncommon (found edge intraluminal cancers), occur up 4 cancer.110,111 To propensity extend tumor; TME extent) of, cm. margin, appears appropriately patients.112 Even shorter motivated therapy.113–115 adequate, creation anastomosis coloanal anastomosis. directly muscles, t

Language: Английский

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Radiation Therapy for Cervical Cancer: Executive Summary of an ASTRO Clinical Practice Guideline

Practical Radiation Oncology, Journal Year: 2020, Volume and Issue: 10(4), P. 220 - 234

Published: May 18, 2020

Language: Английский

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Radical surgery versus organ preservation via short-course radiotherapy followed by transanal endoscopic microsurgery for early-stage rectal cancer (TREC): a randomised, open-label feasibility study

˜The œLancet. Gastroenterology & hepatology, Journal Year: 2020, Volume and Issue: 6(2), P. 92 - 105

Published: Dec. 12, 2020

BackgroundRadical surgery via total mesorectal excision might not be the optimal first-line treatment for early-stage rectal cancer. An organ-preserving strategy with selective could reduce adverse effects of without substantially compromising oncological outcomes. We investigated feasibility recruiting patients to a randomised trial comparing an excision.MethodsTREC was randomised, open-label study done at 21 tertiary referral centres in UK. Eligible participants were aged 18 years or older adenocarcinoma, staged T2 lower, maximum diameter 30 mm less; lymph node involvement metastases excluded. Patients randomly allocated (1:1) by use computer-based randomisation service undergo organ preservation short-course radiotherapy followed transanal endoscopic microsurgery after 8–10 weeks, excision. Where specimen showed histopathological features associated increased risk local recurrence, considered planned early conversion A non-randomised prospective registry captured whom inappropriate, because strong clinical indication one group. The primary endpoint cumulative 12, 18, and 24 months. Secondary outcomes evaluated safety, efficacy, health-related quality life assessed European Organisation Research Treatment Cancer (EORTC) QLQ C30 CR29 intention-to-treat population. This is registered ISRCTN Registry, ISRCTN14422743.FindingsBetween Feb 22, 2012, Dec 19, 2014, 55 assigned 15 sites; 27 28 radical surgery. Cumulatively, had been 12 months, 31 39 No died within days initial treatment, but patient 6 months following anastomotic leakage. Eight (30%) converted Serious events reported four (15%) versus 11 (39%) (p=0·04, χ2 test). most commonly due bleeding pain (reported three cases). Radical medical surgical complications including leakage (two patients), kidney injury cardiac arrest (one patient), pneumonia patients). Histopathological that would tumour recurrence if observed alone present 16 (59%) preservation, (86%) (p=0·03, achieved complete response radiotherapy. who improvements patient-reported bowel toxicities function scores multiple items compared those excision, which sustained over 36 months' follow-up. comprised 61 underwent seven Non-randomised than more likely have life-limiting comorbidities. occurred ten (16%) (14%) high-risk features, while 25 (41%) response. Overall, 19 (70%) 56 (92%) patients.InterpretationShort-course achieves high levels relatively low morbidity indications improved life. These data support unsuitable short-term risks this surgery, further evaluation achieve fit Larger studies, such as ongoing STAR-TREC study, are needed precisely determine different schedules.FundingCancer

Language: Английский

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Radiation Therapy for Rectal Cancer: Executive Summary of an ASTRO Clinical Practice Guideline

Practical Radiation Oncology, Journal Year: 2020, Volume and Issue: 11(1), P. 13 - 25

Published: Oct. 21, 2020

Language: Английский

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Understanding the molecular mechanism responsible for developing therapeutic radiation-induced radioresistance of rectal cancer and improving the clinical outcomes of radiotherapy - A review

Cancer Biology & Therapy, Journal Year: 2024, Volume and Issue: 25(1)

Published: March 6, 2024

Rectal cancer accounts for the second highest cancer-related mortality, which is predominant in Western civilizations. The treatment rectal cancers includes surgery, radiotherapy, chemotherapy, and immunotherapy. Radiotherapy, specifically external beam radiation therapy, most common way to treat because not only limits progression but also significantly reduces risk of local recurrence. However, therapeutic radiation-induced radioresistance cells toxicity normal tissues are major drawbacks. Therefore, understanding mechanistic basis developing during after therapy would provide crucial insight improve clinical outcomes patients. Studies by various groups have shown that radiotherapy-mediated changes tumor microenvironment play a role radioresistance. Therapeutic hypoxia functional alterations stromal cells, tumor-associated macrophage (TAM) cancer-associated fibroblasts (CAF), In addition, signaling pathways, such as – PI3K/AKT pathway, Wnt/β-catenin signaling, hippo modulate responsiveness cells. Different radiosensitizers, small molecules, microRNA, nanomaterials, natural chemical sensitizers, being used increase effectiveness radiotherapy. This review highlights mechanism responsible following radiotherapy potential strategies enhance better management cancer.

