European Rectal Cancer Consensus| Volume 92, ISSUE 2, P148-163, August 2009

Download started.


Multidisciplinary Rectal Cancer Management: 2nd European Rectal Cancer Consensus Conference (EURECA-CC2)


      Background and purpose

      During the first decade of the 21st century a number of important European randomized studies were published. In order to help shape clinical practice based on best scientific evidence from the literature, the International Conference on ‘Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus’ (EURECA-CC2) was organized in Italy under the endorsement of European Society of Medical Oncology (ESMO), European Society of Surgical Oncology (ESSO), and European Society of Therapeutic Radiation Oncology (ESTRO).


      Consensus was achieved using the Delphi method. The document was available to all Committee members as a web-based document customized for the consensus process. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by a topic, and a series of statements were developed. Each member commented and voted, sentence by sentence thrice. Sentences upon which an agreement was not reached after voting round # 2 were openly debated during a Consensus Conference in Perugia (Italy) from 11 December to 13 December 2008. A hand-held televoting system collected the opinions of both the Committee members and the audience after each debate. The Executive Committee scored percentage consensus based on three categories: “large consensus”, “moderate consensus”, and “minimum consensus”.


      The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only 3 (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of the members. All chapters were voted on by at least 75% of the members, and the majority was voted on by >85%.


