Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes

Abstract

Consensus abstractBackground: The management of primary rectal cancer beyond total mesorectal excision planes (PRCbTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority. Methods: Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web- Executive summaryThe executive summary supports the need for standardization of care and a collaborative, cross-discipline consensus statement. Burden of disease:There are 14 000 new rectal cancers per year in the UK, 40 000 in the USA and under half a million new cases per year globally. Of these, 5-10 per cent have invaded adjacent organs at presentation and 10 per cent recur following primary surgery. Complexity of surgery:Major, exenterative, multivisceral resections require specialist multiprofessional care. The surgical procedures are time-consuming (up to 12 h) and are associated with prolonged length of hospital stay (between 10 and 30 days). Long-term 5-year survival rates vary between 30 and 50 per cent. Adverse event rates have been reported in up to 50 per cent of patients. Superspecialist training of surgeons within a multidisciplinary team is required. Inappropriate worldwide variation in practice:There is a wide range of practice from non-specialist and specialist centres, with unequal access to care across global settings. These include differing referral selection criteria, where patients are often denied potentially curative treatment. When surgery is offered, the outcome is neither captured by the national databases nor audited locally. * Collaborating members are shown at the end of the article. 1010The Beyond TME Collaborative Standardization of definitions: Definitions for the rectum, for primary rectal cancer beyond conventional total mesorectal excision planes, and for recurrent rectal cancer have been defined heterogeneously in the literature and between different institutions, leading to a clear requirement for standardization of the exact definition of these terms.The need for policy: Delay in diagnosis is common and inequalities exist in referral patterns based on geography, with no clear clinical guidelines. No current guidelines exist for these patients, despite the significant burden, cost of surgery, morbidity and national variations in care.Resource impact: The cost-effectiveness of the complex assessments and interventions requires further research. The quality of life and morbidity from non-operative management are unknown. There is a need for specialist training of the mul...

Advances in surgical management for locally recurrent rectal cancer: How far have we come?

“…These procedures are technically challenging and their roles are still debatable. Two recent Delphi studies[60,61], have confirmed the views of many world experts that extensive lateral side wall involvement still remains a relative contraindication to curative surgery.…”

Benchmarking trial between France and Australia comparing management of primary rectal cancer beyond TME and locally recurrent rectal cancer (PelviCare Trial): rationale and design

“…This is a non-interventional study, no supplementary examinations to those performed in the framework of patient care management will be carried out for the inclusion of patients. According to the guidelines established by a consensus of international experts [ 1 ], before inclusion, the patients should have a pelvic MRI and a thoracoabdominal-pelvic scan. Patients should be included after MDT meeting discussion, irrespective of a curative or palliative treatment decision.…”

“…These anatomical limits can affect the resectability of primary rectal cancer beyond the total mesorectal plane (PRC-bTME) and locally recurrent rectal cancer (LRRC). In fact, 5 to 10 % of cases of rectal cancer are bTME at the time of diagnosis with an extension to an adjacent organ (T4bNxM0) limiting their resectability [ 1 , 2 ]. After radiochemotherapy, 30 % of these tumours will be resectable at the cost of extensive pelvic surgery and 10 % remain non-resectable [ 3 ].…”

Radiotherapy for locally recurrent rectal cancer treated with surgery alone as the initial treatment

“…However, curative excision is possible in fewer than half of patients with recurrent rectal cancer [6-8]. Radiotherapy or chemoradiotherapy are the alternative treatments for unresectable recurrent cases [9]. Various symptoms are reported in 71%–89% of patients with locally recurrent rectal cancer [8,10].…”