Language: Английский

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Exercise prehabilitation may lead to augmented tumor regression following neoadjuvant chemoradiotherapy in locally advanced rectal cancer

Acta Oncologica, Journal Year: 2019, Volume and Issue: 58(5), P. 588 - 595

Published: Feb. 6, 2019

Purpose: We evaluate the effect of an exercised prehabilitation programme on tumour response in rectal cancer patients following neoadjuvant chemoradiotherapy (NACRT). Patients and Methods: Rectal with (MRI-defined) threatened resection margins who completed standardized NACRT were prospectively studied a post hoc, explorative analysis two previously reported clinical trials. MRI was performed at Weeks 9 14 post-NACRT, surgery Week 15. undertook 6-week preoperative exercise-training programme. Oxygen uptake (VO2) anaerobic threshold (AT) wasmeasured baseline (pre-NACRT), after completion week 6 (post-NACRT). Tumour related outcome variables: regression grading (ymrTRG) 14; histopathological T-stage (ypT); (ypTRG)) compared. Results: 35 (26 males) recruited. 26 tailored unmatched controls. resulted fall VO2 AT -2.0 ml/kg-1/min-1(-1.3,-2.6), p < 0.001. Exercise shown to reverse this effect. increased between groups, (post-NACRT vs. 6) by +1.9 ml/kg-1/min-1(0.6, 3.2), = 0.007. A significantly greater ypTRG exercise group time found (p 0.02). Conclusion: Following NACRT, significant improvements fitness augmented pathological regression.

Language: Английский

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Multi-modal radiomics model to predict treatment response to neoadjuvant chemotherapy for locally advanced rectal cancer

World Journal of Gastroenterology, Journal Year: 2020, Volume and Issue: 26(19), P. 2388 - 2402

Published: May 20, 2020

BACKGROUNDNeoadjuvant chemotherapy is currently recommended as preoperative treatment for locally advanced rectal cancer (LARC); however, evaluation of response to neoadjuvant still challenging. AIMTo create a multi-modal radiomics model assess therapeutic after LARC.

Language: Английский

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Engineered Plant-Derived Nanovesicles Facilitate Tumor Therapy: Natural Bioactivity Plus Drug Controlled Release Platform

International Journal of Nanomedicine, Journal Year: 2023, Volume and Issue: Volume 18, P. 4779 - 4804

Published: Aug. 1, 2023

Tumors are the second-most common disease in world, killing people at an alarming rate.As issues with drug resistance, lack of targeting, and severe side effects revealed, there is a growing demand for precision-targeted delivery systems.Plant-derived nanovesicles (PDNVs), which arecomposed proteins, lipids, RNA, metabolites, widely distributed readily accessible.The potential anti-proliferative, pro-apoptotic, drug-resistant-reversing on tumor cells, as well ability to alter microenvironment (TME) by modulating tumor-specific immune make PDNVs promising antitumor therapeutics.With lipid bilayer structure that allows loading transmembrane capacity endocytosed also expected become new platform.Exogenous modifications enhance their circulating stability, targeting ability, high cell endocytosis rate, controlled-release capacity.In this review, we summarize PDNVs' natural activity, engineered efficient tools therapeutic effects.Additionally, discuss critical considerations related raised area, will encourage researchers improve better anti-tumor therapeutics clinic applications.

Language: Английский

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Short-course radiotherapy with consolidation chemotherapy versus conventionally fractionated long-course chemoradiotherapy for locally advanced rectal cancer: randomized clinical trial

British journal of surgery, Journal Year: 2021, Volume and Issue: 108(5), P. 511 - 520

Published: Jan. 9, 2021

Abstract Background The trial hypothesis was that, in a resource-constrained situation, short-course radiotherapy would improve treatment compliance compared with conventional chemoradiotherapy for locally advanced rectal cancer, without compromising oncological outcomes. Methods In this open-label RCT, patients cT3, cT4 or node-positive non-metastatic cancer were allocated randomly to 5 × Gy and two cycles of XELOX (arm A) concurrent capecitabine B), followed by total mesorectal excision both arms. All received further six adjuvant chemotherapy the regimen. primary endpoint compliance, defined as ability complete planned treatment, including neoadjuvant radiochemotherapy, surgery, dose cycles. Results Of 162 patients, 140 eligible analysis: 69 arm A 71 B. Compliance (primary endpoint) greater (63 versus 41 per cent; P = 0.005). incidence acute toxicities therapy similar (haematological: 28 32 cent, 0.533; gastrointestinal: 14 21 0.305; grade III–IV: 2 4 1.000). Delays less common (9 45 &lt; 0.001), overall times completion shorter (P 0.001). rates R0 resection (87 90 0.554), sphincter preservation (32 35 0.708), pathological response (12 10 0.740), tumour downstaging (75 75 0.920) similar. Downstaging (ypT) more 0.044). There no difference postoperative complications between arms 0.838). Conclusion Reduced delays higher rate observed consolidation chemotherapy, early surgical time- units developing countries, should be standard care.

Language: Английский

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Functional outcomes of surgery for colon cancer: A systematic review and meta-analysis

European Journal of Surgical Oncology, Journal Year: 2020, Volume and Issue: 47(5), P. 960 - 969

Published: Nov. 26, 2020

IntroductionAs survival rates of colon cancer increase, knowledge about functional outcomes is becoming ever more important. The primary aim this systematic review and meta-analysis was to quantify after surgery for cancer. Secondly, we aimed determine the effect time follow-up type colectomy on postoperative outcomes.Materials methodsA literature search performed identify studies reporting bowel function following Outcome parameters were scores and/or prevalence symptoms. Additionally, resection analyzed.ResultsIn total 26 included, describing between 3 178 months right hemicolectomy (n = 4207), left hemicolectomy/sigmoid 4211), subtotal/total 161). In 16 (61.5%) a score used. Pooled liquid solid stool incontinence 24.1% 6.9%, respectively. most prevalent constipation-associated symptoms incomplete evacuation obstructive, difficult emptying (33.3% 31.4%, respectively). Major Low Anterior Resection Syndrome present in 21.1%. No differences or found.ConclusionBowel problems are common, show no improvement over do not depend colectomy. Apart from fecal incontinence, also highly prevalent. Therefore, attention should be paid all possible aspects dysfunction targeted treatment commence promptly.

Language: Английский

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