      This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Radiotherapy and Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Valentini V.
        • Beets-Tan R.
        • Borras J.M.
        • et al.
        Evidence and research in rectal cancer.
        Radiother Oncol. 2008; 87: 449-474
        • Valentini V.
        • Glimelius B.
        • Minsky B.D.
        • et al.
        The multidisciplinary rectal cancer treatment: main convergences, controversial aspects and investigational areas which support the need for an European Consensus.
        Radiother Oncol. 2005; 76: 241-250
        • Rowe G.
        • Wright G.
        The Delphi technique as a forecasting tool: issues and analysis.
        Int J Forecast. 1999; 4: 353-375
        • Ferlay J.
        • Autier P.
        • Boniol M.
        • et al.
        Estimates of the cancer incidence and mortality in Europe in 2006.
        Ann Oncol. 2007; 18: 581-592
        • Berrino F.
        • De Angelis R.
        • Sant M.
        • et al.
        Survival for eight major cancers and all cancers combined for European adults diagnosed in 1995–99: results of EUROCARE-4 study.
        Lancet Oncol. 2007; 8: 773-783
        • Norat T.
        • Bingham S.
        • Ferrari P.
        • et al.
        Meat, fish hand colorectal cancer risk: the European Prospective Investigation into Cancer and Nutrition.
        JNCI. 2005; 97: 906-916
        • Cho E.
        • Smith-Warner S.A.
        • Spiegelman D.
        • et al.
        Dairy foods, calcium and colorectal cancer: a pooled analysis of 10 cohort studies.
        JNCI. 2004; 96: 1015-1022
        • Cho E.
        • Smith-Warner S.A.
        • Ritz J.
        • et al.
        Alcohol intake and colorectal cancer: a pooled analysis of 8 cohort studies.
        Ann Intern Med. 2004; 140: 603-613
        • Browining D.
        • Martin R.M.
        Statins and cancer: a systematic review and meta-analysis.
        Int J Cancer. 2006; 120: 833-843
        • Fernandez E.
        • La Vecchia C.
        • Balducci A.
        • et al.
        Oral contraceptives and colorectal cancer risk: a meta-analysis.
        Br J Cancer. 2001; 84: 722-727
        • Hewitson P.
        • Glasziou P.
        • Watson E.
        • et al.
        Cochrane systematic review of the effects of the screening for colorectal cancer using the faecal occult blood test, hemoccult: an update.
        Am J Gastroenterol. 2008; 103: 1541-1549
        • Bipat S.
        • Glas A.S.
        • Slors F.J.
        • et al.
        Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging: a meta-analysis.
        Radiology. 2004; 232: 773-783
        • Marusch F.
        • Koch A.
        • Schmidt U.
        • et al.
        Routine use of transrectal ultrasound in rectal carcinoma: results of a prospective multicenter study.
        Endoscopy. 2002; 34: 385-390
        • Ptok H.
        • Marusch F.
        • Meyer F.
        • et al.
        Feasibility and accuracy of TRUS in the pre-treatment staging for rectal carcinoma in general practice.
        Eur J Surg Oncol. 2006; 32: 420-425
        • Nesbakken A.
        • Løvig T.
        • Lunde O.C.
        • et al.
        Staging of rectal carcinoma with transrectal ultrasonography.
        Scand J Surg. 2003; 92: 125-129
        • Schnall M.D.
        • Furth E.E.
        • Rosato E.F.
        • et al.
        Rectal tumor stage: correlation of endorectal MR imaging and pathologic findings.
        Radiology. 1994; 190: 709-714
        • Beets-Tan R.G.
        • Beets G.L.
        • Vliegen R.F.
        • et al.
        Accuracy of magnetic resonance imaging in prediction of tumour-free resection margin in rectal cancer surgery.
        Lancet. 2001; 357: 497-504
        • Brown G.
        • Richards C.J.
        • Newcombe R.G.
        • et al.
        Rectal carcinoma: thin-section MR imaging for staging in 28 patients.
        Radiology. 1999; 211: 215-222
        • Kim C.K.
        • Kim S.H.
        • Choi D.
        • et al.
        Comparison between 3-T magnetic resonance imaging and multi-detector row computed tomography for the preoperative evaluation of rectal cancer.
        J Comput Assist Tomogr. 2007; 31: 853-859
        • Vliegen R.
        • Dresen R.
        • Beets G.
        • et al.
        The accuracy of multi-detector row CT for the assessment of tumor invasion of the mesorectal fascia in primary rectal cancer.
        Abdom Imaging. 2008; 33: 604-610
        • Kulinna C.
        • Scheidler J.
        • Strauss T.
        • et al.
        Local staging of rectal cancer: assessment with double-contrast multislice computed tomography and transrectal ultrasound.
        J Comput Assist Tomogr. 2004; 28: 123-130
        • Gearhart S.L.
        • Frassica D.
        • Rosen M.
        • et al.
        Improved staging with pretreatment positron emission tomography/computed.
        Ann Surg Oncol. 2006; 13: 397-404
        • Wolberink S.V.
        • Beets-Tan R.G.
        • de Haas-Kock D.F.
        • et al.
        Conventional CT for the prediction of an involved circumferential resection margin in primary rectal cancer.
        Dig Dis. 2007; 25: 80-85
      1. MERCURY study group. Extramural depth of tumor invasion at thin-section MR in patients with rectal cancer: results of the MERCURY study. Radiology 2007;243:132–9.

