Locally Advanced Rectal Cancer
cT3-4 or N+, MRI-staged
All Pathways
Colorectal SurgeryManagement
Rectal Cancer Neoadjuvant Therapy Selection (NCCN)
Rectal Cancer Neoadjuvant Therapy Selection (NCCN): Locally Advanced Rectal Cancer → MRF (Mesorectal Fascia) Status → High-Risk Features → Total Neoadju...
Pathway Overview
10 steps
Algorithm Steps
10 total
01Start 02Decision MRF (Mesorectal Fascia) Status
- Threatened/involved
- Clear (>1mm)
03Action High-Risk Features
MRF+, EMVI+, N2, low tumor
04Action Total Neoadjuvant Therapy
Chemo + CRT or SCRT + Chemo
- RAPIDO/PRODIGE-23 regimens
- May increase pCR rates
05Action Restaging MRI
6-8 weeks post-treatment
06Decision Clinical Response
- cCR - consider watch-wait
- Near cCR
- Residual disease
07End TME Surgery
Low anterior resection or APR based on level
08Action Standard Risk
MRF clear, no EMVI
09Action Long-Course CRT
50.4 Gy + 5-FU/capecitabine
- 5-6 weeks treatment
- Surgery 6-12 weeks after
- Path rejoins step 05Shared downstream outcome
10Action Short-Course RT
25 Gy in 5 fractions
- For elderly or frail
- Surgery 1-2 weeks or 6-8 weeks
- Path rejoins step 05Shared downstream outcome
Guideline Source
NCCN Rectal Cancer Guidelines: Neoadjuvant Therapy
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Total neoadjuvant therapy (TNT) increasingly favored
- Watch-and-wait for cCR still investigational
- MSI-H tumors may respond to immunotherapy alone
Applicable Regions
USAUUKEU
EU: ESMO guidelines similar approach
US: NCCN guidelines, TNT increasingly adopted
Version 1Next review: 2028-01-01
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Related Resources
Frequently Asked Questions
What is the Rectal Cancer Neoadjuvant Therapy Selection (NCCN)?
The Rectal Cancer Neoadjuvant Therapy Selection (NCCN) is a management clinical algorithm for Colorectal Surgery. It provides a structured decision tree to guide clinical decision-making, based on NCCN Rectal Cancer Guidelines: Neoadjuvant Therapy.
What guideline is the Rectal Cancer Neoadjuvant Therapy Selection (NCCN) based on?
This algorithm is based on NCCN Rectal Cancer Guidelines: Neoadjuvant Therapy (DOI: 10.6004/jnccn.2024.0002).
What are the limitations of the Rectal Cancer Neoadjuvant Therapy Selection (NCCN)?
Known limitations include: Total neoadjuvant therapy (TNT) increasingly favored; Watch-and-wait for cCR still investigational; MSI-H tumors may respond to immunotherapy alone. Individual patient factors may require deviation from these recommendations.
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