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The multidisciplinary management of rectal cancer

Abstract

Rectal cancer treatment has evolved during the past 40 years with the use of a standardized surgical technique for tumour resection: total mesorectal excision. A dramatic reduction in local recurrence rates and improved survival outcomes have been achieved as consequences of a better understanding of the surgical oncology of rectal cancer, and the advent of adjuvant and neoadjuvant treatments to compliment surgery have paved the way for a multidisciplinary approach to disease management. Further improvements in imaging techniques and the ability to identify prognostic factors such as tumour regression, extramural venous invasion and threatened margins have introduced the concept of decision-making based on preoperative staging information. Modern treatment strategies are underpinned by accurate high-resolution imaging guiding both neoadjuvant therapy and precision surgery, followed by meticulous pathological scrutiny identifying the important prognostic factors for adjuvant chemotherapy. Included in these strategies are organ-sparing approaches and watch-and-wait strategies in selected patients. These pathways rely on the close working of interlinked disciplines within a multidisciplinary team. Such multidisciplinary forums are becoming standard in the treatment of rectal cancer across the UK, Europe and, more recently, the USA. This Review examines the essential components of modern-day management of rectal cancer through a multidisciplinary team approach, providing information that is essential for any practising colorectal surgeon to guide the best patient care.

Key points

  • As rectal cancer treatment becomes more precise, high-resolution imaging techniques have been established to identify the important tumour characteristics that help guide management.

  • High-resolution MRI scans are increasingly dictating treatment strategies by providing predictive and prognostic information related to the tumour, and are a standard part of the patient investigation pathway.

  • Surgical management depends on patient and tumour factors with an aim to optimize function and survival with the lowest risk of recurrence.

  • Multiple approaches are currently available for resection, including radical surgery involving excision of the rectum and associated mesentery as well as organ-sparing techniques involving local excision of the lesion, or deferring surgery altogether.

  • The pathological assessment of the resected rectal cancer specimen provides a level of quality control ensuring that surgical principles have been adhered to and that the surgery was performed in an optimal oncological manner.

  • Multidisciplinary team presentation of imaging data, evidence-based oncological, surgical and functional recommendations, and pathological assessment of surgical quality are essential components of formalized cancer care.

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Fig. 1: Worldwide colorectal cancer incidence and mortality.
Fig. 2: MRI-directed treatment decision-making for rectal cancer.
Fig. 3: The mesorectal fascia and oncological planes.
Fig. 4: MRI demonstrating extramural venous invasion by a rectal tumour.
Fig. 5: Multidisciplinary team treatment algorithm for rectal cancer.
Fig. 6: Total mesorectal excision plane.
Fig. 7: Surgical approaches for rectal cancer.
Fig. 8: Complete total mesorectal excision specimen.
Fig. 9: Positive pathological circumferential resection margin.

References

  1. 1.

    Siegel, R. L., Miller, K. D. & Jemal, A. Cancer statistics, 2018. CA Cancer J. Clin. 68, 7–30 (2018).

    PubMed  Google Scholar 

  2. 2.

    Siegel, R. L., Miller, K. D. & Jemal, A. Cancer Statistics, 2017. CA Cancer J. Clin. 67, 7–30 (2017).

    PubMed  Google Scholar 

  3. 3.

    Henley, S. J. et al. Invasive cancer incidence and survival — United States, 2011. MMWR Morb. Mortal. Wkly. Rep. 64, 237–242 (2015).

    PubMed  PubMed Central  Google Scholar 

  4. 4.

    Ferlay, J. et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int. J. Cancer 144, 1941–1953 (2019).

    CAS  PubMed  Google Scholar 

  5. 5.

    Vuik, F. E. et al. Increasing incidence of colorectal cancer in young adults in Europe over the last 25 years. Gut 68, 1820–1826 (2019).

    PubMed  PubMed Central  Google Scholar 

  6. 6.

    Petrelli, F., Sgroi, G., Sarti, E. & Barni, S. Increasing the interval between neoadjuvant chemoradiotherapy and surgery in rectal cancer: a meta-analysis of published studies. Ann. Surg. 263, 458–464 (2016).

    PubMed  Google Scholar 

  7. 7.

    Foster, J. D., Jones, E. L., Falk, S., Cooper, E. J. & Francis, N. K. Timing of surgery after long-course neoadjuvant chemoradiotherapy for rectal cancer: a systematic review of the literature. Dis. Colon Rectum 56, 921–930 (2013).

    PubMed  Google Scholar 

  8. 8.

    Sun, Z. et al. Optimal timing to surgery after neoadjuvant chemoradiotherapy for locally advanced rectal cancer. J. Am. Coll. Surg. 222, 367–374 (2016).

    PubMed  Google Scholar 

  9. 9.

    Lefevre, J. H. et al. Effect of interval (7 or 11 weeks) between neoadjuvant radiochemotherapy and surgery on complete pathologic response in rectal cancer: a multicenter, randomized, controlled trial (GRECCAR-6). J. Clin. Oncol. 34, 3773–3780 (2016).

    PubMed  Google Scholar 

  10. 10.

    National Institute for Health and Care Excellence (NICE). Colorectal cancer: diagnosis and management. Clinical guideline [CG131] https://www.nice.org.uk/guidance/cg131 (2014).

  11. 11.

    Benson, A. B. et al. Rectal Cancer, Version 2.2018, NCCN Clinical Practice Guidelines in Oncology. J. Natl Compr. Canc. Netw. 16, 874–901 (2018).

