Elsevier

Radiotherapy and Oncology

Volume 76, Issue 3, September 2005, Pages 241-250
Radiotherapy and Oncology

Expert opinion
The multidisciplinary rectal cancer treatment: Main convergences, controversial aspects and investigational areas which support the need for an European Consensus

https://doi.org/10.1016/j.radonc.2005.07.001Get rights and content

Abstract

Background and purpose

During the past decades staging and treatment of rectal cancer are used different in Europe and in North America. To promote a process to integrate the daily practice with the best evidence of the literature an International Conference was organized in Italy. Agreement between Experts, Centres, and specialists who participated in the Conference are reported.

Methods

Five aspects were analyzed and a questionnaire was tailored for this purpose. The questionnaire had 159 questions. During the Conference, at the beginning of each Session, the moderators showed the answers from the Experts and the Centres, and, at the end of the session, the audience voted in all controversial issues. Agreements were scored at three levels: minimum, if it was between 51 and 74% of votes for each group; moderate, between 75 and 94%; large, more than 94%.

Results

The main results are: staging: endoanal ultrasound was considered as mandatory in T staging, in the evaluation of sphincter infiltration, and in the restaging of T after chemoradiotherapy (chRT). Magnetic Resonance Imaging is mandatory in the evaluation of mesorectal fascia infiltration. Endoscopy had a moderate agreement for the definition of tumour location, and the barium enema as optional. Digital rectal examination is complementary for staging and PET-CT investigational for T, N and yT staging. Preoperative radiotherapy: for T4 stage chRT was always the preferred treatment, often with moderate agreement, for any tumour location and N status. For T3, chRT received the same agreement except for high location and N0-N1. For T2 stage, N2 and positive nodes outside the mesorectum, chRT received minimum agreement for low and middle tumours; for high tumours only positive nodes outside the mesorectum was agreed upon. Preoperative radiotherapy, negative specimen and sphincter preservation: chRT was agreed by many for all T stages and N presentations of lower third tumours, except for T1-2 N0-N1. Postoperative treatments: the selection for these treatments often received moderate agreement according to the infiltration of surrounding organs, positive nodal status and circumferential radial margins. Therapy of metastatic disease: an agreement was found for FOLFOX as first-line therapy and for FOLFIRI as second-line, although comparaitive studies show similar activity of FOLFOX and FOLFIRI regimens.

Conclusions

This process represents an expertise opinion process that may contribute to increased scientific debate and to promote the development of ‘guidelines’, ‘clinical recommendations’ and ultimately a Consensus on the evolving approach to rectal cancer treatment.

Section snippets

Material and methods

Five aspects of rectal cancer staging and treatment were analyzed: ‘Staging’, ‘Preoperative Radiotherapy’, ‘Preoperative Radiotherapy, Negative Specimen and Sphincter Preservation’, ‘Postoperative Treatment’ and ‘Therapy of Metastatic Disease’. Each of them represented a section in a questionnaire tailored for this purpose. The questionnaire had 159 questions addressing the main aspects in rectal cancer staging and treatment. The questionnaire was defined by the Board of the Experts involved in

Staging (Appendix III)

Endoanal Ultrasound (EUS) was considered as mandatory in T staging, in the evaluation of sphincter infiltration by the tumour, and in the restaging of T after preoperative long course radiotherapy+concomitant chemotherapy. Magnetic Resonance Imaging (MRI) was considered mandatory in the evaluation of mesorectal fascia infiltration. Endoscopy had a moderate agreement for the definition of tumour location, and the barium enema as optional. Digital rectal examination was considered complementary

Discussion

The process analyzed, the outcomes of staging methodologies and treatment modalities to identify which of them had produced a level of agreement among participants to be used as reference for defining future programmes, investigational protocols and ‘guidelines’, i.e. clinical recommendations. The goal was to identify the main convergences, controversial aspects and investigational areas of each diagnostic and therapeutic approach to offer support to the different strategies that

Conclusion

The process addressed the outcomes in the literature of staging and treatment to identify main convergences, controversial aspects and investigational areas to offer a more detailed understanding on the arguments to debate for the following definition of ‘guidelines’, clinical recommendations and official Consensus.

More than 100 Centres, mostly Italian, participated in the process either as Experts or as physicians who treat a high volume of patients. The original data and composition of the

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