        • Lahaye M.J.
        • Engelen S.M.
        • Nelemans P.J.
        • 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. 2005; 26: 259-268
        • Vliegen R.F.
        • Beets-Tan R.G.
        • Vanhauten B.
        • et al.
        Can an FDG-PET/CT predict tumor clearance of the mesorectal fascia after preoperative chemoradiation of locally advanced rectal cancer?.
        Strahlenther Onkol. 2008; 184: 457-464
        • Smith N.
        • Brown G.
        Preoperative staging of rectal cancer.
        Acta Oncol. 2008; 47: 20-31
        • Winter L.
        • Bruhn H.
        • Langrehr J.
        • et al.
        Magnetic resonance imaging in suspected rectal cancer: determining tumor localization, stage, and sphincter-saving resectability at 3-Tesla-sustained high resolution.
        Acta Radiol. 2007; 48: 379-387
        • Pomerri F.
        • Maretto I.
        • Pucciarelli S.
        • et al.
        Prediction of rectal lymph node metastasis by pelvic computed tomography.
        Eur J Surg Oncol. 2009; 35: 168-173
        • Koh D.M.
        • Chau I.
        • Tait D.
        • et al.
        Evaluating mesorectal lymph nodes in rectal cancer before and after neoadjuvant.
        Int J Radiat Oncol Biol Phys. 2008; 71: 456-461
        • Engelen S.M.
        • Beets G.L.
        • Beets-Tan R.G.
        • et al.
        Role of preoperative local and distant staging in rectal cancer.
        Onkologie. 2007; 30: 141-145
        • Bipat S.
        • van Leeuwen M.S.
        • Comans E.F.
        • et al.
        Colorectal liver metastases: CT, MR imaging, and PET for diagnosis – meta-analysis.
        Radiology. 2005; 237: 123-131
        • Barbaro B.
        • Fiorucci C.
        • Tebala C.
        • et al.
        Locally advanced rectal cancer: MR imaging in prediction of response after preoperative chemotherapy and radiation therapy.
        Radiology. 2009; 250: 730-739
        • Calvo F.A.
        • Domper M.
        • Matute R.
        • et al.
        18F-FDG positron emission tomography staging and restaging in rectal cancer treated with preoperative chemoradiation.
        Int J Radiat Oncol Biol Phys. 2004; 58: 528-535
        • Sebag-Montefiore D.
        • Stephens R.J.
        • Steele R.
        • et al.
        Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial.
        Lancet. 2009; 373: 811-820
      2. Quirke P, Williams GT. The Royal College of Pathologists. Minimum dataset for colorectal cancer histopathology reports. London: The Royal College of Pathologists; 1998. Available from:

        • Nagtegaal I.D.
        • Van De Velde C.J.H.
        • Van Der Worp E.
        • et al.
        Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control.
        J Clin Oncol. 2002; 20: 1729-1734
        • Goldstein N.S.
        Lymph node recoveries from 2427 pT3 colorectal resection specimens spanning 45 years.
        Am J Surg Pathol. 2002; 26: 179-189
        • Quirke P.
        • Williams G.T.
        • Ectors N.
        • et al.
        The future of the TNM staging system in colorectal cancer: time for a debate?.
        Lancet Oncol. 2007; 8: 651-657
        • Nagtegaal I.D.
        • Quirke P.
        What is the role for the circumferential margin in the modern treatment of rectal cancer?.
        J Clin Oncol. 2008; 26: 303-312
        • Nagtegaal I.D.
        • Marijnen C.A.M.
        • Kranenbarg E.K.
        • et al.
        Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma. Not one millimetre but two millimetres is the limit.
        Am J Surg Pathol. 2002; 26: 350-357
      3. Quirke P. CORE study: capicitabine/oxaliplatin, radiotherapy and excision protocol Study No. C8601. Pathological technique; 2002. Appendix 7.