    PubMed  Google Scholar 

  12. 12.

    Wibe, A. et al. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer. Br. J. Surg. 89, 327–334 (2002).

    CAS  PubMed  Google Scholar 

  13. 13.

    Balyasnikova, S. & Brown, G. Optimal imaging strategies for rectal cancer staging and ongoing management. Curr. Treat. Options Oncol. 17, 32 (2016).

    PubMed  PubMed Central  Google Scholar 

  14. 14.

    Taylor, F. G. et al. One millimetre is the safe cut-off for magnetic resonance imaging prediction of surgical margin status in rectal cancer. Br. J. Surg. 98, 872–879 (2011).

    CAS  PubMed  Google Scholar 

  15. 15.

    Glynne-Jones, R. et al. Rectal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann. Oncol. 28, iv22–iv40 (2017).

    CAS  PubMed  Google Scholar 

  16. 16.

    Merkel, S. et al. The prognostic inhomogeneity in pT3 rectal carcinomas. Int. J. Colorectal Dis. 16, 298–304 (2001).

    CAS  PubMed  Google Scholar 

  17. 17.

    Merkel, S, et al. The prognostic inhomogeneity of colorectal carcinomas Stage III: a proposal for subdivision of Stage III. Cancer 92, 1435–1443 (2001).

    CAS  PubMed  Google Scholar 

  18. 18.

    Willett, C. G., Badizadegan, K., Ancukiewicz, M. & Shellito, P. C. Prognostic factors in stage T3N0 rectal cancer: do all patients require postoperative pelvic irradiation and chemotherapy. Dis. Colon Rectum 42, 167–173 (1999).

    CAS  PubMed  Google Scholar 

  19. 19.

    Taylor, F. G. et al. Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multicenter, European study. Ann. Surg. 253, 711–719 (2011).

    PubMed  Google Scholar 

  20. 20.

    Georgiou, P. A. et al. Diagnostic accuracy and value of magnetic resonance imaging (MRI) in planning exenterative pelvic surgery for advanced colorectal cancer. Eur. J. Cancer 49, 72–81 (2013).

    PubMed  Google Scholar 

  21. 21.

    Tekkis, P. P. et al. Diagnostic accuracy and value of magnetic resonance imaging (MRI) in planning exenterative pelvic surgery for advanced colorectal pelvic cancer. J. Clin. Oncol. 29 (Suppl. 4), 370 (2011).

    Google Scholar 

  22. 22.

    Chadi, S. A. et al. Factors affecting local regrowth after watch and wait for patients with a clinical complete response following chemoradiotherapy in rectal cancer (InterCoRe consortium): an individual participant data meta-analysis. Lancet Gastroenterol. Hepatol. 3, 825–836 (2018).

    PubMed  Google Scholar 

  23. 23.

    Habr-Gama, A. et al. Baseline T classification predicts early tumor regrowth after nonoperative management in distal rectal cancer after extended neoadjuvant chemoradiation and initial complete clinical response. Dis. Colon Rectum 60, 586–594 (2017).

    PubMed  Google Scholar 

  24. 24.

    Chand, M., Siddiqui, M. R., Swift, I. & Brown, G. Systematic review of prognostic importance of extramural venous invasion in rectal cancer. World J. Gastroenterol. 22, 1721–1726 (2016).

    CAS  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Talbot, I. C. et al. The clinical significance of invasion of veins by rectal cancer. Br. J. Surg. 67, 439–442 (1980).

    CAS  PubMed  Google Scholar 

  26. 26.

    Smith, N. J. et al. Prognostic significance of magnetic resonance imaging-detected extramural vascular invasion in rectal cancer. Br. J. Surg. 95, 229–236 (2008).

    CAS  PubMed  Google Scholar 

  27. 27.

    Smith, N. J., Shihab, O., Arnaout, A., Swift, R. I. & Brown, G. MRI for detection of extramural vascular invasion in rectal cancer. AJR Am. J. Roentgenol. 191, 1517–1522 (2008).

    PubMed  Google Scholar 

  28. 28.

    Battersby, N. J. et al. Prospective validation of a low rectal cancer magnetic resonance imaging staging system and development of a local recurrence risk stratification model: the MERCURY II study. Ann. Surg. 263, 751–760 (2016).

    PubMed  Google Scholar 

  29. 29.

    Chand, M., Swift, R. I., Tekkis, P. P., Chau, I. & Brown, G. Extramural venous invasion is a potential imaging predictive biomarker of neoadjuvant treatment in rectal cancer. Br. J. Cancer 110, 19–25 (2014).

    CAS  PubMed  Google Scholar 

  30. 30.

    Chand, M. et al. EMVI-positive stage II rectal cancer has similar clinical outcomes as stage III disease following pre-operative chemoradiotherapy. Ann. Oncol. 25, 858–863 (2014).

    CAS  PubMed  Google Scholar 

  31. 31.

    Chand, M. et al. Adjuvant chemotherapy may improve disease-free survival in patients with mrEMVI-positive rectal cancer following chemoradiation. Colorectal Dis. 19, 537–543 (2017).

    CAS  PubMed  Google Scholar 

  32. 32.

    Chand, M., Moran, B. J., Jones, R. G., Heald, R. J. & Brown, G. Lymph node status does not predict local recurrence in the total mesorectal excision era.Dis. Colon Rectum 57, 127–129 (2014).

    PubMed  Google Scholar 

  33. 33.

