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Fundamentals of Rectal Cancer SurgeryFundamentals of Rectal Cancer Surgery

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Rationale for Multi-Modality Therapy

Rationale for Multi-Modality Therapy is a topic covered in the Fundamentals of Rectal Cancer Surgery.

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Rationale and Evolution of Neoadjuvant Therapy

The concept of adjuvant therapy for rectal cancer dates back nearly one century when gold filtered radon emanation seeds were implanted directly into rectal cancers.[1] Contact radiation with emanation seeds containing radium salts or radon was subsequently suggested as a curative treatment, and surgery was considered a salvage procedure for patients with tumors resistant to radiation.[2] As surgery became safer and the limitations of contact radiation as solitary treatment were appreciated, radiation was considered an adjuvant to be used in only selected patients. Proctectomy alone became standard treatment for rectal cancer until it was eventually realized that the outcomes of surgery alone were often suboptimal with 5-year local recurrence rates of 25-30%.[3],[4],[5] External beam radiotherapy with or without chemotherapy was added to the treatment of these patients following proctectomy to reduce the risk of local recurrence. The National Institutes of Health eventually advocated adjuvant external beam radiotherapy and chemotherapy for patients with stage II and stage III tumors in 1990 when it was demonstrated that adjuvant chemoradiotherapy improved oncologic outcomes.[6] Proctectomy followed by selective postoperative chemoradiotherapy became the regimen recommended for many patients with locally advanced rectal cancer in the United States.

As experience with this adjuvant radiotherapy increased, it was recognized that this treatment was associated with relatively high toxicity and was poorly tolerated by many patients. Accordingly, several centers explored utilizing short-course neoadjuvant radiotherapy or long-course neoadjuvant radiotherapy with or without sensitizing chemotherapy. In general, studies that used higher biologically equivalent radiation doses and a higher number of beams proved to reduce local recurrence in patients treated with preoperative radiation compared to surgery alone. The Swedish Rectal Cancer trial demonstrated that short-course preoperative radiation (25 Gy of radiation delivered in 5 equal doses in 5 consecutive days) improved both local recurrence and overall survival.[4] However, this study was later criticized because TME surgery was not standardized, and the rate of local recurrence in the control arm was considered high for those years’ standards.

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Rationale and Evolution of Neoadjuvant Therapy

The concept of adjuvant therapy for rectal cancer dates back nearly one century when gold filtered radon emanation seeds were implanted directly into rectal cancers.[1] Contact radiation with emanation seeds containing radium salts or radon was subsequently suggested as a curative treatment, and surgery was considered a salvage procedure for patients with tumors resistant to radiation.[2] As surgery became safer and the limitations of contact radiation as solitary treatment were appreciated, radiation was considered an adjuvant to be used in only selected patients. Proctectomy alone became standard treatment for rectal cancer until it was eventually realized that the outcomes of surgery alone were often suboptimal with 5-year local recurrence rates of 25-30%.[3],[4],[5] External beam radiotherapy with or without chemotherapy was added to the treatment of these patients following proctectomy to reduce the risk of local recurrence. The National Institutes of Health eventually advocated adjuvant external beam radiotherapy and chemotherapy for patients with stage II and stage III tumors in 1990 when it was demonstrated that adjuvant chemoradiotherapy improved oncologic outcomes.[6] Proctectomy followed by selective postoperative chemoradiotherapy became the regimen recommended for many patients with locally advanced rectal cancer in the United States.

As experience with this adjuvant radiotherapy increased, it was recognized that this treatment was associated with relatively high toxicity and was poorly tolerated by many patients. Accordingly, several centers explored utilizing short-course neoadjuvant radiotherapy or long-course neoadjuvant radiotherapy with or without sensitizing chemotherapy. In general, studies that used higher biologically equivalent radiation doses and a higher number of beams proved to reduce local recurrence in patients treated with preoperative radiation compared to surgery alone. The Swedish Rectal Cancer trial demonstrated that short-course preoperative radiation (25 Gy of radiation delivered in 5 equal doses in 5 consecutive days) improved both local recurrence and overall survival.[4] However, this study was later criticized because TME surgery was not standardized, and the rate of local recurrence in the control arm was considered high for those years’ standards.

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Last updated: September 17, 2021

Citation

"Rationale for Multi-Modality Therapy." Fundamentals of Rectal Cancer Surgery, 2021. ASCRS U, www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831003/all/Rationale for Multi-Modality Therapy.
Rationale for Multi-Modality Therapy. Fundamentals of Rectal Cancer Surgery. 2021. https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831003/all/Rationale for Multi-Modality Therapy. Accessed March 21, 2023.
Rationale for Multi-Modality Therapy. (2021). In Fundamentals of Rectal Cancer Surgery https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831003/all/Rationale for Multi-Modality Therapy
Rationale for Multi-Modality Therapy [Internet]. In: Fundamentals of Rectal Cancer Surgery. ; 2021. [cited 2023 March 21]. Available from: https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831003/all/Rationale for Multi-Modality Therapy.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Rationale for Multi-Modality Therapy ID - 2831003 Y1 - 2021/09/17/ BT - Fundamentals of Rectal Cancer Surgery UR - https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831003/all/Rationale for Multi-Modality Therapy DB - ASCRS U DP - Unbound Medicine ER -
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Grapherence® [↑45]
    • Fundamentals of Rectal Cancer Surgery
    • Background
    • Rectal Anatomy
    • Rectal Cancer Biology and Hereditary Cancer Syndromes
    • Rationale for Multi-Modality Therapy
    • Preoperative Issues
    • Preoperative Staging
    • Role of Tumor Board
    • Indications for Preoperative Neoadjuvant Therapy
    • Local Excision
    • Indications for LAR Versus Intersphincteric Resection Versus APR
    • Indications for Extended Resection
    • Preoperative Preparation
    • Interoperative
    • Patient Positioning and Equipment for Rectal Cancer Surgery
    • Inferior Mesenteric Artery
    • Inferior Mesenteric Vein (IMV)
    • Splenic Flexure Mobilization
    • Surgical Techniques for Length
    • Technique of Total Mesorectal Excision (TME)
    • Tailored Mesorectal Excision (TME)
    • Bowel Transection and Anastomosis
    • Indications for Fecal Diversion
    • Abdominoperineal Resection
    • Standardized Operative Report
    • Management of Intraoperative Vascular and Urinary Complications
    • Postoperative Issues
    • Rectal Cancer Pathology Assessment
    • Adjuvant Therapy for Rectal Adenocarcinoma
    • Surveillance After Rectal Cancer Treatment
    • Management of Local Recurrences
    • Short-Term Complications - Anastomotic
    • Short-Term Complications - Urinary
    • Ostomy Complications and Management
    • Long-Term Complications – Bowel Dysfunction
    • Long-Term Complications - Sexual Dysfunction and Its Management
    • Parastomal and Perineal Hernias
    • Impact of Postoperative Complications On Oncologic Outcomes
    • Course Complete
    • Final Assessment
Grapherence® [↑45]
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  • Indications for Preoperative Neoadjuvant Therapy
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