General Information About Rectal Cancer
Incidence and Mortality
Genetic risk factors
Other risk factors
Clinical Presentation and Symptoms
Clinical Evaluation and Staging
Incidence and Mortality
Estimated new cases and deaths from rectal cancer in the United States in 2014:
- New cases: 40,000 (rectal cancer only).
- Deaths: 50,310 (colon and rectal cancers combined).
It is difficult to separate epidemiological considerations of rectal cancer from those of colon cancer because epidemiological studies often consider colon and rectal cancer (i.e., colorectal cancer) together.Epidemiology
Worldwide, colorectal cancer is the third most common form of cancer. In 2000, colorectal cancer accounted for 9.4% of the world's new cancers, with 945,000 cases diagnosed, and 7.9% of the world's cancer deaths, with 492,000 deaths. Colorectal cancer affects men and women almost equally. Among all racial groups in the United States, African Americans have the highest sporadic colorectal cancer incidence and mortality rates.[3,4]
Adenocarcinomas account for the vast majority of rectal tumors in the United States. Rare tumors, including carcinoid tumors, lymphomas, and neuroendocrine tumors, account for less than 3% of colorectal tumors.
Gastrointestinal stromal tumors can occur in the rectum. (Refer to the PDQ summary on Gastrointestinal Stromal Tumors Treatment for more information.)Anatomy
The rectum is located within the pelvis, extending from the transitional mucosa of the anal dentate line to the sigmoid colon at the peritoneal reflection; by rigid sigmoidoscopy, the rectum measures between 10 cm and 15 cm from the anal verge. The location of a rectal tumor is usually indicated by the distance between the anal verge, dentate line, or anorectal ring and the lower edge of the tumor, with measurements differing depending on the use of a rigid or flexible endoscope or digital examination. The distance of the tumor from the anal sphincter musculature has implications for the ability to perform sphincter-sparing surgery. The bony constraints of the pelvis limit surgical access to the rectum, which results in a lesser likelihood of attaining widely negative margins and a higher risk of local recurrence.Risk Factors
Genetic risk factors
Individuals with certain known single-gene disorders are at an increased risk of developing rectal cancer. Single-gene disorders related to known syndromes account for about 10% to 15% of colorectal cancers. (Refer to the PDQ summary on Genetics of Colorectal Cancer for more information.) The hereditary colorectal cancer syndromes and some genes that are involved include:[7-9]
- Hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome: mismatch repair (MMR) genes.
- Familial adenomatous polyposis (FAP): APC gene.
- Turcot syndrome: APC gene; MMR genes.
- Attenuated familial adenomatous polyposis (AFAP): APC gene.
- Hyperplastic polyposis syndrome: BRAF and KRAS2 genes.
- Peutz-Jeghers syndrome: STK11/LKB1 gene.
- Juvenile polyposis syndrome: SMAD4/DPC4 and BMPR1A genes.
- Cowden syndrome: PTEN gene.
- Ruvalcaba–Myhre–Smith syndrome: PTEN gene.
- Hereditary mixed polyposis syndrome.
HNPCC, the result of defects in MMR genes (involving hMSH2, hMLH1, hPMS1, hPMS2, or hMSH6) represents the most common form of hereditary colorectal cancer, accounting for approximately 3% to 5% of all colorectal malignancies. The majority of genetically defined cases involve hMSH2 on chromosome 2p, and hMLH1 on chromosome 3p. In affected families, 15% to 60% of family members are found to have mutations in hMSH2 or hMLH1; the mutation prevalence depends on features of the family history. Ashkenazi Jews also have an increased risk for colorectal cancer related to a mutation in the APC gene (I1307K), which occurs in 6% to 7% of the Ashkenazi Jewish population.Other risk factors
More common conditions with an increased risk include:
- Personal history of colorectal cancer or colorectal adenomas.
- First-degree family history of colorectal cancer or colorectal adenomas.