    Chand, M., Heald, R. J. & Brown, G. The importance of not overstaging mesorectal lymph nodes seen on MRI. Colorectal Dis. 15, 1201–1204 (2013).

    CAS  PubMed  Google Scholar 

  34. 34.

    Chand, M. et al. Adjuvant therapy decisions based on magnetic resonance imaging of extramural venous invasion and other prognostic factors in colorectal cancer. Ann. R. Coll. Surg. Engl. 96, 543–546 (2014).

    CAS  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Quirke, P. et al. Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet 373, 821–828 (2009).

    PubMed  PubMed Central  Google Scholar 

  36. 36.

    Cercek, A. et al. Adoption of total neoadjuvant therapy for locally advanced rectal cancer. JAMA Oncol. 4, e180071 (2018).

    PubMed  PubMed Central  Google Scholar 

  37. 37.

    Glynne-Jones, R., Grainger, J., Harrison, M., Ostler, P. & Makris, A. Neoadjuvant chemotherapy prior to preoperative chemoradiation or radiation in rectal cancer: should we be more cautious. Br. J. Cancer 94, 363–371 (2006).

    CAS  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Garcia-Aguilar, J. et al. Effect of adding mFOLFOX6 after neoadjuvant chemoradiation in locally advanced rectal cancer: a multicentre, phase 2 trial. Lancet Oncol. 16, 957–966 (2015).

    CAS  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Ngan, S. Y. et al. Randomized trial of short-course radiotherapy versus long-course chemoradiation comparing rates of local recurrence in patients with T3 rectal cancer: Trans-Tasman Radiation Oncology Group trial 01.04. J. Clin. Oncol. 30, 3827–3833 (2012).

    PubMed  Google Scholar 

  40. 40.

    Monson, J. R. et al. Practice parameters for the management of rectal cancer (revised). Dis. Colon Rectum 56, 535–550 (2013).

    CAS  PubMed  Google Scholar 

  41. 41.

    NCCN. Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Rectal Cancer, Version 3.2017. nccn.org https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf (2017).

  42. 42.

    Fernandez-Martos, C. et al. Chemoradiation, surgery and adjuvant chemotherapy versus induction chemotherapy followed by chemoradiation and surgery: long-term results of the Spanish GCR-3 phase II randomized trial†. Ann. Oncol. 26, 1722–1728 (2015).

    CAS  PubMed  Google Scholar 

  43. 43.

    Wright, M. E., Beaty, J. S., Thorson, A. G., Rojas, R. & Ternent, C. A. Cost-effectiveness analysis of total neoadjuvant therapy followed by radical resection versus conventional therapy for locally advanced rectal cancer. Dis. Colon Rectum 62, 568–578 (2019).

    PubMed  Google Scholar 

  44. 44.

    Patel, U. B. et al. Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience. J. Clin. Oncol. 29, 3753–3760 (2011).

    PubMed  Google Scholar 

  45. 45.

    MERCURY Study Group. Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. BMJ 333, 779 (2006).

    PubMed Central  Google Scholar 

  46. 46.

    Beets-Tan, R. G. & Beets, G. L. MRI for assessing and predicting response to neoadjuvant treatment in rectal cancer. Nat. Rev. Gastroenterol. Hepatol. 11, 480–488 (2014).

    CAS  PubMed  Google Scholar 

  47. 47.

    Habr-Gama, A. et al. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann. Surg. 240, 711–717 (2004).

    PubMed  PubMed Central  Google Scholar 

  48. 48.

    Habr-Gama, A. et al. Complete clinical response after neoadjuvant chemoradiation therapy for distal rectal cancer: characterization of clinical and endoscopic findings for standardization. Dis. Colon Rectum 53, 1692–1698 (2010).

    PubMed  Google Scholar 

  49. 49.

    Habr-Gama, A. et al. Organ preservation in cT2N0 rectal cancer after neoadjuvant chemoradiation therapy: the impact of radiation therapy dose-escalation and consolidation chemotherapy. Ann. Surg. 269, 102–107 (2019).

    PubMed  Google Scholar 

  50. 50.

    Leeds, I. L. & Fang, S. H. Neoadjuvant therapy for rectal cancer. Dis. Colon Rectum 61, 883–886 (2018).

    PubMed  PubMed Central  Google Scholar 

  51. 51.

    Heald, R. J., Moran, B. J., Ryall, R. D., Sexton, R. & MacFarlane, J. K. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch. Surg. 133, 894–899 (1998).

    CAS  PubMed  Google Scholar 

  52. 52.

    Chude, G. G. et al. Defunctioning loop ileostomy with low anterior resection for distal rectal cancer: should we make an ileostomy as a routine procedure? A prospective randomized study. Hepatogastroenterology 55, 1562–1567 (2008).

    CAS  PubMed  Google Scholar 

  53. 53.

    Bailey, C. M., Wheeler, J. M., Birks, M. & Farouk, R. The incidence and causes of permanent stoma after anterior resection. Colorectal Dis. 5, 331–334 (2003).

    CAS  PubMed  Google Scholar 

  54. 54.

    Sherman, K. L. & Wexner, S. D. Considerations in stoma reversal. Clin. Colon Rectal Surg. 30, 172–177 (2017).

    PubMed  PubMed Central  Google Scholar 

  55. 55.

    Seo, S. I. et al. The role of diverting stoma after an ultra-low anterior resection for rectal cancer. Ann. Coloproctol. 29, 66–71 (2013).

    PubMed  PubMed Central  Google Scholar 

  56. 56.

