Background Information

A 62-year old man was diagnosed with a moderately differentiated adenocarcinoma of the rectum. Staging examinations were performed and the pelvic MRI showed a circumferential thickening of the mid-low rectum invading through the rectal wall, infiltrating the mesorectal fat and reaching the mesorectal fascia anteriorly (positive CRM).

The tumour was located 4 cm from the anal-rectal ring and had a length of 5.5 cm in the cranio-caudal direction. There were more than 3 enlarged lymph nodes with a necrotic aspect located in the mesorectum, with the axial diameter > 2 cm.

Chest and abdominal computer tomography showed no lung, liver or adrenal glands metastases. An ¹⁸F-2-fluoro-2-deoxy-D-glucose positron emission tomography showed an increased metabolic activity of the mid-low rectum (SUV max 19.2).

 

The diagnosis of an adenocarcinoma of the rectum clinical stage cT3N2M0, stage IIIC was made.

 

Which kind of treatment would you propose for this patient?

 

• Preoperative short course radiotherapy (25 Gy in 5 fractions) followed by immediate Total Mesorectal Excision (TME) surgery
• Preoperative chemoradiation (50.4 Gy in 28 fractions) followed by TME surgery after 8 weeks
• TME surgery alone 
• TME surgery followed by chemoradiation