- Personal history of ovarian, endometrial, or breast cancer.[13,14]
These high-risk groups account for only 23% of all colorectal cancers. Limiting screening or early cancer detection to only these high-risk groups would miss the majority of colorectal cancers. (Refer to the PDQ summaries on Colorectal Cancer Screening and Colorectal Cancer Prevention for more information.)Clinical Presentation and Symptoms
Similar to colon cancer, symptoms of rectal cancer may include the following:
- Gastrointestinal bleeding.
- Change in bowel habits.
- Abdominal pain.
- Intestinal obstruction.
- Weight loss.
- Change in appetite.
Excepting obstructive symptoms, the symptoms of rectal cancer neither necessarily correlate with the stage of disease nor signify a particular diagnosis. Physical examination may reveal a palpable mass and bright blood in the rectum. With metastatic disease, adenopathy, hepatomegaly, or pulmonary signs may be present. Laboratory examination may reveal iron-deficiency anemia and electrolyte and liver function abnormalities.Clinical Evaluation and Staging
Accurate staging provides crucial information about the location and size of the primary tumor in the rectum, and, if present, the size, number, and location of any metastases. Accurate initial staging can influence therapy by helping to determine the type of surgical intervention and the choice of neoadjuvant therapy to maximize the likelihood of resection with clear margins. In primary rectal cancer, pelvic imaging helps determine the depth of tumor invasion, the distance from the sphincter complex, the potential for achieving negative circumferential (radial) margins, and the involvement of locoregional lymph nodes or adjacent organs. The initial clinical evaluation and staging procedures may include the following:[7,18-23]
- Digital-rectal examination and/or rectovaginal exam and rigid proctoscopy to determine if sphincter-saving surgery is possible.[7,18,19]
- Complete colonoscopy to rule out cancers elsewhere in the bowel.
- Pan-body computed tomography (CT) scan to rule out metastatic disease.
- Magnetic resonance imaging (MRI) of the abdomen and pelvis to determine the depth of penetration and the potential for achieving negative circumferential (radial) margins, as well as to identify locoregional nodal metastases and distant metastatic disease.
- Endorectal ultrasound (ERUS) with a rigid probe or a flexible scope for stenotic lesions to determine the depth of penetration and identify locoregional nodal metastases.[19,21]
- Positron emission tomography (PET) to image distant metastatic disease.
- Measurement of the serum carcinoembryonic antigen (CEA) level for prognostic assessment and the determination of response to therapy.[22,23]
In the tumor (T) staging of rectal carcinoma, several studies indicate that the accuracy of ERUS ranges from 80% to 95% compared with 65% to 75% for CT and 75% to 85% for MRI. The accuracy in determining metastatic nodal involvement by ERUS is approximately 70% to 75% compared with 55% to 65% for CT and 60% to 70% for MRI. In a meta-analysis of 84 studies, none of the three imaging modalities, including ERUS, CT, and MRI, were found to be significantly superior to the others in staging nodal status. ERUS using a rigid probe may be similarly accurate in T and regional lymph node (N) staging when compared to ERUS using a flexible scope; however, a technically difficult ERUS may give an inconclusive or inaccurate result for both T stage and N stage. In this case, further assessment by MRI or flexible ERUS may be considered.[21,25]
In patients with rectal cancer, the circumferential resection margin (CRM) is an important pathological staging parameter. Measured in millimeters, it is defined as the retroperitoneal or peritoneal adventitial soft-tissue margin closest to the deepest penetration of tumor.