    Nurkin, S., Kakarla, V. R., Ruiz, D. E., Cance, W. G. & Tiszenkel, H. I. The role of faecal diversion in low rectal cancer: a review of 1791 patients having rectal resection with anastomosis for cancer, with and without a proximal stoma. Colorectal Dis. 15, e309–e316 (2013).

    CAS  PubMed  Google Scholar 

  57. 57.

    Jayne, D. G. et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J. Clin. Oncol. 25, 3061–3068 (2007).

    PubMed  Google Scholar 

  58. 58.

    van der Pas, M. H. et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 14, 210–218 (2013).

    Google Scholar 

  59. 59.

    Martling, A. L. et al. Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project. Lancet 356, 93–96 (2000).

    CAS  PubMed  Google Scholar 

  60. 60.

    Wibe, A. et al. A national strategic change in treatment policy for rectal cancer — implementation of total mesorectal excision as routine treatment in Norway. A national audit. Dis. Colon Rectum 45, 857–866 (2002).

    PubMed  Google Scholar 

  61. 61.

    Leroy, J. et al. Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes. Surg. Endosc. 18, 281–289 (2004).

    CAS  PubMed  Google Scholar 

  62. 62.

    Kang, S. B. et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol. 11, 637–645 (2010).

    PubMed  Google Scholar 

  63. 63.

    Buunen, M. et al. COLOR II. A randomized clinical trial comparing laparoscopic and open surgery for rectal cancer. Dan. Med. Bull. 56, 89–91 (2009).

    CAS  PubMed  Google Scholar 

  64. 64.

    Stevenson, A. R. et al. Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA 314, 1356–1363 (2015).

    CAS  PubMed  Google Scholar 

  65. 65.

    Fleshman, J. et al. Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA 314, 1346–1355 (2015).

    CAS  PubMed  PubMed Central  Google Scholar 

  66. 66.

    Strong, S. A. & Soper, N. J. Minimally invasive approaches to rectal cancer and diverticulitis: does less mean more. JAMA 314, 1343–1345 (2015).

    CAS  PubMed  Google Scholar 

  67. 67.

    Fleshman, J. et al. Disease-free survival and local recurrence for laparoscopic resection compared with open resection of stage II to III rectal cancer: follow-up results of the ACOSOG Z6051 randomized controlled trial. Ann. Surg. 269, 589–595 (2019).

    PubMed  Google Scholar 

  68. 68.

    Stevenson, A. R. L. et al. Disease-free survival and local recurrence after laparoscopic-assisted resection or open resection for rectal cancer: the Australasian laparoscopic cancer of the rectum randomized clinical trial. Ann. Surg. 269, 596–602 (2019).

    PubMed  Google Scholar 

  69. 69.

    Bianchi, P. P. et al. Robotic versus laparoscopic total mesorectal excision for rectal cancer: a comparative analysis of oncological safety and short-term outcomes. Surg. Endosc. 24, 2888–2894 (2010).

    CAS  PubMed  Google Scholar 

  70. 70.

    D’Annibale, A. et al. Total mesorectal excision: a comparison of oncological and functional outcomes between robotic and laparoscopic surgery for rectal cancer. Surg. Endosc. 27, 1887–1895 (2013).

    PubMed  Google Scholar 

  71. 71.

    Jayne, D. et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR Randomized Clinical Trial. JAMA 318, 1569–1580 (2017).

    PubMed  PubMed Central  Google Scholar 

  72. 72.

    Emile, S. H. et al. Evolution of transanal total mesorectal excision for rectal cancer: from top to bottom. World J. Gastrointest. Surg. 10, 28–39 (2018).

    PubMed  PubMed Central  Google Scholar 

  73. 73.

    Sylla, P., Rattner, D. W., Delgado, S. & Lacy, A. M. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg. Endosc. 24, 1205–1210 (2010).

    PubMed  Google Scholar 

  74. 74.

    Lacy, A. M. et al. Transanal total mesorectal excision for rectal cancer: outcomes after 140 patients. J. Am. Coll. Surg. 221, 415–423 (2015).

    PubMed  Google Scholar 

  75. 75.

    Penna, M. et al. Transanal total mesorectal excision: international registry results of the first 720 cases. Ann. Surg. 266, 111–117 (2017).

    PubMed  Google Scholar 

  76. 76.

    Atallah, S. et al. Transanal minimally invasive surgery for total mesorectal excision (TAMIS-TME): results and experience with the first 20 patients undergoing curative-intent rectal cancer surgery at a single institution. Tech. Coloproctol. 18, 473–480 (2014).

    CAS  PubMed  Google Scholar 

  77. 77.

    Burke, J. P. et al. Transanal total mesorectal excision for rectal cancer: early outcomes in 50 consecutive patients. Colorectal Dis. 18, 570–577 (2016).

    CAS  PubMed  Google Scholar 

  78. 78.

    Caycedo-Marulanda, A., Jiang, H. Y. & Kohtakangas, E. L. Outcomes of a single surgeon-based transanal-total mesorectal excision (TATME) for rectal cancer. J. Gastrointest. Cancer 49, 455–462 (2018).

    CAS  PubMed  Google Scholar 

  79. 79.

    de Lacy, F. B. et al. Transanal total mesorectal excision: pathological results of 186 patients with mid and low rectal cancer. Surg. Endosc. 32, 2442–2447 (2018).

    PubMed  Google Scholar 

  80. 80.

