Multidisciplinary Management
of Rectal Cancer
,Contents
Part I Introduction
1 What Do We Consider Cancer of the Rectum?. . . . . . . . . . . . . 3
Marilyne M. Lange and Cornelis J.H. van de Velde
2 What Is the Ongoing Recommendation in the
Management of Rectal Cancer? . . . . . . . . . . . . . . . . . . . . . . . . . 9
Vincenzo Valentini, Hans-Joachim Schmoll,
and Cornelis J.H. van de Velde
Part II Q&As on Risk Factor Identification
3 What Prognostic Clinical Factors Must Be Considered
Before Treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Claus Rödel
4 What Are the Relevant Imaging Factors to Optimize
Treatment Decisions?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Manish Chand and Gina Brown
5 What Biochemical and Molecular Biological Factors
Have Greater Relevance to Treatment Decisions? . . . . . . . . . . 41
Guido Lammering and Jeroen Buijsen
6 Do Different Populations of Rectal Cancer Exist? . . . . . . . . . . 49
Vincenzo Valentini, Francesco Cellini, Maria Cristina Barba,
and Ruud van Stiphout
Part III Q&As on Imaging
7 How Can We Identify Tumour Penetration?. . . . . . . . . . . . . . . 59
Manish Chand and Gina Brown
8 How Can We Identify Mesorectal Fascia Involvement?. . . . . . 67
Regina G.H. Beets-Tan
9 How Can We Identify Nodal Involvement? . . . . . . . . . . . . . . . . 73
Regina G.H. Beets-Tan
10 How Can We Identify Pathologic Complete Responders
After Radiochemotherapy?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Brunella Barbaro and Lucia Leccisotti
ix
,x Contents
11 How Can We Identify Local Relapse? . . . . . . . . . . . . . . . . . . . . 95
Doenja M.J. Lambregts and Regina G.H. Beets-Tan
Part IV Q&As on Radiotherapy
12 When Should Preoperative Short-Course Radiotherapy
or Long-Course Chemoradiotherapy Be Performed? . . . . . . . 105
David Sebag-Montefiore and Robert Glynne-Jones
13 Should We Tailor the Delineation of Pelvic Structures
According to Tumor Presentation? . . . . . . . . . . . . . . . . . . . . . . 117
Maria Antonietta Gambacorta and Vincenzo Valentini
14 What Is the Role of IMRT and IGRT in Rectal Cancer?. . . . . 129
Jasper Nijkamp, Karin Haustermans, and Corrie A.M. Marijnen
15 What Are the Dose-Volume Constraints to Reduce
Late Toxicity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Krzysztof Bujko
16 What Is the Contribution of Intraoperative Radiotherapy
(IORT) in Tailoring Local Therapy in Primary or Recurrent
Rectal Cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Felipe A. Calvo
17 What Is the Contribution of Brachytherapy in Tailoring
Local Therapy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Jean-Pierre Gérard, Te Vuong, Jean-Michel Hannoun-Lévi,
and Arthur Sun Myint
Part V Q&As on Chemotherapy
18 Should Oxaliplatin Be Added to Preoperative
Chemoradiation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Carlo Aschele
19 Should Biologic Targeted Agents Be Combined
with Preoperative Chemoradiation in Rectal Cancer? . . . . . . 181
Pieter-Jan Cuyle and Eric Van Cutsem
20 Should Upfront Chemotherapy Precede Preoperative
Chemoradiation and Surgery? . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Carlos Fernandez-Martos and Xabier Garcia de Albeniz
21 How to Achieve Long-Term Survival in Patients
with Metastatic Rectal Cancer? . . . . . . . . . . . . . . . . . . . . . . . . . 205
Alexander Stein and Hans-Joachim Schmoll
22 Will Adjuvant Chemotherapy Improve Outcome
After Preoperative Chemoradiation?. . . . . . . . . . . . . . . . . . . . . 217
Bengt Glimelius and Peter Nygren