Although based on retrospective data, the American Joint Committee on Cancer and a National Cancer Institute-sponsored panel have recommended that at least 12 lymph nodes be examined in patients with colon and rectal cancer to confirm the absence of nodal involvement by the tumor.[7,26-28][Level of evidence: 3iiiA] This recommendation takes into consideration that the number of lymph nodes examined is a reflection of both the aggressiveness of lymphovascular mesenteric dissection at the time of surgical resection and the pathologic identification of nodes in the specimen. Retrospective studies have demonstrated that the number of lymph nodes examined in colon and rectal surgery may be associated with therapeutic outcome.[29-32] Staging studies may be required if recurrence or progression of disease is suspected; MRI may be particularly helpful in determining sacral involvement in local recurrence.Treatment
Because of the increased risk of local recurrence and a poorer overall prognosis, the management of rectal cancer varies somewhat from that of colon cancer. Differences include surgical technique, the use of radiation therapy, and the method of chemotherapy administration. In addition to determining the intent of rectal cancer surgery (i.e., curative or palliative), it is important to consider therapeutic issues related to the maintenance or restoration of normal anal sphincter, genitourinary, and sexual functions.[25,33] The approach to the management of rectal cancer should be multimodal and should involve a multidisciplinary team of cancer specialists with expertise in gastroenterology, medical oncology, surgical oncology, radiation oncology, and radiology.
The surgical approach to treatment varies according to the location, stage, and presence or absence of high-risk features (i.e., positive margins, lymphovascular invasion, perineural invasion, and poorly differentiated histology) and may include:[25,33,34]
- Polypectomy for select T1 cancers.
- Transanal local excision (LE) and transanal endoscopic microsurgery (TEM) for select clinically staged T1/T2 N0 rectal cancers.
- Total mesorectal excision (TME) with autonomic nerve preservation (ANP) techniques via low anterior resection (LAR).
- TME via abdominoperineal resection (APR) for patients who are not candidates for sphincter-preserving operations, leaving patients with a permanent end-colostomy.
Polypectomy alone for cure may be used in certain instances in which polyps with invasive cancer can be completely resected with clear margins and have favorable histologic features.[35,36] For patients with advanced cancers of the mid- to upper rectum, LAR followed by the creation of a colorectal anastomosis may be the treatment of choice. However, in general, for locally advanced rectal cancers for which radical resection is indicated, TME with ANP techniques via LAR is preferable to APR.[25,33]
Although postoperative therapy for patients with stage II or III rectal cancer remains an acceptable option, neoadjuvant therapy for rectal cancer, using preoperative chemoradiation, is now the preferred option for patients with stage II and III disease.[Level of evidence: 1iA] Benefits of neoadjuvant chemoradiation include tumor regression, downstaging and improvement in resectability, and a higher rate of sphincter preservation and local control. Complete pathologic response rates of 10% to 25% may be achieved with preoperative chemoradiation therapy.[38-45] However, preoperative radiation therapy is associated with increased complications compared to surgery alone; some patients with cancers at a lower risk of local recurrence might be adequately treated with surgery and adjuvant chemotherapy.[46-49] (See Treatment Option Overview section for more information.)Prognostic Factors
- Presence or absence of nodal involvement and the number of positive lymph nodes.[7,29-32]
- Adherence to or invasion of adjacent organs.
- Presence or absence of distant metastases.[7,26]
- Presence or absence of high-risk pathologic features, including positive surgical margins, lymphovascular invasion, perineural invasion, and poorly differentiated histology.[50,51,53]
- Perforation or obstruction of the bowel.[7,52]
- CRM or depth of penetration of the tumor through the bowel wall.[7,25,54]
However, only disease stage (tumor, nodal, and distant) has been validated in multi-institutional prospective studies.
A large number of studies have evaluated various other clinical, pathologic, and molecular parameters; as yet, none has been validated in multi-institutional prospective trials.[55-61] For example, MSI-H, also associated with hereditary nonpolyposis rectal cancer, was shown to be associated with improved survival independent of tumor stage in a population-based series of 607 patients with colorectal cancer who were 50 years old or younger at the time of diagnosis. In addition, gene expression profiling has been reported to be useful in predicting the response of rectal adenocarcinomas to preoperative chemoradiation therapy and in determining the prognosis of stage II and III rectal cancer after neoadjuvant 5-fluorouracil-based chemoradiation therapy.[63,64] Racial and ethnic differences in overall survival (OS) after adjuvant therapy for rectal cancer have been observed, with shorter OS for blacks compared to whites; factors contributing to this disparity may include tumor position, type of surgical procedure, and various comorbid conditions.Follow-up
The primary goals of postoperative surveillance programs for rectal cancer are the following:
- To assess the efficacy of initial therapy.