    Ma, B. et al. Transanal total mesorectal excision (taTME) for rectal cancer: a systematic review and meta-analysis of oncological and perioperative outcomes compared with laparoscopic total mesorectal excision. BMC Cancer 16, 380 (2016).

    PubMed  PubMed Central  Google Scholar 

  81. 81.

    Muratore, A., Mellano, A., Marsanic, P. & De Simone, M. Transanal total mesorectal excision (taTME) for cancer located in the lower rectum: short- and mid-term results. Eur. J. Surg. Oncol. 41, 478–483 (2015).

    CAS  PubMed  Google Scholar 

  82. 82.

    Motson, R. W., Whiteford, M. H., Hompes, R., Albert, M. & Miles, W. F. Current status of trans-anal total mesorectal excision (TaTME) following the Second International Consensus Conference. Colorectal Dis. 18, 13–18 (2016).

    CAS  PubMed  Google Scholar 

  83. 83.

    Penna, M., Hompes, R., Mackenzie, H., Carter, F. & Francis, N. K. First international training and assessment consensus workshop on transanal total mesorectal excision (taTME). Tech. Coloproctol. 20, 343–352 (2016).

    CAS  PubMed  Google Scholar 

  84. 84.

    Francis, N. et al. Consensus on structured training curriculum for transanal total mesorectal excision (TaTME). Surg. Endosc. 31, 2711–2719 (2017).

    PubMed  Google Scholar 

  85. 85.

    Clancy, C., Burke, J. P., Albert, M. R., O’Connell, P. R. & Winter, D. C. Transanal endoscopic microsurgery versus standard transanal excision for the removal of rectal neoplasms: a systematic review and meta-analysis. Dis. Colon Rectum 58, 254–261 (2015).

    PubMed  Google Scholar 

  86. 86.

    Martin-Perez, B., Andrade-Ribeiro, G. D., Hunter, L. & Atallah, S. A systematic review of transanal minimally invasive surgery (TAMIS) from 2010 to 2013. Tech. Coloproctol. 18, 775–788 (2014).

    CAS  PubMed  Google Scholar 

  87. 87.

    Kidane, B., Chadi, S. A., Kanters, S., Colquhoun, P. H. & Ott, M. C. Local resection compared with radical resection in the treatment of T1N0M0 rectal adenocarcinoma: a systematic review and meta-analysis. Dis. Colon Rectum 58, 122–140 (2015).

    PubMed  Google Scholar 

  88. 88.

    You, Y. N., Baxter, N. N., Stewart, A. & Nelson, H. Is the increasing rate of local excision for stage I rectal cancer in the United States justified? A nationwide cohort study from the National Cancer Database. Ann. Surg. 245, 726–733 (2007).

    PubMed  PubMed Central  Google Scholar 

  89. 89.

    Stitzenberg, K. B., Sanoff, H. K., Penn, D. C., Meyers, M. O. & Tepper, J. E. Practice patterns and long-term survival for early-stage rectal cancer. J. Clin. Oncol. 31, 4276–4282 (2013).

    PubMed  PubMed Central  Google Scholar 

  90. 90.

    Paty, P. B. et al. Long-term results of local excision for rectal cancer. Ann. Surg. 236, 522–529 (2002).

    PubMed  PubMed Central  Google Scholar 

  91. 91.

    Sengupta, S. & Tjandra, J. J. Local excision of rectal cancer: what is the evidence. Dis. Colon Rectum 44, 1345–1361 (2001).

    CAS  PubMed  Google Scholar 

  92. 92.

    Smart, C. J. et al. Multicentre study of short-course radiotherapy and transanal endoscopic microsurgery for early rectal cancer. Br. J. Surg. 103, 1069–1075 (2016).

    CAS  PubMed  Google Scholar 

  93. 93.

    Lezoche, E. et al. Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br. J. Surg. 99, 1211–1218 (2012).

    CAS  PubMed  Google Scholar 

  94. 94.

    Garcia-Aguilar, J. et al. Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol. 16, 1537–1546 (2015).

    PubMed  PubMed Central  Google Scholar 

  95. 95.

    Rullier, E. et al. Organ preservation for rectal cancer (GRECCAR 2): a prospective, randomised, open-label, multicentre, phase 3 trial. Lancet 390, 469–479 (2017).

    PubMed  Google Scholar 

  96. 96.

    Martens, M. H. et al. Long-term outcome of an organ preservation program after neoadjuvant treatment for rectal cancer. J. Natl Cancer Inst. 108, djw171 (2016).

    PubMed  Google Scholar 

  97. 97.

    Dossa, F., Chesney, T. R., Acuna, S. A. & Baxter, N. N. A watch-and-wait approach for locally advanced rectal cancer after a clinical complete response following neoadjuvant chemoradiation: a systematic review and meta-analysis. Lancet Gastroenterol. Hepatol. 2, 501–513 (2017).

    PubMed  Google Scholar 

  98. 98.

    Dattani, M. et al. Oncological and survival outcomes in watch and wait patients with a clinical complete response after neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and pooled analysis. Ann. Surg. 268, 955–967 (2018).

    PubMed  Google Scholar 

  99. 99.

    Maas, M. et al. Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer. J. Clin. Oncol. 29, 4633–4640 (2011).

    PubMed  Google Scholar 

  100. 100.

    Renehan, A. G. et al. Watch-and-wait approach versus surgical resection after chemoradiotherapy for patients with rectal cancer (the OnCoRe project): a propensity-score matched cohort analysis. Lancet Oncol. 17, 174–183 (2016).