, Contents xi
Part VI Q&As on Surgery
23 How to Evaluate the Quality of Surgery? Suggestions
for Critical Reading of Surgical and Pathological Reports . . . 229
Lars Påhlman
24 How Is Nerve-Sparing Surgery Well Performed?. . . . . . . . . . . 233
Zoran Krivokapic and Ivan Dimitrijevic
25 Is Laparoscopic Rectal Surgery the Gold Standard? . . . . . . . . 249
David Jayne and Laeeq Khan
26 Is a Diverting Stoma Always Necessary for a Low
Anterior Resection of a Rectal Cancer?. . . . . . . . . . . . . . . . . . . 257
Geerard L. Beets
27 Will Extralevator Abdominoperineal Excision Become
the New Gold Standard? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Ingrid Martijnse, Nicholas West, Phil Quirke, Richard Heald,
Cornelius J.H. van de Velde, and Harm Rutten
28 Which Patients Do Benefit from Extended Resections
in Case of Locally Advanced Rectal Cancer? . . . . . . . . . . . . . . 275
Ralph L. Dudink, Miranda Kusters, and Harm Rutten
29 Can Standard Surgical Procedure Reliably Be Avoided
in Major Responders After Radio(chemo)therapy?. . . . . . . . . 291
Claudio Coco and Gianluca Rizzo
Part VII Q&As on Pathology
30 What Is the Correct Procedure for Handling
the Surgical Specimen? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Nigel Scott
31 What Is the Prognostic Value of (y)pT and (y)pN?. . . . . . . . . . 319
Nadine Ectors
32 What Is the Prognostic Value of CRM Involvement?. . . . . . . . 327
Iris D. Nagtegaal
33 What Is the Prognostic Value of TRG? . . . . . . . . . . . . . . . . . . . 333
Fabio M. Vecchio
Part VIII Q&As on Multidisciplinary Team Management
34 What Are the Recommendations to Ensure a Successful
Multidisciplinary Team in Rectal Cancer? . . . . . . . . . . . . . . . . 341
Sujay Shah, Pawan Mathur, and Robert Glynne-Jones
of Rectal Cancer
,Contents
Part I Introduction
1 What Do We Consider Cancer of the Rectum?. . . . . . . . . . . . . 3
Marilyne M. Lange and Cornelis J.H. van de Velde
2 What Is the Ongoing Recommendation in the
Management of Rectal Cancer? . . . . . . . . . . . . . . . . . . . . . . . . . 9
Vincenzo Valentini, Hans-Joachim Schmoll,
and Cornelis J.H. van de Velde
Part II Q&As on Risk Factor Identification
3 What Prognostic Clinical Factors Must Be Considered
Before Treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Claus Rödel
4 What Are the Relevant Imaging Factors to Optimize
Treatment Decisions?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Manish Chand and Gina Brown
5 What Biochemical and Molecular Biological Factors
Have Greater Relevance to Treatment Decisions? . . . . . . . . . . 41
Guido Lammering and Jeroen Buijsen
6 Do Different Populations of Rectal Cancer Exist? . . . . . . . . . . 49
Vincenzo Valentini, Francesco Cellini, Maria Cristina Barba,
and Ruud van Stiphout
Part III Q&As on Imaging
7 How Can We Identify Tumour Penetration?. . . . . . . . . . . . . . . 59
Manish Chand and Gina Brown
8 How Can We Identify Mesorectal Fascia Involvement?. . . . . . 67
Regina G.H. Beets-Tan
9 How Can We Identify Nodal Involvement? . . . . . . . . . . . . . . . . 73
Regina G.H. Beets-Tan
10 How Can We Identify Pathologic Complete Responders
After Radiochemotherapy?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Brunella Barbaro and Lucia Leccisotti
ix
,x Contents
11 How Can We Identify Local Relapse? . . . . . . . . . . . . . . . . . . . . 95
Doenja M.J. Lambregts and Regina G.H. Beets-Tan
Part IV Q&As on Radiotherapy
12 When Should Preoperative Short-Course Radiotherapy
or Long-Course Chemoradiotherapy Be Performed? . . . . . . . 105