- To detect new or metachronous malignancies.
- To detect potentially curable recurrent or metastatic cancers.
Routine, periodic studies following patients treated for rectal cancer may lead to earlier identification and management of recurrent disease.[66-70] A statistically significant survival benefit has been demonstrated for more intensive follow-up protocols in two clinical trials. A meta-analysis that combined these two trials with four others was reported to show a statistically significant improvement in survival for patients who were intensively followed.[66,71,72] Guidelines for surveillance after initial treatment with curative intent for colorectal cancer vary between leading U.S. and European societies, and optimal surveillance strategies remain uncertain.[73,74] Large, well-designed, prospective, multi-institutional, randomized studies may be required to establish an evidence-based consensus for follow-up evaluation.
Measurement of CEA, a serum glycoprotein, is frequently used in the management and follow-up of patients with rectal cancer. A review of the use of this tumor marker for rectal cancer suggests the following:
- Serum CEA testing is not a valuable screening tool for rectal cancer because of its low sensitivity and low specificity.
- Postoperative CEA testing should be restricted to patients who are potential candidates for further intervention, as follows:
- Patients with stage II or III rectal cancer (every 2 to 3 months for at least 2 years after diagnosis).
- Patients with rectal cancer who would be candidates for resection of liver metastases.
In one retrospective study of the Dutch TME trial for the treatment of rectal cancer, investigators found that the preoperative serum CEA level was normal in the majority of patients with rectal cancer, and yet, serum CEA levels rose by at least 50% in patients with recurrence; the authors concluded that serial, postoperative CEA testing cannot be discarded based on a normal preoperative serum CEA level in patients with rectal cancer.[75,76]Related Summaries
Other PDQ summaries containing information related to rectal cancer include the following:
- Unusual Cancers of Childhood Treatment (colorectal cancer in children).
- Genetics of Colorectal Cancer.
- Colorectal Cancer Prevention.
- Colorectal Cancer Screening.
- American Cancer Society: Cancer Facts and Figures 2014. Atlanta, Ga: American Cancer Society, 2014. Available online. Last accessed May 21, 2014.
- Parkin DM: Global cancer statistics in the year 2000. Lancet Oncol 2 (9): 533-43, 2001. [PUBMED Abstract]
- Albano JD, Ward E, Jemal A, et al.: Cancer mortality in the United States by education level and race. J Natl Cancer Inst 99 (18): 1384-94, 2007. [PUBMED Abstract]
- Kauh J, Brawley OW, Berger M: Racial disparities in colorectal cancer. Curr Probl Cancer 31 (3): 123-33, 2007 May-Jun. [PUBMED Abstract]
- Kang H, O'Connell JB, Leonardi MJ, et al.: Rare tumors of the colon and rectum: a national review. Int J Colorectal Dis 22 (2): 183-9, 2007. [PUBMED Abstract]
- Wolpin BM, Meyerhardt JA, Mamon HJ, et al.: Adjuvant treatment of colorectal cancer. CA Cancer J Clin 57 (3): 168-85, 2007 May-Jun. [PUBMED Abstract]
- Libutti SK, Willett CG, Saltz LB: Cancer of the rectum. In: DeVita VT Jr, Lawrence TS, Rosenberg SA: Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2011, pp 1127-41.