        • Rödel C.
        • Martus P.
        • Papadoupolos T.
        • et al.
        Prognostic significance of tumor regression after preoperative chemoradiotherapy for rectal cancer.
        J Clin Oncol. 2005; 23: 8688-8696
        • West N.P.
        • Finan P.J.
        • Anderin C.
        • et al.
        Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer.
        J Clin Oncol. 2008; 26: 3517-3522
        • Påhlman L.
        • Bohe M.
        • Cedermark B.
        • et al.
        The Swedish rectal cancer registry.
        Br J Surg. 2007; 94: 1285-1292
        • Bories E.
        • Pesenti C.
        • Monges G.
        • et al.
        Endoscopic mucosal resection for advanced sessile adenoma and early-stage colorectal carcinoma.
        Endoscopy. 2006; 38: 231-235
        • Buess G.F.
        • Raestrup H.
        Transanal endoscopic microsurgery.
        Surg Oncol Clin N Am. 2001; 10: 709-731
        • Guerrieri M.
        • Baldarelli M.
        • Organetti L.
        • et al.
        Transanal endoscopic microsurgery for the treatment of selected patients with distal rectal cancer: 15 years experience.
        Surg Endosc. 2008; 22: 2030-2035
        • Peeters K.C.
        • Marijnen C.A.
        • Nagtegaal I.D.
        • et al.
        Dutch Colorectal Cancer Group the TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma.
        Ann Surg. 2007; 246: 693-701
        • Martling A.
        • Cedermark B.
        • Johansson H.
        • et al.
        The surgeon as a prognostic factor after the introduction of total mesorectal excision in the treatment of rectal cancer.
        Br J Surg. 2002; 89: 1008-1013
        • Rutten H.J.
        • den Dulk M.
        • Lemmens V.E.
        • et al.
        Controversies of total mesorectal excision for rectal cancer in elderly patients.
        Lancet Oncol. 2008; 9: 494-501
        • Rutten H.
        • den Dulk M.
        • Lemmens V.
        • et al.
        Survival of elderly rectal cancer patients not improved: analysis of population based data on the impact of TME surgery.
        Eur J Cancer. 2007; 43: 2295-2300
        • Heald R.J.
        • Husband E.M.
        • Ryall R.D.H.
        • et al.
        The mesorectum in rectal cancer surgery: the clue to pelvic recurrence.
        Br J Surg. 1982; 69: 613-616
        • Marr R.
        • Birbeck K.F.
        • Garvican J.
        • et al.
        The modern abdomino-perineal excision – the next challenge after total mesorectal excision.
        Ann Surg. 2005; 242: 74-82
        • Quirke P.
        Optimal management of rectal cancer: the role of the pathologist.
        Eur J Cancer. 2005; 65: 349-357
        • Nagtegaal I.D.
        • Van de Velde C.J.
        • Marijnen C.A.
        • et al.
        Low rectal cancer: a call for a change of approach in abdominoperineal resection.
        J Clin Oncol. 2005; 23: 9257-9264
        • Wallner C.
        • Lange M.M.
        • Bonsing B.A.
        • et al.
        Causes of fecal and urinary incontinence after total mesorectal excision for rectal cancer based on cadaveric surgery: a study from the Cooperative Clinical Investigators of the Dutch total mesorectal.
        J Clin Oncol. 2008; 26: 4466-4472
        • Holm T.
        • Ljung A.
        • Häggmark T.
        • et al.
        Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer.
        Br J Surg. 2007; 94: 232-238
        • Påhlman L.
        Optimal management of rectal cancer – is sphincter saving an important end-point?.
        EJC Suppl. 2005; 65: 365-369
      4. Wong RKS, Tandan V, De Silva S, et al. Pre-operative radiotherapy and curative surgery for the management of localized rectal carcinoma. Cochrane Database of Systematic Reviews Issue 2. Art. No. CD002102.

