Multidisciplinary treatment of patients with rectal cancer: Development during the past decades and plans for the future

Figures & data

Table I. TNM classification (version 5, 1997) with subclassifications.

TNM	Stage	Extension to
Tis N0 M0	0	Carcinoma in situ: intraepithelial or invasion of lamina propria
T1 N0 M0	I	Submucosa
T2 N0 M0	I	Muscularis propria
T3 N0 M0	IIA	Subserosa/perirectal tissue
	Substaging^a	T3a	Less than 1 mm
		T3b	1–5 mm
		T3c	5–15 mm
		T3d	15 + mm
T4 N0 M0	IIB	(b) Perforation into visceral peritoneum; or (a) invasion to other organs^b
T1–2 N1 M0	IIIA	1–3 regional nodes involved
T3–4 N1 M0	IIIB	1–3 regional nodes involved^c
T1–4 N2 M0	IIIC	4 or more regional nodes involved
T1–4 N1–2 M1	IV	Distant metastases

^aThis subclassification based upon an evaluation using MRI prior to treatment decision is clinically valuable, and used when describing the treatment strategy for primary rectal cancer. It can be used also in the histopathological classification but is not yet validated and therefore not incorporated in any of the TNM versions 5–7.

^bThis is the subclassification in TNM 5. It has been reversed in TNM 6 and 7.

^cLymph node classification is modified in TNM 7. Tumour cell deposits without a visible lymph node structure are also considered. It is recommended to investigate at least 12 nodes for proper staging.

Figure 1. Subgrouping of localized rectal cancer assessed by MRI ¹⁾ and recommended primary treatment. ¹⁾The algorithm does not primarily address the risk of systemic disease, although this risk also increases with the presence of many of ‘the risk factors’, however, not necessarily parallel to the local failure rate (LFR). The algorithm is also ‘too simplified’ in that also other factors like size of the mesorectum, anterior or posterior location, extramural vascular invasion (EMVI+) are relevant. The recommendations are the ones in use at most centres in Sweden in 2011. ²⁾Calculated in the group of patients planned for surgery, i.e. irrespective of the surgical outcome. The figures are valid if the surgeon is an experienced rectal cancer surgeon and no pretreatment is given. ³⁾A local procedure is possible in a few patients (chiefly pT1, sm1 (+2), N0). This group is in the text referred to as ‘very favourable’. ⁴⁾CRT means chemoradiotherapy to 50.4 Gy in 1.8 Gy fractions with 5-fluorouracil (capecitabine); 5 × 5 Gy with delayed surgery is used in patients not fit for CRT.