- Strate LL, Syngal S: Hereditary colorectal cancer syndromes. Cancer Causes Control 16 (3): 201-13, 2005. [PUBMED Abstract]
- Young J, Jenkins M, Parry S, et al.: Serrated pathway colorectal cancer in the population: genetic consideration. Gut 56 (10): 1453-9, 2007. [PUBMED Abstract]
- Syngal S, Fox EA, Li C, et al.: Interpretation of genetic test results for hereditary nonpolyposis colorectal cancer: implications for clinical predisposition testing. JAMA 282 (3): 247-53, 1999. [PUBMED Abstract]
- Locker GY, Kaul K, Weinberg DS, et al.: The I1307K APC polymorphism in Ashkenazi Jews with colorectal cancer: clinical and pathologic features. Cancer Genet Cytogenet 169 (1): 33-8, 2006. [PUBMED Abstract]
- Fuchs CS, Giovannucci EL, Colditz GA, et al.: A prospective study of family history and the risk of colorectal cancer. N Engl J Med 331 (25): 1669-74, 1994. [PUBMED Abstract]
- Weinberg DS, Newschaffer CJ, Topham A: Risk for colorectal cancer after gynecologic cancer. Ann Intern Med 131 (3): 189-93, 1999. [PUBMED Abstract]
- Burstein HJ, Winer EP: Primary care for survivors of breast cancer. N Engl J Med 343 (15): 1086-94, 2000. [PUBMED Abstract]
- Winawer SJ: Screening for colorectal cancer. Cancer: Principles and Practice of Oncology Updates 2(1): 1-16, 1987.
- Stein W, Farina A, Gaffney K, et al.: Characteristics of colon cancer at time of presentation. Fam Pract Res J 13 (4): 355-63, 1993. [PUBMED Abstract]
- Majumdar SR, Fletcher RH, Evans AT: How does colorectal cancer present? Symptoms, duration, and clues to location. Am J Gastroenterol 94 (10): 3039-45, 1999. [PUBMED Abstract]
- Schmidt CR, Gollub MJ, Weiser MR: Contemporary imaging for colorectal cancer. Surg Oncol Clin N Am 16 (2): 369-88, 2007. [PUBMED Abstract]
- Siddiqui AA, Fayiga Y, Huerta S: The role of endoscopic ultrasound in the evaluation of rectal cancer. Int Semin Surg Oncol 3: 36, 2006. [PUBMED Abstract]
- Søreide K: Molecular testing for microsatellite instability and DNA mismatch repair defects in hereditary and sporadic colorectal cancers--ready for prime time? Tumour Biol 28 (5): 290-300, 2007. [PUBMED Abstract]
- Zammit M, Jenkins JT, Urie A, et al.: A technically difficult endorectal ultrasound is more likely to be inaccurate. Colorectal Dis 7 (5): 486-91, 2005. [PUBMED Abstract]
- Goldstein MJ, Mitchell EP: Carcinoembryonic antigen in the staging and follow-up of patients with colorectal cancer. Cancer Invest 23 (4): 338-51, 2005. [PUBMED Abstract]
- Das P, Skibber JM, Rodriguez-Bigas MA, et al.: Predictors of tumor response and downstaging in patients who receive preoperative chemoradiation for rectal cancer. Cancer 109 (9): 1750-5, 2007. [PUBMED Abstract]
- Lahaye MJ, Engelen SM, Nelemans PJ, et al.: Imaging for predicting the risk factors--the circumferential resection margin and nodal disease--of local recurrence in rectal cancer: a meta-analysis. Semin Ultrasound CT MR 26 (4): 259-68, 2005. [PUBMED Abstract]
- Balch GC, De Meo A, Guillem JG: Modern management of rectal cancer: a 2006 update. World J Gastroenterol 12 (20): 3186-95, 2006. [PUBMED Abstract]
- Compton CC, Greene FL: The staging of colorectal cancer: 2004 and beyond. CA Cancer J Clin 54 (6): 295-308, 2004 Nov-Dec. [PUBMED Abstract]
- Colon and rectum. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 143-64.