        • Bujko K.
        • Kepka L.
        • Michalski W.
        • et al.
        Does rectal cancer shrinkage induced by preoperative radio(chemo)therapy increase the likelihood of anterior resection? A systematic review of randomised trials.
        Radiother Oncol. 2006; 80: 4-12
        • Minsky B.D.
        • Cohen A.M.
        • Enker W.E.
        • et al.
        Preoperative 5-FU, low-dose leucovorin, and radiation therapy for locally advanced and unresectable rectal cancer.
        Int J Radiat Oncol Biol Phys. 1997; 37: 289-295
        • Moriya Y.
        • Akasu T.
        • Fujita S.
        • et al.
        Aggressive surgical treatment for patients with T4 rectal cancer.
        Colorectal Dis. 2003; 5: 427-431
        • Yamada K.
        • Ishizawa T.
        • Niwa K.
        • et al.
        Pelvic exenteration and sacral resection for locally advanced primary and recurrent rectal cancer.
        Dis Colon Rectum. 2002; 45: 1078-1084
        • Hojo K.
        • Sawada T.
        • Moriya Y.
        An analysis of survival and voiding, sexual function after wide iliopelvic lymphadenectomy in patients with carcinoma of the rectum, compared with conventional lymphadenectomy.
        Dis Colon Rectum. 1989; 32: 128-133
        • Michelassi F.
        • Block G.E.
        Morbidity and mortality of wide pelvic lymphadenectomy for rectal adenocarcinoma.
        Dis Colon Rectum. 1992; 35: 1143-1147
        • Watanabe T.
        • Tsurita G.
        • Muto T.
        • et al.
        Extended lymphadenectomy and preoperative radiotherapy for lower rectal cancers.
        Surgery. 2002; 132: 27-33
        • Minsky B.D.
        • Mies C.
        • Rich T.A.
        • et al.
        Lymphatic vessel invasion is an independent prognostic factor for survival in colorectal cancer.
        Int J Radiat Oncol Biol Phys. 1989; 17: 311-318
        • Stamos M.J.
        • Murrell Z.
        Management of early rectal T1 and T2 cancers.
        Clin Cancer Res. 2007; 13: 6885s-6889s
        • Willett C.G.
        Sphincter preservation in rectal cancer. Local excision followed by postoperative radiation therapy.
        Semin Radiat Oncol. 1998; 8: 24-29
        • Wagman R.T.
        • Minsky B.D.
        Conservative management of rectal cancer with local excision and adjuvant therapy.
        Oncology (Huntingt). 2001; 15: 513-519
        • Gérard J.P.
        • Ortholan C.
        • Benezery K.
        • et al.
        Contact X-ray therapy for rectal cancer: experience in Centre Antoine-Lacassagne, Nice, 2002–2006.
        Int J Radiat Oncol Biol Phys. 2008; 72: 665-670
        • Radu C.
        • Berglund K.
        • Påhlman L.
        • et al.
        Short-course preoperative radiotherapy with delayed surgery in rectal cancer – a retrospective study.
        Radiother Oncol. 2008; 87: 343-349
        • Camma C.
        • Giunta M.
        • Fiorica F.
        • et al.
        Preoperative radiotherapy for resectable rectal cancer: a metaanalysis.
        JAMA. 2000; 284: 1008-1015
      5. Colorectal Cancer Collaborative Group. Adjuvant radiotherapy for rectal cancer: a systematic overview of 8507 patients from 22 randomised trials. Lancet 2001;358:1291–304.

        • Munro A.J.
        • Bentley A.
        Adjuvant radiotherapy in operable rectal cancer: a systematic review.
        Sem Colon Rectal Surg. 2002; 13: 31-42
        • Glimelius B.
        • Gronberg H.
        • Jarnhult J.
        • et al.
        A systematic overview of radiation therapy effects in rectal cancer.
        Acta Oncol. 2003; 42: 476-492
        • Bosset J.F.
        • Collette L.
        • Calais G.
        • et al.
        EORTC Radiotherapy Group Trial 22921. Chemotherapy with preoperative radiotherapy in rectal cancer.
        N Engl J Med. 2006; 355: 1114-1123
        • Gérard J.P.
        • Conroy T.
        • Bonnetain F.
        • et al.
        Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3–4 rectal cancers: results of FFCD 9203.
        J Clin Oncol. 2006; 24: 4620-4625
        • Pucciarelli S.
        • Toppan P.
        • Friso M.L.
        • et al.
        Complete pathologic response following preoperative chemoradiation therapy for middle to lower rectal cancer is not a prognostic factor for a better outcome.
        Dis Colon Rectum. 2004; 47: 1798-1807
        • Capirci C.
        • Valentini V.
        • Cionini L.
        • et al.
        Prognostic value of pathologic complete response after neoadjuvant therapy in locally advanced rectal cancer: long-term analysis of 566 ypCR patients.
        Int J Radiat Oncol Biol Phys. 2008; 72: 99-107
        • Vecchio F.M.
        • Valentini V.
        • Minsky B.D.
        • et al.
        The relationship of pathologic tumor regression grade (TRG) and outcomes after preoperative therapy in rectal cancer.
        Int J Radiat Oncol Biol Phys. 2005; 62: 752-760
        • Bujko K.
        • Nowacki M.P.
        • Nasierowska-Guttmejer A.
        • et al.
        Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer.
        Br J Surg. 2006; 93: 1215-1223
        • Guillem J.G.
        • Díaz-González J.A.
        • Minsky B.D.
        • et al.
        CT3N0 rectal cancer: potential overtreatment with preoperative chemoradiotherapy is warranted.
        J Clin Oncol. 2008; 26: 368-373
        • Glehen O.
        • Chapet O.
        • Adham M.
        • et al.
        Long-term results of the Lyons R90–01 randomized trial of preoperative radiotherapy with delayed surgery and its effect on sphincter-saving surgery in rectal cancer.
        Br J Surg. 2003; 90: 996-998
        • Collette L.
        • Bosset J.F.
        • den Dulk M.
        • et al.
        Patients with curative resection of cT3–4 rectal cancer after preoperative radiotherapy or radiochemotherapy: does anybody benefit from adjuvant fluorouracil-based chemotherapy? A trial of the Europea.
        J Clin Oncol. 2007; 25: 4379-4386
      6. QUASAR Collaborative Group, Gray R, Barnwell J, McConkey C, et al. Adjuvant chemotherapy versus observation in patients with colorectal cancer: a randomised study. Lancet 2007;370:2020–9.

