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Treatment Policies – Rectal Cancers

Treatment Guidelines for Rectal Cancer (2012)

1. Colon cancer, rectal cancer, Rs cancer, intramucosal cancer (Ip, Is, LST): endoscopic mucous membrane resection

Cases where resection is difficult, with remaining lesions (where additional resection difficult) or sm massive (vertically 1,000 μm, Ip 3,000 μm) or more, or testing positive for budding or vascular invasion require resection/D2 removal (or above) with laparoscopic assistance

SM cancer: D2 removal (or above) with laparoscopic assistance

PM cancer / SS cancer (5 cm or smaller): resection/D3 removal with laparoscopic assistance

SS cancer 5 cm or larger: also consider open surgery

2. Rectal cancer Ra (cut end at anus 3 cm), Rb area (cut end at anus 2 cm), intramucosal cancer (Ip, Is, LST): endoscopic mucose membrane resection

Cases where resection is difficult, with remaining lesions (where additional resection difficult) or sm massive (vertically 1,000 μm, Ip 3,000 μm) or more, or testing positive for budding or vascular invasion require D2 removal or more with laparoscopic assistance

SM cancer: D2 removal (or above) with laparoscopic assistance

Cases with lymph node delineation: D3 removal

PM cancer onwards: D3 removal with laparoscopic assistance (+ lateral removal: where lower margin is Rb or lower)

【 Indicators for super-low anterior Resection】

A1 or above = Rectal cancer, cut end at anus: Using the TME cut end at the anus as a resected specimen, in cases where resection is considered possible 2 cm from the tumor    Up to PM = Consider possibility of internal sphincter resection

【 Internal anal sphincter resection indicators】

Cases of cancer with dentate line up to MP (A1)

【 Indicators for ileostomy】

High Risk Groups for super-low anterior resection, internal sphincter resection or suture failure (stenosis, incomplete evacuation, poor condition of resectioned ring)

【 Pelvic evisceration】

Proactively considered in cases of rectal cancer infiltrating urinary organs (bladder, prostate)

Note 1: Diagnosis of invasion depth should be done in reference to diagnostic criteria when using lower alimentary canal contrast imaging or endoscopy. Ultrasound endoscopy is used to diagnose invasion depth in the rectal area, and early stage cancer invasion depth diagnosis is done using enlarged pit diagnosis.

3. Chemotherapy (adjuvant)

No chemotherapy in Stage 0, I or Stage II

Six months of 5-FU type oral drug administration in cases of Stage II severe (high CEA, ileus stenosis, fenestration, low differentiation, positive vascular invasion, examination of fewer than 12 lymph nodes) and Stage III A

Six months of Xelox (eight courses) in Stage III B

4. Chemotherapy (recurrence treatment): In line with guidelines for treatment of large intestine cancer

5.Radiotherapy Treatment

Absolute indicators for radiotherapy treatment: Cancer of anal flat epithelium
Rectal Ra and b advanced cancers: pre-surgery chemoradiation therapy

6. Post-surgical monitoring (in line with guidelines)

Blood testing: Every three months during first year, and subsequently every six months
Abdominal CT: every 6 months
Thoracic CT: Annually
PET: 6 months after rectal cancer surgery
Colon endoscopy: One year after surgery, then providing no findings, subsequently in the fourth year