Locally advanced rectal cancer: The importance of a multidisciplinary approach

Table 2 Clinical management of rectal cancer according to risk categories[2]

Risk group	Management
Very early (some cT1)	Local excision (TEM)If poor prognostic characteristics are present, (such as high grade, vascular invasion, etc), TME resection (or possibly CRT) can be considered
Early (cT1-2, some cT3), or “good”	Surgery alone (TME) is sufficient, and should result in a few rate of local recurrences (< 3%-4% after 5 yr)If poor prognostic characteristics are present, such as circumferential margin or nodal involvement, post-operative CRT or CT can be added
Intermediate (cT3- some cT4a), or “bad”	Surgery alone results in a high rates of local recurrences (> 8%-10% after 5 yr if surgery alone)Add preoperative RT (5 × 5 Gy) or CRT followed by TMEIf cCR is obtained with CRT, wait-and-see policy may be considered in selected cases (such as high risk patients for surgery)
Locally advanced (cT3crm +, some cT4a, all cT4b), or “ugly”	Preoperative CRT is needed to achieve high probability of R0 surgery (TEM) and a decrease of local recurrencesPreoperative 5 × 5 Gy RT with a delay to surgery can be considered in elderly or in patients with severe comorbidity who cannot tolerate CRT

TEM: Total mesorectal excision; CRT: Chemoradiotherapy; cCR: Clinical complete response; CT: Computed tomography.