    PubMed  Google Scholar 

  101. 101.

    van der Valk, M. J. M. et al. Long-term outcomes of clinical complete responders after neoadjuvant treatment for rectal cancer in the International Watch & Wait Database (IWWD): an international multicentre registry study. Lancet 391, 2537–2545 (2018).

    PubMed  Google Scholar 

  102. 102.

    Habr-Gama, A. et al. Local recurrence after complete clinical response and watch and wait in rectal cancer after neoadjuvant chemoradiation: impact of salvage therapy on local disease control. Int. J. Radiat. Oncol. Biol. Phys. 88, 822–828 (2014).

    PubMed  Google Scholar 

  103. 103.

    Appelt, A. L., Pløen, J., Vogelius, I. R., Bentzen, S. M. & Jakobsen, A. Radiation dose-response model for locally advanced rectal cancer after preoperative chemoradiation therapy. Int. J. Radiat. Oncol. Biol. Phys. 85, 74–80 (2013).

    PubMed  Google Scholar 

  104. 104.

    Habr-Gama, A. et al. Achieving a complete clinical response after neoadjuvant chemoradiation that does not require surgical resection - It may take longer than you think! Dis. Colon Rectum 62, 802–808 (2019).

    PubMed  Google Scholar 

  105. 105.

    Parmar, K. L., Malcomson, L. & Renehan, A. G. Watch and wait or surgery for clinical complete response in rectal cancer: a need to study both sides. Colorectal Dis. https://doi.org/10.1111/codi.14912 (2019).

  106. 106.

    Maas, M. et al. Assessment of clinical complete response after chemoradiation for rectal cancer with digital rectal examination, endoscopy, and MRI: selection for organ-saving treatment. Ann. Surg. Oncol. 22, 3873–3880 (2015).

    PubMed  PubMed Central  Google Scholar 

  107. 107.

    Sammour, T., Price, B. A., Krause, K. J. & Chang, G. J. Nonoperative management or ‘watch and wait’ for rectal cancer with complete clinical response after neoadjuvant chemoradiotherapy: a critical appraisal. Ann. Surg. Oncol. 24, 1904–1915 (2017).

    PubMed  PubMed Central  Google Scholar 

  108. 108.

    Glynne-Jones, R. et al. Rectal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann. Oncol. 29 (Suppl. 4), iv263 (2018).

    CAS  PubMed  Google Scholar 

  109. 109.

    American College of Surgeons Commission on Cancer. The National Accreditation Program for Rectal Cancer Standards Manual. 2017 edition. facs.org https://www.facs.org/-/media/files/quality-programs/cancer/naprc/naprc-standards-manual.ashx (2017).

  110. 110.

    Bosch, S. L. & Nagtegaal, I. D. The importance of the pathologist’s role in assessment of the quality of the mesorectum. Curr. Colorectal Cancer Rep. 8, 90–98 (2012).

    PubMed  PubMed Central  Google Scholar 

  111. 111.

    Maslekar, S. et al. Mesorectal grades predict recurrences after curative resection for rectal cancer. Dis. Colon Rectum 50, 168–175 (2007).

    PubMed  Google Scholar 

  112. 112.

    Nagtegaal, I. D. et al. Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J. Clin. Oncol. 20, 1729–1734 (2002).

    PubMed  Google Scholar 

  113. 113.

    Kitz, J. et al. Association of plane of total mesorectal excision with prognosis of rectal cancer: secondary analysis of the CAO/ARO/AIO-04 phase 3 randomized clinical trial. JAMA Surg. 153, e181607 (2018).

    PubMed  PubMed Central  Google Scholar 

  114. 114.

    College of American Pathologists (CAP). Protocol for the Examination of Specimens from Patients with Primary Carcinoma of the Colon and Rectum. Based on AJCC/UICC TNM, 7th edition. ColonRectum 3.1.0.0 cap.org http://webapps.cap.org/apps/docs/committees/cancer/cancer_protocols/2009/Colon_09protocol.pdf (2011).

  115. 115.

    Royal College of Pathologists. Standards and datasets for reporting cancers. Dataset for histopathological reporting of colorectal cancer. 2017. https://www.rcpath.org/uploads/assets/c8b61ba0-ae3f-43f1-85ffd3ab9f17cfe6/G049-dataset-for-histopathological-reporting-of-colorectal-cancer.pdf.

  116. 116.

    Nagtegaal, I. D. & Quirke, P. What is the role for the circumferential margin in the modern treatment of rectal cancer. J. Clin. Oncol. 26, 303–312 (2008).

    PubMed  Google Scholar 

  117. 117.

    Glynne-Jones, R., Mawdsley, S. & Novell, J. R. The clinical significance of the circumferential resection margin following preoperative pelvic chemo-radiotherapy in rectal cancer: why we need a common language. Colorectal Dis. 8, 800–807 (2006).

    CAS  PubMed  Google Scholar 

  118. 118.

    Hong, K. S., Moon, N., Chung, S. S., Lee, R. A. & Kim, K. H. Oncologic outcomes in rectal cancer with close distal resection margins: a retrospective analysis. Ann. Surg. Treat. Res. 89, 23–29 (2015).

    PubMed  PubMed Central  Google Scholar 

  119. 119.

    Persiani, R. et al. Prognostic implications of the lymph node count after neoadjuvant treatment for rectal cancer. Br. J. Surg. 101, 133–142 (2014).

    CAS  PubMed  Google Scholar 

  120. 120.

