title: Second St. Gallen European Organisation for Research and Treatment of Cancer Gastrointestinal Cancer Conference: consensus recommendations on controversial issues in the primary treatment of rectal cancer.
abstract: Primary treatment of rectal cancer was the focus of the second St. Gallen European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Cancer Conference. In the context of the conference, a multidisciplinary international expert panel discussed and voted on controversial issues which could not be easily answered using published evidence. Main topics included optimal pretherapeutic imaging, indication and type of neoadjuvant treatment, and the treatment strategies in advanced tumours. Here we report the key recommendations and summarise the related evidence. The treatment strategy for localised rectal cancer varies from local excision in early tumours to neoadjuvant radiochemotherapy (RCT) in combination with extended surgery in locally advanced disease. Optimal pretherapeutic staging is a key to any treatment decision. The panel recommended magnetic resonance imaging (MRI) or MRI + endoscopic ultrasonography (EUS) as mandatory staging modalities, except for early T1 cancers with an option for local excision, where EUS in addition to MRI was considered to be most important because of its superior near-field resolution. Primary surgery with total mesorectal excision was recommended by most panellists for some early tumours with limited risk of recurrence (i.e. cT1-2 or cT3a N0 with clear mesorectal fascia on MRI and clearly above the levator muscles), whereas all other stages were considered for multimodal treatment. The consensus panel recommended long-course RCT over short-course radiotherapy for most clinical situations where neoadjuvant treatment is indicated, with the exception of T3a/b N0 tumours where short-course radiotherapy or even no neoadjuvant therapy were regarded to be an option. In patients with potentially resectable tumours and synchronous liver metastases, most panel members did not see an indication to start with classical fluoropyrimidine-based RCT but rather favoured preoperative short-course radiotherapy with systemic combination chemotherapy or alternatively a liver-first resection approach in resectable metastases, which both allow optimal systemic therapy for the metastatic disease. In general, proper patient selection and discussion in an experienced multidisciplinary team was considered as crucial component of care.
authors.affiliation: CaritasKlinikum St. Theresia, Saarbrücken, Germany. Electronic address: m.lutz@caritasklinikum.de.
authors.forename: Manfred P
authors.initials: MP
authors.lastname: Lutz
authors.affiliation: Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, The Alfred Centre, Melbourne, Australia.
authors.forename: John R
authors.initials: JR
authors.lastname: Zalcberg
authors.affiliation: Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, UK.
authors.forename: Rob
authors.initials: R
authors.lastname: Glynne-Jones
authors.affiliation: The Netherlands Cancer Institute, Amsterdam, The Netherlands.
authors.forename: Theo
authors.initials: T
authors.lastname: Ruers
authors.affiliation: Gustave Roussy, Université Paris-Saclay, Département de Médecine, Villejuif, France.
authors.forename: Michel
authors.initials: M
authors.lastname: Ducreux
authors.affiliation: CUF Hospitals, Oncology Center, Lisbon, Portugal.
authors.forename: Dirk
authors.initials: D
authors.lastname: Arnold
authors.affiliation: Universitätsklinikum Carl Gustav Carus, Dresden, Germany.
authors.forename: Daniela
authors.initials: D
authors.lastname: Aust
authors.affiliation: Department of Diagnostic Imaging, The Royal Marsden NHS Foundation Trust, London, UK.
authors.forename: Gina
authors.initials: G
authors.lastname: Brown
authors.affiliation: The Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland.
authors.forename: Krzysztof
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authors.affiliation: Oxford University Hospitals NHS Trust, Oxford, UK.
authors.forename: Christopher
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authors.affiliation: Institut Bergonié, Université de Bordeaux, Bordeaux, France.
authors.forename: Serge
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authors.lastname: Evrard
authors.affiliation: Universitätsklinikum Carl Gustav Carus, Dresden, Germany.
authors.forename: Gunnar
authors.initials: G
authors.lastname: Folprecht
authors.affiliation: Centre A Lacassagne, Nice, France.
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Gerard
authors.affiliation: Angelita and Joaquim Gama Institute, São Paulo, Brazil.
authors.forename: Angelita
authors.initials: A
authors.lastname: Habr-Gama
authors.affiliation: Department of Radiation Oncology, University Hospitals Leuven, Belgium.
authors.forename: Karin
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authors.lastname: Haustermans
authors.affiliation: Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Torbjörn
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authors.lastname: Holm
authors.affiliation: The Netherlands Cancer Institute, Amsterdam, The Netherlands.
authors.forename: Koert F
authors.initials: KF
authors.lastname: Kuhlmann
authors.affiliation: University Cancer Center Leipzig (UCCL), University Medicine Leipzig, Germany.
authors.forename: Florian
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authors.lastname: Lordick
authors.affiliation: Visceral Surgery, HUG, Geneva, Switzerland.
authors.forename: Gilles
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authors.lastname: Mentha
authors.affiliation: I. Med. Klinik und Poliklinik, Johannes Gutenberg Universität Mainz, Mainz, Germany.
authors.forename: Markus
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authors.lastname: Moehler
authors.affiliation: Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: Iris D
authors.initials: ID
authors.lastname: Nagtegaal
authors.affiliation: Department of Surgery, University of California, Irvine, CA, USA.
authors.forename: Alessio
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authors.lastname: Pigazzi
authors.affiliation: Clinica Chirurgica I, University of Padova, Padua, Italy.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Pucciarelli
authors.affiliation: Visceral Surgery, HUG, Geneva, Switzerland.
authors.forename: Arnaud
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authors.lastname: Roth
authors.affiliation: Catharina Hospital Eindhoven, Eindhoven and GROW: School of Oncology and Developmental Biology, University Maastricht, Maastricht, The Netherlands.
authors.forename: Harm
authors.initials: H
authors.lastname: Rutten
authors.affiliation: Department of Oncology/Haematology, Martin-Luther-University Halle, Halle (Saale), Germany.
authors.forename: Hans-Joachim
authors.initials: HJ
authors.lastname: Schmoll
authors.affiliation: Department of Oncology, Haukeland University Hospital, University of Bergen, Norway; Department of Clinical Science, Haukeland University Hospital, University of Bergen, Norway.
authors.forename: Halfdan
authors.initials: H
authors.lastname: Sorbye
authors.affiliation: Digestive Oncology, University Hospitals Gasthuisberg/Leuven, Leuven, Belgium.
authors.forename: Eric
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authors.lastname: Van Cutsem
authors.affiliation: Universitätsklinikum Carl Gustav Carus, Dresden, Germany.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Weitz
authors.affiliation: Tumor- und Brustzentrum ZeTuP, St. Gallen, Switzerland.
authors.forename: Florian
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authors.lastname: Otto
mesh_terms: D000970:Antineoplastic Agents / Q000627:therapeutic use; D059248:Chemoradiotherapy / Q000379:methods; D003131:Combined Modality Therapy; D003952:Diagnostic Imaging / Q000379:methods; D005060:Europe; D006801:Humans; D020360:Neoadjuvant Therapy / Q000379:methods; D009367:Neoplasm Staging / Q000379:methods; D012004:Rectal Neoplasms / Q000175:diagnosis / Q000628:therapy*; D018570:Risk Assessment / Q000379:methods
chemical_list: D000970:Antineoplastic Agents
keywords: Imaging; Radiochemotherapy; Radiotherapy; Rectal cancer; Staging; Surgery