The NCCN Rectal Cancer Guidelines panel believes that a multidisciplinary approach, including representation from gastroenterology, medical oncology, surgical oncology, radiation oncology, and radiology is necessary for treating patients with rectal cancer. Adequate pathologic assessment of the resected lymph nodes is important with a goal of evaluating at least 12 nodes when possible. Patients with very early stage tumors lesions that are node-negative by endorectal ultrasound or endorectal or pelvic MRI and who meet carefully defined criteria can be managed with a transanal excision. A transabdominal resection is appropriate for all other rectal lesions. Preoperative chemoRT is preferred for the majority of patients with suspected or proven T3/T4 disease and/or regional node involvement and adjuvant chemotherapy is recommended. Patients with recurrent localized disease should be considered for resection with or without radiotherapy. A patient with metastatic disease in the liver or lung should be considered for surgical resection if he or she is a candidate for surgery and if complete resection (RO) or ablation can be achieved. Preoperative chemotherapy can be considered as initial therapy in patients with synchronous or metachronous resectable metastatic disease (i.e., neoadjuvant therapy) or when a response to chemotherapy may convert a patient from an unresectable to resectable state (i.e., conversion therapy). Other options for patients with resectable synchronous metastases are initial treatment with chemoRT or chemotherapy with or without a bevacizumab or cetuximab (KRAS wild type tumor only) followed by consolidating chemoRT. Resection should be followed by adjuvant therapy based on prior therapy received. The recommended post-treatment surveillance program for rectal cancer patients includes serial CEA determinations, as well as periodic chest, abdominal and pelvic CT scans, and periodic evaluations by colonoscopy and proctoscopy. Recommendations for patients with previously untreated disseminated metastatic disease represent a continuum of care in which lines of treatment are blurred rather than discrete. Principles to consider at the start of therapy include pre-planned strategies for altering therapy for patients in both the presence and absence of disease progression, including plans for adjusting therapy for patients who experience certain toxicities. Recommended initial therapy options for advanced or metastatic disease depend on whether or not the patient is appropriate for intensive therapy. The more intensive initial therapy options include FOLFOX, FOLFIRI, CapeOX, and FOLFOXIRI (category 2B). Addition of a biologic agent (e.g., bevacizumab or cetuximab) is either recommended, or listed as an option, in combination with some of these regimens, depending on available data. Chemotherapy options for patients with progressive disease are dependent on the choice of initial therapy. The panel endorses the concept that treating patients in a clinical trial has priority over standard or accepted therapy. © Journal of the National Comprehensive Cancer Network 2009.
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