- Nelson H, Petrelli N, Carlin A, et al.: Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst 93 (8): 583-96, 2001. [PUBMED Abstract]
- Swanson RS, Compton CC, Stewart AK, et al.: The prognosis of T3N0 colon cancer is dependent on the number of lymph nodes examined. Ann Surg Oncol 10 (1): 65-71, 2003 Jan-Feb. [PUBMED Abstract]
- Le Voyer TE, Sigurdson ER, Hanlon AL, et al.: Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol 21 (15): 2912-9, 2003. [PUBMED Abstract]
- Prandi M, Lionetto R, Bini A, et al.: Prognostic evaluation of stage B colon cancer patients is improved by an adequate lymphadenectomy: results of a secondary analysis of a large scale adjuvant trial. Ann Surg 235 (4): 458-63, 2002. [PUBMED Abstract]
- Tepper JE, O'Connell MJ, Niedzwiecki D, et al.: Impact of number of nodes retrieved on outcome in patients with rectal cancer. J Clin Oncol 19 (1): 157-63, 2001. [PUBMED Abstract]
- Baxter NN, Garcia-Aguilar J: Organ preservation for rectal cancer. J Clin Oncol 25 (8): 1014-20, 2007. [PUBMED Abstract]
- Guillem JG, Cohen AM: Current issues in colorectal cancer surgery. Semin Oncol 26 (5): 505-13, 1999. [PUBMED Abstract]
- Cooper HS, Deppisch LM, Gourley WK, et al.: Endoscopically removed malignant colorectal polyps: clinicopathologic correlations. Gastroenterology 108 (6): 1657-65, 1995. [PUBMED Abstract]
- Seitz U, Bohnacker S, Seewald S, et al.: Is endoscopic polypectomy an adequate therapy for malignant colorectal adenomas? Presentation of 114 patients and review of the literature. Dis Colon Rectum 47 (11): 1789-96; discussion 1796-7, 2004. [PUBMED Abstract]
- Sauer R, Becker H, Hohenberger W, et al.: Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351 (17): 1731-40, 2004. [PUBMED Abstract]
- Janjan NA, Khoo VS, Abbruzzese J, et al.: Tumor downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the M. D. Anderson Cancer Center experience. Int J Radiat Oncol Biol Phys 44 (5): 1027-38, 1999. [PUBMED Abstract]
- Crane CH, Skibber JM, Birnbaum EH, et al.: The addition of continuous infusion 5-FU to preoperative radiation therapy increases tumor response, leading to increased sphincter preservation in locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 57 (1): 84-9, 2003. [PUBMED Abstract]
- Grann A, Minsky BD, Cohen AM, et al.: Preliminary results of preoperative 5-fluorouracil, low-dose leucovorin, and concurrent radiation therapy for clinically resectable T3 rectal cancer. Dis Colon Rectum 40 (5): 515-22, 1997. [PUBMED Abstract]
- Rich TA, Skibber JM, Ajani JA, et al.: Preoperative infusional chemoradiation therapy for stage T3 rectal cancer. Int J Radiat Oncol Biol Phys 32 (4): 1025-9, 1995. [PUBMED Abstract]
- Chari RS, Tyler DS, Anscher MS, et al.: Preoperative radiation and chemotherapy in the treatment of adenocarcinoma of the rectum. Ann Surg 221 (6): 778-86; discussion 786-7, 1995. [PUBMED Abstract]
- Hyams DM, Mamounas EP, Petrelli N, et al.: A clinical trial to evaluate the worth of preoperative multimodality therapy in patients with operable carcinoma of the rectum: a progress report of National Surgical Breast and Bowel Project Protocol R-03. Dis Colon Rectum 40 (2): 131-9, 1997. [PUBMED Abstract]