    Rullier, A. et al. Lymph nodes after preoperative chemoradiotherapy for rectal carcinoma: number, status, and impact on survival. Am. J. Surg. Pathol. 32, 45–50 (2008).

    PubMed  Google Scholar 

  121. 121.

    Awwad, G. E., Tou, S. I. & Rieger, N. A. Prognostic significance of lymph node yield after long-course preoperative radiotherapy in patients with rectal cancer: a systematic review. Colorectal Dis. 15, 394–403 (2013).

    CAS  PubMed  Google Scholar 

  122. 122.

    Chang, G. J., Rodriguez-Bigas, M. A., Eng, C. & Skibber, J. M. Lymph node status after neoadjuvant radiotherapy for rectal cancer is a biologic predictor of outcome. Cancer 115, 5432–5440 (2009).

    PubMed  Google Scholar 

  123. 123.

    Berman, H. L. The Tumor Board: is it worth saving. Mil. Med. 140, 529–531 (1975).

    CAS  PubMed  Google Scholar 

  124. 124.

    The Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. A policy framework for commissioning cancer services : A report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. (The Calman-Hine Report). (Department of Health, 1995).

  125. 125.

    Berrino, F. et al. Survival for eight major cancers and all cancers combined for European adults diagnosed in 1995-99: results of the EUROCARE-4 study. Lancet Oncol. 8, 773–783 (2007).

    PubMed  Google Scholar 

  126. 126.

    Dietz, D. W. Consortium, for optimizing surgical treatment of rectal cancer (OSTRiCh). Multidisciplinary management of rectal cancer: the OSTRICH. J. Gastrointest. Surg. 17, 1863–1868 (2013).

    PubMed  Google Scholar 

  127. 127.

    Monson, J. R. et al. Failure of evidence-based cancer care in the United States: the association between rectal cancer treatment, cancer center volume, and geography. Ann. Surg. 260, 625–631 (2014).

    PubMed  Google Scholar 

  128. 128.

    van Leeuwen, A. F., Voogt, E., Visser, A., van der Rijt, C. C. & van der Heide, A. Considerations of healthcare professionals in medical decision-making about treatment for clinical end-stage cancer patients. J. Pain Symptom Manage. 28, 351–355 (2004).

    PubMed  Google Scholar 

  129. 129.

    Patkar, V. et al. Cancer multidisciplinary team meetings: evidence, challenges, and the role of clinical decision support technology. Int. J. Breast Cancer 2011, 831605 (2011).

    PubMed  PubMed Central  Google Scholar 

  130. 130.

    National Institute for Clinical Excellence (NICE). Improving Outcomes in Colorectal Cancers: Manual Update. nice.org https://www.nice.org.uk/guidance/ng151 (2004).

  131. 131.

    Rickles, A. S. et al. High rate of positive circumferential resection margins following rectal cancer surgery: a call to action. Ann. Surg. 262, 891–898 (2015).

    PubMed  PubMed Central  Google Scholar 

  132. 132.

    Patel, A., Franko, E. R. & Fleshman, J. W. Utilizing the multidisciplinary team for planning and monitoring care and quality improvement. Clin. Colon Rectal Surg. 28, 12–20 (2015).

    CAS  PubMed  PubMed Central  Google Scholar 

  133. 133.

    An international, multidisciplinary approach to the management of advanced colorectal cancer. The International Working Group in Colorectal Cancer. Eur. J. Surg. Oncol. 23 (Suppl. A), 1–66 (1997).

  134. 134.

    Jessop, J. & Daniels, I. in Challenges in Colorectal Cancer, 2nd ed. (eds Scholefield, J. H., Abcarian, H., Maughan, T. & Grothey, A.). 167–177 (Blackwell, 2006).

  135. 135.

    Richardson, B. et al. The effect of multidisciplinary teams for rectal cancer on delivery of care and patient outcome: has the use of multidisciplinary teams for rectal cancer affected the utilization of available resources, proportion of patients meeting the standard of care, and does this translate into changes in patient outcome. Am. J. Surg. 211, 46–52 (2016).

    PubMed  Google Scholar 

  136. 136.

    Swellengrebel, H. A. et al. Multidisciplinary discussion and management of rectal cancer: a population-based study. World J. Surg. 35, 2125–2133 (2011).

    CAS  PubMed  PubMed Central  Google Scholar 

  137. 137.

    Brännström, F. et al. Multidisciplinary team conferences promote treatment according to guidelines in rectal cancer. Acta Oncol. 54, 447–453 (2015).

    PubMed  Google Scholar 

  138. 138.

    Verdecchia, A. et al. Survival trends in European cancer patients diagnosed from 1988 to 1999. Eur. J. Cancer 45, 1042–1066 (2009).

    PubMed  Google Scholar 

  139. 139.

    Wille-Jørgensen, P. et al. Result of the implementation of multidisciplinary teams in rectal cancer. Colorectal Dis. 15, 410–413 (2013).

    PubMed  Google Scholar 

  140. 140.

    Munro, A., Brown, M., Niblock, P., Steele, R. & Carey, F. Do multidisciplinary team (MDT) processes influence survival in patients with colorectal cancer? A population-based experience. BMC Cancer 15, 686 (2015).

    PubMed  PubMed Central  Google Scholar 

  141. 141.

    Taylor, C. et al. Multidisciplinary team working in cancer: what is the evidence. BMJ 340, c951 (2010).

    PubMed  Google Scholar 

  142. 142.

