Last updated March 15, 2022

Management of Rectal Cancer

Recommendations

PREOPERATIVE ASSESSMENT

Evaluation

A cancer-specific history should be obtained eliciting disease-specific symptoms, associated symptoms, family history, and perioperative medical risk. Routine laboratory values, including CEA level, should also be evaluated, as indicated.  (1B)
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As a part of a complete physical examination, the distance of the distal extent of the cancer from the anal verge and the cancer’s relation to the sphincter complex should typically be assessed. (1C)
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Before elective treatment, the histological diagnosis of invasive adenocarcinoma should be confirmed, and patients should typically undergo a full colonic evaluation so the treatment plan can address synchronous pathology, as needed. (1B)
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Staging

Rectal cancer should typically be staged according to the American Joint Committee on Cancer TNM system before initiating treatment. (1B)
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Rectal cancer protocol pelvic MRI is the preferred modality for locoregional clinical staging. Endorectal ultrasound (EUS) may be considered when differentiating between early T stages (ie, T1 versus T2 tumors) or when MRI is contraindicated. (1B)
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Clinical staging for metastatic disease should typically be conducted in patients with rectal cancer. (1B)
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Restaging evaluation should be considered after neoadjuvant therapy in patients with locally advanced rectal cancer. (1C)
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Multidisciplinary Treatment Planning

The treatment of patients with rectal cancer should typically incorporate a multidisciplinary team tumor board discussion. (1C)
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If either a temporary or permanent ostomy is being considered, preoperative education and stoma site marking should typically be performed. (1B)
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TREATMENT

Surgical Techniques and Operative Considerations

Local Excision
Local excision is an appropriate treatment modality for carefully selected patients with cT1N0 rectal cancer without high-risk features. (1B)
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Radical Resection
A thorough surgical exploration should typically be performed at the time of operation. (1C)
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For curative resection of tumors of the upper third of the rectum, a tumor-specific mesorectal excision should typically be performed as part of a low anterior resection (LAR) with the mesorectum divided, ideally, at least 5cm below the distal margin of the tumor. For tumors of the middle and lower thirds of the rectum, total mesorectal excision (TME) should typically be performed as a part of an ultralow anterior resection or abdominoperineal resection (APR). A 2-cm distal mural margin is usually adequate for distal rectal cancers when combined with TME. A 1-cm distal mural margin is generally acceptable for cancers located at or below the mesorectal margin. (1A)
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Vascular ligation at the origin of the superior rectal artery with resection of the associated lymphatic drainage is typically appropriate for rectal cancer resection. (1B)
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In the absence of a clinically positive lymph node in the lateral pelvic compartment, routine lateral pelvic lymph node dissection is not typically required.  (1C)
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In patients with T4 rectal cancer, curative-intent resection of involved adjacent organs should typically be performed en bloc. (1B)
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Intraoperative radiation therapy may be used in selected patients with microscopically involved (R1) or close resection margins. (2C)
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Minimally invasive approaches to TME can be considered and should typically be performed by experienced surgeons with technical expertise. (1A)
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Transanal total mesorectal excision (taTME) remains controversial with regard to perioperative and longterm oncologic outcomes. (1B)
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Patients with an apparent complete clinical response to neoadjuvant therapy should typically be offered radical resection. A “watch and wait” management approach can be considered for highly selected patients in the context of a protocolized setting. (1B)
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In patients undergoing a TME, rectal washout may be considered. (2C)
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During LAR, a colonic reservoir may be considered. (2B)
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During LAR, assessment of anastomotic integrity should typically be performed. (1B)
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A diverting ostomy should be considered after LAR. (1B)
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A management plan for the perineal defect after rectal cancer resection should typically be established preoperatively, incorporating options such as omentoplasty or reconstruction with a myocutaneous flap. (2B)
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Oophorectomy is typically advised for grossly abnormal ovaries or contiguous extension of rectal cancer, but routine prophylactic oophorectomy is not recommended. (1C)
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Tumor-Related Emergencies

The management of patients with rectal cancer presenting with tumor-related emergencies should follow the principles of optimal oncologic therapy when possible, depending on the specific clinical circumstances. (1C)
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In patients with obstruction due to extraperitoneal rectal cancer, decompression with a proximal diverting stoma should be considered. (1C)
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Multimodality Therapy for Nonmetastatic Rectal Cancer

Neoadjuvant Therapy
Neoadjuvant therapy should typically be recommended for patients with clinical stage II/III rectal cancer. (1A)
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The neoadjuvant regimen should typically be tailored to the individual patient after multidisciplinary team discussion. (1A)
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Pathologic response to neoadjuvant therapy should be evaluated at the time of radical resection. (1B)
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Adjuvant Therapy
Adjuvant chemotherapy should typically be recommended for patients with clinical or pathologic stage II or III rectal cancer if systemic chemotherapy has not been given preoperatively and it should typically begin within 8 weeks of radical resection. (1B)
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Adjuvant radiotherapy should typically be considered in selected patients with high-risk, pathologic stage II or III rectal cancer, in particular, if neoadjuvant therapy has not been given. (1B)
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Multimodality Therapy for Rectal Cancer With Synchronous Metastatic Disease

Multidisciplinary assessment of patients with rectal cancer with synchronous metastases should establish the treatment intent as potentially curative or palliative. (1B)
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In patients with symptomatic rectal cancer and unresectable metastatic disease, palliative intervention should typically be considered. (1C)
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In patients with asymptomatic rectal cancer and unresectable metastatic disease, chemotherapy is typically considered first-line therapy because the upfront resection of rectal cancer is usually not recommended under these circumstances. (1B)
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In patients with rectal cancer and synchronous resectable (or potentially resectable) metastatic disease, individualized treatment should typically coordinate curative-intent therapies addressing all sites of disease. (1B)
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DOCUMENTATION

The operative report should typically contain information regarding the diagnostic workup, intraoperative findings, and technical details of the procedure. (1C)
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Accurate, detailed, and consistent rectal cancer pathology reporting is integral to determining prognosis, facilitating treatment planning, and improving quality assessment. (1C)
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Recommendation Grading

Overview

Title

Management of Rectal Cancer

Authoring Organization

Publication Month/Year

January 1, 2013

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Outpatient, Radiology services

Intended Users

Surgical technologist, radiology technologist, nurse, nurse practitioner, physician, physician assistant

Scope

Prevention, Management

Diseases/Conditions (MeSH)

D012003 - Rectal Fistula, D012004 - Rectal Neoplasms

Keywords

chemotherapy, colorectal cancer, total mesorectal excision