ABSTRACT
The benefits of neoadjuvant therapy for locally advanced tumours are now generally accepted, with good evidence for both down-staging and downsizing after optimal neoadjuvant therapy. Debate persists as to what the term ‘locally advanced’ means, and until recently the definition lacked the objective fine detail of good-quality MRI. The evidence for neoadjuvant therapy is strongest for a reduction in local recurrence in operable rectal cancer and has been reported in a number of randomized controlled trials such as the Swedish, Stockholm, Dutch and UK CR07 trials. There is little evidence of a survival benefit from radiation in these trials, however, with well-documented reports of immediate and long-term side effects associated with radiotherapy. Unquestionably, tissue healing is impaired by radiotherapy, with an increase in perineal wound failure in patients who have an abdominoperineal excision and an increase in anastomotic leakage when reconstruction by anterior resection is performed. Additionally, in the medium to long term, bladder, bowel and sexual function are impaired by radiotherapy. There are also increasing reports of long-term complications such as an increase in second primary tumours, excess
There have been several key advances in the optimal management of rectal cancer, but none so important as standardization and improvement in the appropriate surgical procedure. In addition to surgical advances, neoadjuvant and adjuvant radiotherapy and chemoradiotherapy, preoperative imaging (by computed tomography (CT) of the chest and abdomen looking for metastatic disease, and by magnetic resonance imaging (MRI) to assess local tumour extent), pathological assessment and audit have all contributed to better results for this complex but eminently curable cancer. These advances, and complex management decisions, are undoubtedly best coordinated by a multidisciplinary team approach, but surgery, and the surgeon, are the key to optimal decision-making and outcome. Multidisciplinary team management should be individualized to each patient with rectal cancer and should focus on helping the surgeon and the patient choose the best course of action. The preoperative MRI provides optimal local staging and is a key visual component in the multidisciplinary team discussion of the optimal management of a patient with rectal cancer. The combination of clinical examination and good-quality MRI facilitates selection for neoadjuvant (preoperative) radiotherapy or chemoradiotherapy. This decision is crucial
cardiovascular deaths, and reoperation for bowel obstruction, all of which emphasize the need for a selective approach. There is no doubt that patients with advanced tumours benefit from radiotherapy and, if used in rectal cancer, radiotherapy should be given before surgery with randomized trials supporting this strategy.