        • Bosset J.F.
        • Horiot J.C.
        • Hamers H.P.
        • et al.
        Postoperative pelvic radiotherapy with or without elective irradiation of para-aortic nodes and liver in rectal cancer patients. A controlled clinical trial of the EORTC Radiotherapy Group.
        Radiother Oncol. 2001; 61: 7-13
      7. NIH Consensus Conference. Adjuvant therapy for patients with colon and rectal cancer. JAMA 1990;264:1444–50.

        • Sauer R.
        • Becker H.
        • Hoyhenberger W.
        • et al.
        For the German Rectal Cancer Study Group. Pre-operative versus post-operative chemoradiotherapy for rectal cancer.
        New Engl J Med. 2004; 351: 1731-1740
        • Gunderson L.L.
        • Sargent D.J.
        • Tepper J.E.
        • et al.
        Impact of T and N substage on survival and disease relapse in adjuvant rectal cancer: a pooled analysis.
        Int J Radiat Oncol Biol Phys. 2002; 54: 386-396
        • Lee J.H.
        • Lee J.H.
        • Ahn J.H.
        • et al.
        Randomized trial of postoperative adjuvant therapy in stage II and III rectal cancer to define the optimal sequence of chemotherapy and radiotherapy: a preliminary report.
        J Clin Oncol. 2002; 20: 1751-1758
        • Fountzilas G.
        • Zisiadis A.
        • Dafni U.
        • et al.
        Postoperative radiation and concomitant bolus fluorouracil with or without additional chemotherapy with fluorouracil and high-dose leucovorin in patients with high-risk rectal cancer: a randomized pha.
        Ann Oncol. 1999; 10: 671-676
        • Tveit K.M.
        • Guldvog I.
        • Hagen S.
        • et al.
        Randomized controlled trial of postoperative radiotherapy and short-term timescheduled 5-fluorouracil against surgery alone in the treatment of Dukes B and C rectal cancer. Norwegian adjuvant rectal C.
        Br J Surg. 1997; 84: 1130-1135
        • Pahlman L.
        • Glimelius B.
        Pre- or postoperative radiotherapy in rectal and rectosigmoid carcinoma. Report from a randomized multicenter trial.
        Ann Surg. 1990; 211: 187-195
        • Braendengen M.
        • Tveit K.M.
        • Berglund A.
        • et al.
        Randomized phase III study comparing preoperative radiotherapy with chemoradiotherapy in nonresectable rectal cancer.
        J Clin Oncol. 2008; 26: 3687-3694
        • Vermaas M.
        • Ferenschild F.T.
        • Verhoef C.
        • et al.
        Total pelvic exenteration for primary locally advanced and locally recurrent rectal cancer.
        Eur J Surg Oncol. 2007; 33: 452-458
        • Myerson R.J.
        • Valentini V.
        • Birnbaum E.H.
        • et al.
        A phase I/II trial of three-dimensionally planned concurrent boost radiotherapy and protracted venous infusion of 5-FU chemotherapy for locally advanced rectal carcinoma.
        Int J Radiat Oncol Biol Phys. 2001; 50: 1299-1308
        • Mohiuddin M.
        • Winter K.
        • Mitchell E.
        • et al.
        Randomized phase II study of neoadjuvant combined-modality chemoradiation for distal rectal cancer: Radiation Therapy Oncology Group Trial 0012.
        J Clin Oncol. 2006; 24: 650-655
        • De Ridder M.
        • Tournel K.
        • Van Nieuwenhove Y.
        • et al.