- Bosset JF, Magnin V, Maingon P, et al.: Preoperative radiochemotherapy in rectal cancer: long-term results of a phase II trial. Int J Radiat Oncol Biol Phys 46 (2): 323-7, 2000. [PUBMED Abstract]
- Hiotis SP, Weber SM, Cohen AM, et al.: Assessing the predictive value of clinical complete response to neoadjuvant therapy for rectal cancer: an analysis of 488 patients. J Am Coll Surg 194 (2): 131-5; discussion 135-6, 2002. [PUBMED Abstract]
- Lai LL, Fuller CD, Kachnic LA, et al.: Can pelvic radiotherapy be omitted in select patients with rectal cancer? Semin Oncol 33 (6 Suppl 11): S70-4, 2006. [PUBMED Abstract]
- Peeters KC, van de Velde CJ, Leer JW, et al.: Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients--a Dutch colorectal cancer group study. J Clin Oncol 23 (25): 6199-206, 2005. [PUBMED Abstract]
- Tepper JE, O'Connell M, Niedzwiecki D, et al.: Adjuvant therapy in rectal cancer: analysis of stage, sex, and local control--final report of intergroup 0114. J Clin Oncol 20 (7): 1744-50, 2002. [PUBMED Abstract]
- Gunderson LL, Sargent DJ, Tepper JE, et al.: Impact of T and N stage and treatment on survival and relapse in adjuvant rectal cancer: a pooled analysis. J Clin Oncol 22 (10): 1785-96, 2004. [PUBMED Abstract]
- Weiser MR, Landmann RG, Wong WD, et al.: Surgical salvage of recurrent rectal cancer after transanal excision. Dis Colon Rectum 48 (6): 1169-75, 2005. [PUBMED Abstract]
- Fujita S, Nakanisi Y, Taniguchi H, et al.: Cancer invasion to Auerbach's plexus is an important prognostic factor in patients with pT3-pT4 colorectal cancer. Dis Colon Rectum 50 (11): 1860-6, 2007. [PUBMED Abstract]
- Griffin MR, Bergstralh EJ, Coffey RJ, et al.: Predictors of survival after curative resection of carcinoma of the colon and rectum. Cancer 60 (9): 2318-24, 1987. [PUBMED Abstract]
- DeVita VT Jr, Lawrence TS, Rosenberg SA: Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2011.
- Wieder HA, Rosenberg R, Lordick F, et al.: Rectal cancer: MR imaging before neoadjuvant chemotherapy and radiation therapy for prediction of tumor-free circumferential resection margins and long-term survival. Radiology 243 (3): 744-51, 2007. [PUBMED Abstract]
- McLeod HL, Murray GI: Tumour markers of prognosis in colorectal cancer. Br J Cancer 79 (2): 191-203, 1999. [PUBMED Abstract]
- Jen J, Kim H, Piantadosi S, et al.: Allelic loss of chromosome 18q and prognosis in colorectal cancer. N Engl J Med 331 (4): 213-21, 1994. [PUBMED Abstract]
- Lanza G, Matteuzzi M, Gafá R, et al.: Chromosome 18q allelic loss and prognosis in stage II and III colon cancer. Int J Cancer 79 (4): 390-5, 1998. [PUBMED Abstract]
- Roth JA: p53 prognostication: paradigm or paradox? Clin Cancer Res 5 (11): 3345, 1999. [PUBMED Abstract]
- Nishio H, Hamady ZZ, Malik HZ, et al.: Outcome following repeat liver resection for colorectal liver metastases. Eur J Surg Oncol 33 (6): 729-34, 2007. [PUBMED Abstract]
- Edler D, Hallström M, Johnston PG, et al.: Thymidylate synthase expression: an independent prognostic factor for local recurrence, distant metastasis, disease-free and overall survival in rectal cancer. Clin Cancer Res 6 (4): 1378-84, 2000. [PUBMED Abstract]