David Sebag-Montefiore and Robert Glynne-Jones
13 Should We Tailor the Delineation of Pelvic Structures
According to Tumor Presentation? . . . . . . . . . . . . . . . . . . . . . . 117
Maria Antonietta Gambacorta and Vincenzo Valentini
14 What Is the Role of IMRT and IGRT in Rectal Cancer?. . . . . 129
Jasper Nijkamp, Karin Haustermans, and Corrie A.M. Marijnen
15 What Are the Dose-Volume Constraints to Reduce
Late Toxicity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Krzysztof Bujko
16 What Is the Contribution of Intraoperative Radiotherapy
(IORT) in Tailoring Local Therapy in Primary or Recurrent
Rectal Cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Felipe A. Calvo
17 What Is the Contribution of Brachytherapy in Tailoring
Local Therapy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Jean-Pierre Gérard, Te Vuong, Jean-Michel Hannoun-Lévi,
and Arthur Sun Myint
Part V Q&As on Chemotherapy
18 Should Oxaliplatin Be Added to Preoperative
Chemoradiation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Carlo Aschele
19 Should Biologic Targeted Agents Be Combined
with Preoperative Chemoradiation in Rectal Cancer? . . . . . . 181
Pieter-Jan Cuyle and Eric Van Cutsem
20 Should Upfront Chemotherapy Precede Preoperative
Chemoradiation and Surgery? . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Carlos Fernandez-Martos and Xabier Garcia de Albeniz
21 How to Achieve Long-Term Survival in Patients
with Metastatic Rectal Cancer? . . . . . . . . . . . . . . . . . . . . . . . . . 205
Alexander Stein and Hans-Joachim Schmoll
22 Will Adjuvant Chemotherapy Improve Outcome
After Preoperative Chemoradiation?. . . . . . . . . . . . . . . . . . . . . 217
Bengt Glimelius and Peter Nygren
, Contents xi
Part VI Q&As on Surgery
23 How to Evaluate the Quality of Surgery? Suggestions
for Critical Reading of Surgical and Pathological Reports . . . 229
Lars Påhlman
24 How Is Nerve-Sparing Surgery Well Performed?. . . . . . . . . . . 233
Zoran Krivokapic and Ivan Dimitrijevic
25 Is Laparoscopic Rectal Surgery the Gold Standard? . . . . . . . . 249
David Jayne and Laeeq Khan
26 Is a Diverting Stoma Always Necessary for a Low
Anterior Resection of a Rectal Cancer?. . . . . . . . . . . . . . . . . . . 257
Geerard L. Beets
27 Will Extralevator Abdominoperineal Excision Become
the New Gold Standard? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Ingrid Martijnse, Nicholas West, Phil Quirke, Richard Heald,
Cornelius J.H. van de Velde, and Harm Rutten
28 Which Patients Do Benefit from Extended Resections
in Case of Locally Advanced Rectal Cancer? . . . . . . . . . . . . . . 275
Ralph L. Dudink, Miranda Kusters, and Harm Rutten
29 Can Standard Surgical Procedure Reliably Be Avoided
in Major Responders After Radio(chemo)therapy?. . . . . . . . . 291
Claudio Coco and Gianluca Rizzo
Part VII Q&As on Pathology
30 What Is the Correct Procedure for Handling
the Surgical Specimen? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Nigel Scott
31 What Is the Prognostic Value of (y)pT and (y)pN?. . . . . . . . . . 319
Nadine Ectors
32 What Is the Prognostic Value of CRM Involvement?. . . . . . . . 327
Iris D. Nagtegaal
33 What Is the Prognostic Value of TRG? . . . . . . . . . . . . . . . . . . . 333
Fabio M. Vecchio
Part VIII Q&As on Multidisciplinary Team Management
34 What Are the Recommendations to Ensure a Successful
Multidisciplinary Team in Rectal Cancer? . . . . . . . . . . . . . . . . 341
Sujay Shah, Pawan Mathur, and Robert Glynne-Jones
