title: Modern multidisciplinary treatment of rectal cancer based on staging with magnetic resonance imaging leads to excellent local control, but distant control remains a challenge.
abstract: OBJECTIVE
  The purpose of this multicenter cohort study was to evaluate whether a differentiated treatment of primary rectal cancer based on magnetic resonance imaging (MRI) can reduce the number of incomplete resections and local recurrences and improve recurrence-free and overall survival.
  
  
  METHODS
  From February 2003 until January 2008, 296 patients with rectal cancer underwent preoperative MRI using a lymph node specific contrast agent to predict circumferential resection margin (CRM), T- and N-stage. Based on expert reading of the MRI, patients were stratified in: (a) low risk for local recurrence (CRM>2mm and N0 status), (b) intermediate risk and (c) high risk (close/involved CRM, N2 status or distal tumours). Mainly based on this MRI risk assessment patients were treated with (a) surgery only (TME or local excision), (b) preoperative 5 × 5 Gy+TME and (c) a long course of chemoradiation therapy followed by surgery after a 6-8 week interval.
  
  
  RESULTS
  Overall 228 patients underwent treatment with curative intent: 49 with surgery only, 86 with 5 × 5 Gy and surgery and 93 with chemoradiation and surgery. The number of complete resections (margin>1mm) was 218 (95.6%). At a median follow-up of 41 months the three-year local recurrence rate, disease-free survival rate and overall survival rate is 2.2%, 80% and 84.5%, respectively.
  
  
  CONCLUSIONS
  With a differentiated multimodality treatment based on dedicated preoperative MR imaging, local recurrence is no longer the main problem in rectal cancer treatment. The new challenges are early diagnosis and treatment, reducing morbidity of treatment and preferably prevention of metastatic disease.
authors.affiliation: Maastricht University Medical Center, Department of Surgery, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
authors.forename: S M E
authors.initials: SM
authors.lastname: Engelen
authors.forename: M
authors.initials: M
authors.lastname: Maas
authors.forename: M J
authors.initials: MJ
authors.lastname: Lahaye
authors.forename: J W A
authors.initials: JW
authors.lastname: Leijtens
authors.forename: C L H
authors.initials: CL
authors.lastname: van Berlo
authors.forename: R L H
authors.initials: RL
authors.lastname: Jansen
authors.forename: S O
authors.initials: SO
authors.lastname: Breukink
authors.forename: C H C
authors.initials: CH
authors.lastname: Dejong
authors.forename: C J H
authors.initials: CJ
authors.lastname: van de Velde
authors.forename: R G H
authors.initials: RG
authors.lastname: Beets-Tan
authors.forename: G L
authors.initials: GL
authors.lastname: Beets
mesh_terms: D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D000069287:Capecitabine; D059248:Chemoradiotherapy / Q000379:methods*; D003841:Deoxycytidine / Q000008:administration & dosage / Q000031:analogs & derivatives; D018572:Disease-Free Survival; D005260:Female; D005472:Fluorouracil / Q000008:administration & dosage / Q000031:analogs & derivatives; D005500:Follow-Up Studies; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000517:prevention & control*; D009367:Neoplasm Staging; D009944:Organoplatinum Compounds / Q000008:administration & dosage; D000077150:Oxaliplatin; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery* / Q000628:therapy*; D012074:Remission Induction; D016896:Treatment Outcome
chemical_list: D009944:Organoplatinum Compounds; D000077150:Oxaliplatin; D003841:Deoxycytidine; D000069287:Capecitabine; D005472:Fluorouracil