- Popat S, Chen Z, Zhao D, et al.: A prospective, blinded analysis of thymidylate synthase and p53 expression as prognostic markers in the adjuvant treatment of colorectal cancer. Ann Oncol 17 (12): 1810-7, 2006. [PUBMED Abstract]
- Gryfe R, Kim H, Hsieh ET, et al.: Tumor microsatellite instability and clinical outcome in young patients with colorectal cancer. N Engl J Med 342 (2): 69-77, 2000. [PUBMED Abstract]
- Liersch T, Langer C, Ghadimi BM, et al.: Lymph node status and TS gene expression are prognostic markers in stage II/III rectal cancer after neoadjuvant fluorouracil-based chemoradiotherapy. J Clin Oncol 24 (25): 4062-8, 2006. [PUBMED Abstract]
- Ghadimi BM, Grade M, Difilippantonio MJ, et al.: Effectiveness of gene expression profiling for response prediction of rectal adenocarcinomas to preoperative chemoradiotherapy. J Clin Oncol 23 (9): 1826-38, 2005. [PUBMED Abstract]
- Dignam JJ, Ye Y, Colangelo L, et al.: Prognosis after rectal cancer in blacks and whites participating in adjuvant therapy randomized trials. J Clin Oncol 21 (3): 413-20, 2003. [PUBMED Abstract]
- Abir F, Alva S, Longo WE, et al.: The postoperative surveillance of patients with colon cancer and rectal cancer. Am J Surg 192 (1): 100-8, 2006. [PUBMED Abstract]
- Martin EW Jr, Minton JP, Carey LC: CEA-directed second-look surgery in the asymptomatic patient after primary resection of colorectal carcinoma. Ann Surg 202 (3): 310-7, 1985. [PUBMED Abstract]
- Bruinvels DJ, Stiggelbout AM, Kievit J, et al.: Follow-up of patients with colorectal cancer. A meta-analysis. Ann Surg 219 (2): 174-82, 1994. [PUBMED Abstract]
- Lautenbach E, Forde KA, Neugut AI: Benefits of colonoscopic surveillance after curative resection of colorectal cancer. Ann Surg 220 (2): 206-11, 1994. [PUBMED Abstract]
- Khoury DA, Opelka FG, Beck DE, et al.: Colon surveillance after colorectal cancer surgery. Dis Colon Rectum 39 (3): 252-6, 1996. [PUBMED Abstract]
- Pietra N, Sarli L, Costi R, et al.: Role of follow-up in management of local recurrences of colorectal cancer: a prospective, randomized study. Dis Colon Rectum 41 (9): 1127-33, 1998. [PUBMED Abstract]
- Secco GB, Fardelli R, Gianquinto D, et al.: Efficacy and cost of risk-adapted follow-up in patients after colorectal cancer surgery: a prospective, randomized and controlled trial. Eur J Surg Oncol 28 (4): 418-23, 2002. [PUBMED Abstract]
- Pfister DG, Benson AB 3rd, Somerfield MR: Clinical practice. Surveillance strategies after curative treatment of colorectal cancer. N Engl J Med 350 (23): 2375-82, 2004. [PUBMED Abstract]
- Li Destri G, Di Cataldo A, Puleo S: Colorectal cancer follow-up: useful or useless? Surg Oncol 15 (1): 1-12, 2006. [PUBMED Abstract]
- Kapiteijn E, Kranenbarg EK, Steup WH, et al.: Total mesorectal excision (TME) with or without preoperative radiotherapy in the treatment of primary rectal cancer. Prospective randomised trial with standard operative and histopathological techniques. Dutch ColoRectal Cancer Group. Eur J Surg 165 (5): 410-20, 1999. [PUBMED Abstract]
- Grossmann I, de Bock GH, Meershoek-Klein Kranenbarg WM, et al.: Carcinoembryonic antigen (CEA) measurement during follow-up for rectal carcinoma is useful even if normal levels exist before surgery. A retrospective study of CEA values in the TME trial. Eur J Surg Oncol 33 (2): 183-7, 2007. [PUBMED Abstract]