        Phase II study of preoperative helical tomotherapy for rectal cancer.
        Int J Radiat Oncol Biol Phys. 2008; 70: 728-734
        • Janjan N.A.
        • Crane C.N.
        • Feig B.W.
        • et al.
        Prospective trial of preoperative concomitant boost radiotherapy with continuous infusion 5-fluorouracil for locally advanced rectal cancer.
        Int J Radiat Oncol Biol Phys. 2000; 47: 713-718
        • Gunderson L.L.
        • Nelson H.
        • Martenson J.A.
        • et al.
        Locally advanced primary colorectal cancer: intraoperative electron and external beam irradiation +/− 5-FU.
        Int J Radiat Oncol Biol Phys. 1997; 37: 601-614
        • Mannaerts G.H.
        • Rutten H.J.
        • Martijn H.
        • et al.
        Comparison of intraoperative radiation therapy-containing multimodality treatment with historical treatment modalities for locally recurrent rectal cancer.
        Dis Colon Rectum. 2001; 44: 1749-1758
        • Wiig J.N.
        • Tveit K.M.
        • Poulsen J.P.
        • et al.
        Preoperative irradiation and surgery for recurrent rectal cancer. Will intraoperative radiotherapy (IORT) be of additional benefit? A prospective study.
        Radiother Oncol. 2002; 62: 207-213
        • Nordlinger B.
        • Sorbye H.
        • Glimelius B.
        • et al.
        Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983): a randomised controlled trial.
        Lancet. 2008; 371: 1007-1016
        • Fazio V.W.
        • Zutshi M.
        • Remzi F.H.
        • et al.
        A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers.
        Ann Surg. 2007; 246: 481-488
        • Marijnen C.A.
        • Van De Velde C.J.
        • Putter H.
        • et al.
        Impact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: report of a multicenter randomized trial.
        J Clin Oncol. 2005; 23: 1847-1858
        • Pollack J.
        • Holm T.
        • Cedermark B.
        • et al.
        Long-term effect of preoperative radiation therapy on anorectal function.
        Dis Colon Rectum. 2006; 49: 345-352
        • Pietrzak L.
        • Bujko K.
        • Nowacki M.P.
        • et al.
        Quality of life, anorectal and sexual functions after preoperative radiotherapy for rectal cancer: report of a randomised trial.
        Radiother Oncol. 2007; 84: 217-225
        • Birgisson H.
        • Påhlman L.
        • Gunnarsson U.
        • et al.
        Adverse effects of preoperative radiation therapy for rectal cancer: long-term follow-up of the Swedish Rectal Cancer Trial.
        J Clin Oncol. 2005; 23: 8697-8705
        • Kollmorgen C.F.
        • Meagher A.P.
        • Pemberton J.H.
        • et al.
        The long-term effect of adjuvant postoperative chemoradiotherapy for rectal cancer on bowel function.
        Ann Surg. 1994; 220: 76-81
        • Lange M.M.
        • Maas C.P.
        • Marijnen C.A.
        • et al.
        Urinary dysfunction after rectal cancer treatment is mainly caused by surgery.
        Br J Surg. 2008; 95: 1020-1028
      8. Lange MM, Marijnen CA, Maas CP, et al. Risk factors for sexual dysfunction after rectal cancer treatment. Total mesorectal excision trial. Eur J Cancer 2009 [Epub ahead of print].