    El Saghir, N. S. et al. Global practice and efficiency of multidisciplinary tumor boards: results of an American Society of Cinical Oncology international survey. J. Glob. Oncol. 1, 57–64 (2015).

    PubMed  PubMed Central  Google Scholar 

  143. 143.

    Ugwumadu, L. et al. The role of the multidisciplinary team in the management of deep infiltrating endometriosis. Gynecol. Surg. 14, 15 (2017).

    PubMed  PubMed Central  Google Scholar 

  144. 144.

    Berho, M., Narang, R., Van Koughnett, J. A. & Wexner, S. D. Modern multidisciplinary perioperative management of rectal cancer. JAMA Surg. 150, 260–266 (2015).

    PubMed  Google Scholar 

  145. 145.

    Wexner, S. D. & Berho, M. E. The rationale for and reality of the new national accreditation program for rectal cancer. Dis. Colon Rectum 60, 595–602 (2017).

    PubMed  Google Scholar 

  146. 146.

    Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N. Engl. J. Med. 336, 980–987 (1997).

  147. 147.

    Kapiteijn, E. et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N. Engl. J. Med. 345, 638–646 (2001).

    CAS  PubMed  Google Scholar 

  148. 148.

    Sauer, R. et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N. Engl. J. Med. 351, 1731–1740 (2004).

    CAS  PubMed  Google Scholar 

  149. 149.

    Bosset, J. F. et al. Chemotherapy with preoperative radiotherapy in rectal cancer. N. Engl. J. Med. 355, 1114–1123 (2006).

    CAS  PubMed  Google Scholar 

  150. 150.

    Hong, Y. S. et al. Oxaliplatin, fluorouracil, and leucovorin versus fluorouracil and leucovorin as adjuvant chemotherapy for locally advanced rectal cancer after preoperative chemoradiotherapy (ADORE): an open-label, multicentre, phase 2, randomised controlled trial. Lancet Oncol. 15, 1245–1253 (2014).

    CAS  PubMed  Google Scholar 

  151. 151.

    Rödel, C. et al. Oxaliplatin added to fluorouracil-based preoperative chemoradiotherapy and postoperative chemotherapy of locally advanced rectal cancer (the German CAO/ARO/AIO-04 study): final results of the multicentre, open-label, randomised, phase 3 trial. Lancet Oncol. 16, 979–989 (2015).

    PubMed  Google Scholar 

  152. 152.

    Guillou, P. J. et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365, 1718–1726 (2005).

    PubMed  Google Scholar 

  153. 153.

    Laurent, C., Leblanc, F., Wutrich, P., Scheffler, M. & Rullier, E. Laparoscopic versus open surgery for rectal cancer: long-term oncologic results. Ann. Surg. 250, 54–61 (2009).

    PubMed  Google Scholar 

  154. 154.

    Lujan, J. et al. The learning curve of laparoscopic treatment of rectal cancer does not increase morbidity. Cir. Esp. 92, 485–490 (2014).

    PubMed  Google Scholar 

  155. 155.

    Segelman, J., Singnomklao, T., Hellborg, H. & Martling, A. Differences in multidisciplinary team assessment and treatment between patients with stage IV colon and rectal cancer. Colorectal Dis. 11, 768–774 (2009).

    CAS  PubMed  Google Scholar 

  156. 156.

    Lordan, J. T., Karanjia, N. D., Quiney, N., Fawcett, W. J. & Worthington, T. R. A 10-year study of outcome following hepatic resection for colorectal liver metastases - The effect of evaluation in a multidisciplinary team setting. Eur. J. Surg. Oncol. 35, 302–306 (2009).

    CAS  PubMed  Google Scholar 

  157. 157.

    MacDermid, E. et al. Improving patient survival with the colorectal cancer multi-disciplinary team. Colorectal Dis. 11, 291–295 (2009).

    CAS  PubMed  Google Scholar 

  158. 158.

    Palmer, G., Martling, A., Cedermark, B. & Holm, T. Preoperative tumour staging with multidisciplinary team assessment improves the outcome in locally advanced primary rectal cancer. Colorectal Dis. 13, 1361–1369 (2011).

    CAS  PubMed  Google Scholar 

  159. 159.

    Du, C. Z. et al. Effect of multidisciplinary team treatment on outcomes of patients with gastrointestinal malignancy. World J. Gastroenterol. 17, 2013–2018 (2011).

    PubMed  PubMed Central  Google Scholar 

  160. 160.

    Ye, Y. J. et al. Impact of multidisciplinary team working on the management of colorectal cancer. Chin. Med. J. 125, 172–177 (2012).

    PubMed  Google Scholar 

  161. 161.

    Levine, R. A., Chawla, B., Bergeron, S. & Wasvary, H. Multidisciplinary management of colorectal cancer enhances access to multimodal therapy and compliance with National Comprehensive Cancer Network (NCCN) guidelines. Int. J. Colorectal Dis. 27, 1531–1538 (2012).

    PubMed  Google Scholar 

  162. 162.

    Prades, J., Remue, E., van Hoof, E. & Borras, J. M. Is it worth reorganising cancer services on the basis of multidisciplinary teams (MDTs)? A systematic review of the objectives and organisation of MDTs and their impact on patient outcomes. Health Policy 119, 464–474 (2015).

    PubMed  PubMed Central  Google Scholar 

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Keller, D.S., Berho, M., Perez, R.O. et al. The multidisciplinary management of rectal cancer. Nat Rev Gastroenterol Hepatol 17, 414–429 (2020). https://doi.org/10.1038/s41575-020-0275-y

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