. 2019 Feb;31(1):117–134. doi: 10.21147/j.issn.1000-9604.2019.01.07

9.

Treatment of cT3/cT4N+ rectal cancer

Stage	Stratification	Class I recommendation	Class II recommendation	Class III recommendation
^a, Concurrent radiochemotherapy + surgery + adjuvant chemotherapy is the standard treatment for locally advanced top and lower rectal cancers (1-8). Concurrent chemoradiotherapy: capecitabine 825 mg/m² bid or 5-FU CIV: 225 mg/(m²·d), 5 d every week. Radiotherapy dose is 45.0−50.4 Gy/25−28 fractions. Either 3D-CRT or intensity modulated radiation therapy (IMRT) can be used. ^b, Surgery should be carried out after 5−12 weeks if long-course chemoradiotherapy is used. ^c, Refer to Section 3.1.1.2 postoperative adjuvant treatment as a reference for adjuvant chemotherapy. ^d, Short-course radiotherapy 5 × 5 Gy (9-12) is mainly suitable for low-risk patients. Multidisciplinary team (MDT) discussion should be taken considering the necessity of downstaging and long-term toxicity. ^e, The recommended total adjuvant treatment course is 6 months including neoadjuvant radiochemotherapy and postoperative adjuvant chemotherapy (13). If postoperative pathology after neoadjuvant radiochemotherapy shows the stage is greater than yp stage II, adjuvant fluorouracil monochemotherapy can be considered after communicating with the patient (14). ^f, Surgery + adjuvant chemotherapy can be used on rectal cancer patients with a low risk of local recurrence. ^g, The treatment strategy of preoperative chemotherapy + radiochemotherapy + surgery is based on a small number of phase II or retrospective studies (15,16) and can be an alternative. ^h, Chemotherapy is recommended if surgery contraindications are present. The FOLFOXIRI regimen is not recommended. The recommended total adjuvant treatment course is 6 months (13). ⁱ, If comprehensive therapy can be carried out on re-evaluation, the total adjuvant treatment course (including chemotherapy and radiotherapy) should not exceed 6 months (13). Postoperative adjuvant therapy should be started as soon as possible (not later than 8 weeks). If poor wound healing in perineum, delayed recovery of intestinal function, or other conditions occur, postoperative adjuvant radiotherapy can be delayed, but no later than 12 weeks.
cT3N0	Middle rectal cancers with peritoneum covered	Concurrent radiochemotherapy^a + transabdominal resection^b + adjuvant chemotherapy^c (Level 1A evidence)	Short-course radiotherapy^d + transabdominal resection^b + adjuvant chemotherapy^c (Level 1B evidence)	Transabdominal resection^b +/− adjuvant therapy^c,e,f
cT3N0	Middle rectal cancers without peritoneum covered or lower rectal cancers	Concurrent radiochemotherapy^a + transabdominal resection^b + adjuvant chemotherapy^c (Level 1A evidence)	Short-course radiotherapy^d + transabdominal resection^b + adjuvant chemotherapy^c (Level 1B evidence)	—
cT4/any N, cT/N1−2, or locally unresectable	None	Concurrent radiochemotherapy^a + transabdominal resection^b + adjuvant chemotherapy^c (Level 1A evidence)	Chemotherapy^g + concurrent radiochemotherapy^a + transabdominal resection^b +/− chemotherapy^h (Level 2A evidence)	—
cT3,4 or N+	Medical factors that contraindicate surgical resection are present	Concurrent radiochemotherapy^a + transabdominal resection^b + adjuvant chemotherapy^c (Level 1A evidence)	Chemotherapy^g + concurrent radiochemotherapy^a + transabdominal resection^b +/− chemotherapy^h (Level 2A evidence)	—
cT3,4N0, any T/N+, or patients who did not undergo preoperative radiotherapy due to contraindications for multimodal therapy or other reasons	pT1−2N0 after transabdominal resection	Observation		—
	pT3−4N0 or any pT/N1−2 after transabdominal resection	Re-evaluationⁱ: Adjuvant chemotherapy^c + adjuvant radiochemotherapy^a + adjuvant chemotherapy^c (Level 1A evidence)	Re-evaluationⁱ: Adjuvant radiochemotherapy^a + adjuvant chemotherapy^c (Level 1B evidence)	—