        • Rosen M.
        • Chan L.
        • Beart Jr., R.W.
        • et al.
        Follow-up of colorectal cancer. A meta-analysis.
        Dis Colon Rectum. 1998; 41: 1116-1126
      9. Jeffery GM, Hickey BE, Hider P. Follow-up strategies for patients treated for non-metastatic colorectal cancer (Cochrane Review). The Cochrane Library, Issue 4, Oxford: Update Software; 2002.

        • Figueredo A.
        • Rumble R.B.
        • Maroun J.
        • et al.
        Follow-up of patients with curatively resected colorectal cancer: a practice guideline.
        BMC Cancer. 2003; 3: 26
        • Renehan A.G.
        • Egger M.
        • Saunders M.P.
        • et al.
        Impact on survival of intensive follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomised trials.
        BMJ. 2002; 324: 813-821
        • Birgisson H.
        • Påhlman L.
        • Gunnarsson U.
        • et al.
        Occurrence of second cancers in patients treated with radiotherapy for rectal cancer.
        J Clin Oncol. 2005; 23: 6126-6131
        • Desch C.E.
        • Benson 3rd, A.B.
        • Somerfield M.R.
        • et al.
        Colorectal cancer surveillance. 2005 update of an American Society of Clinical Oncology practice guideline.
        J Clin Oncol. 2005; 23: 8512-8519
        • Rex D.K.
        • Kahi C.J.
        • Levin B.
        • et al.
        Guidelines for colonoscopy surveillance after cancer resection: a consensus update by the American Cancer Society and the US Multi-Society Task Force on Colorectal Cancer.
        Gastroenterology. 2006; 130: 1865-1871
        • Tytherleigh M.G.
        • Warren B.F.
        • Mortensen N.J.
        Management of early rectal cancer.
        Br J Surg. 2008; 95: 409-423
        • Schaefer O.
        • Langer M.
        Detection of recurrent rectal cancer with CT, MRI and PET/CT.
        Eur Radiol. 2007; 17: 2044-2054
        • Kinkel K.
        • Lu Y.
        • Both M.
        • et al.
        Detection of hepatic metastases from cancers of the gastrointestinal tract by using noninvasive imaging methods (US, CT, MR imaging, PET): a meta-analysis.
        Radiology. 2002; 224: 748-756
        • Salerno G.
        • Daniels I.R.
        • Moran B.J.
        • et al.
        Clarifying margins in the multidisciplinary management of rectal cancer: the MERCURY experience.
        Clin Radiol. 2006; 61: 916-923
        • Habr-Gama A.
        • Perez R.O.
        • Proscurshim I.
        • et al.
        Patterns of failure and survival for nonoperative treatment of stage c0 distal rectal cancer following neoadjuvant chemoradiation therapy.
        J Gastrointest Surg. 2006; 10: 1319-1328
        • Habr-Gama A.
        • Perez R.O.
        • Proscurshim I.
        • et al.
        Interval between surgery and neoadjuvant chemoradiation therapy for distal rectal cancer: does delayed surgery have an impact on outcome?.
        Int J Radiat Oncol Biol Phys. 2008; 71: 1181-1188
        • Guillou P.J.
        • Quirke P.
        • Thorpe H.
        • et al.
        Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial.
        Lancet. 2005; 365: 1718-1726
        • Czito B.G.
        • Bendell J.C.
        • Willett C.G.
        • et al.
        Bevacizumab, oxaliplatin, and capecitabine with radiation therapy in rectal cancer: phase I trial results.
        Int J Radiat Oncol Biol Phys. 2007; 68: 472-478
        • Rodel C.
        • Arnold D.
        • Hipp M.
        • et al.
        Phase I–II trial of cetuximab, capecitabine, oxaliplatin, and radiotherapy as preoperative treatment in rectal cancer.
        Int J Radiat Oncol Biol Phys. 2008; 70: 1081-1086