How We Treat Localized Rectal Cancer—An Institutional Paradigm for Total Neoadjuvant Therapy

Abstract

Total neoadjuvant therapy (TNT)—the neoadjuvant employment of radiotherapy (RT) or chemoradiation (CRT) as well as chemotherapy (CHT) before surgery—may lead to increased pathological complete response (pCR) rates as well as a reduction in the risk of distant metastases in locally advanced rectal cancer. Furthermore, increased response rates may allow organ-sparing strategies in a growing number of patients with low rectal cancer and upfront immunotherapy has shown very promising early results in patients with microsatellite instability (MSI)-high/mismatch-repair-deficient (dMMR) tumors. Despite the lack of a generally accepted treatment standard, we strongly believe that existing data is sufficient to adopt the concept of TNT and immunotherapy in clinical practice. The treatment algorithm presented in the following is based on our interpretation of the current data and should serve as a practical guide for treating physicians—without any claim to general validity.

Special Issue “Current Management of Early and Advanced Rectal Cancer”

“…The second approach to maximizing the likelihood of sphincter-saving rectal surgery is to increase neoadjuvant treatment by providing both chemotherapy and chemoradiation before surgery to further improve downstaging-this is known as total neoadjuvant therapy (TNT). Indeed, as reported by Falk et al [3], TNT could provide both increased distant control and a higher pathologic complete response rate, paving the way for organ-sparing procedures, from minimally invasive transanal local excisions to "watch and wait" strategies. However, as Sclafani and colleagues point out, what is currently lacking is the ability to properly select those patients who will benefit from TNT and allow for personalized escalation of neoadjuvant treatments [4].…”

Effects of MRI radiomics combined with clinical data in evaluating lymph node metastasis in mrT1-3a staging rectal cancer

“…However, if LN metastasis exists in the patients with T1-3a staging (cT1-3aN1-2M0), it is strongly suggested that patients receive neoadjuvant chemoradiotherapy (nCRT); otherwise, the recurrence rate would increase ( 6 ). By contrast, unnecessary nCRT may be performed if LN staging is overestimated, resulting in potential complications such as dysuria and sexual dysfunction ( 7 , 8 ). Therefore, accurate preoperative assessment of LN staging is the premise for precision treatment in T1-3a rectal cancers, and also directly affects the prognosis in patients with rectal cancer.…”