Identification of Locally Advanced Rectal Cancer with Low Risk of Local Recurrence

Abstract

BackgroundThe routine application of neoadjuvant chemoradiotherapy for T3N0 rectal cancer remains controversial. The aim of this study was to use clinical, Magnetic resonance imaging, and pathological parameters to identify a subgroup of patients with low risk of local recurrence who might be precluded from neoadjuvant chemoradiotherapy.MethodsWe retrospectively reviewed a prospectively maintained database of consecutive rectal cancer patients who underwent curative resection. 166 pathologic confirmed T3N0 rectal cancer patients with tumor located 5–12cm above the anal verge and preoperative circumferential resection margin>1mm were included in analysis. The primary outcomes measured were3- and 5-year local recurrence rates.ResultsLocal recurrence was demonstrated during follow-up in 5 patients; the actuarial overall 3- and 5-year local recurrence rates were 2.5% and 3.4%, respectively. Inadequate sampling of lymph nodes (≤12) was associated with higher local recurrence (P = 0.03) in this group of patients.ConclusionFor upper and middle T3N0 rectal cancer with preoperative circumferential resection margin>1mm, local recurrence rate after total mesorectal excision is low and surgery alone may be enough for this group of patients.

Surgical treatment following neoadjuvant chemoradiotherapy in locally advanced rectal cancer

“…According to data compiled by the European Society for Medical Oncology (ESMO) Guidelines Committee, preoperative RT or NCRT reduces LR without improving OS in middle/lower stage II/III rectal cancers . Considering the heterogeneity among literature reviews, the ESMO panelists did not recommend NCRT for upper rectal cancers (>12 cm from the anal verge) above the peritoneal reflection . Popek et al explored the role of neoadjuvant therapy for upper LARC (≥10‐15 cm), and they suggested that patients with T3 N0 tumors would not likely benefit from neoadjuvant RT and that treatment of patients with T4 N0 should be individualized .…”

“…A subgroup of patients with upper rectal cancer who may require a more aggressive therapy than only primary resection followed by adjuvant therapy can be identified . For patients with upper and middle T3 N0 rectal cancer with a preoperative CRM of >1 mm, the LR rate after TME is low and surgery alone may be sufficient for this group of patients . A previous study analyzed LR and survival rates of 4153 patients registered from 1995 to 1997 in the Swedish Rectal Cancer Registry .…”

“…3,32 Considering the heterogeneity among literature reviews, the ESMO panelists did not recommend NCRT for upper rectal cancers (>12 cm from the anal verge) above the peritoneal reflection. [28][29][30][31] Popek et al explored the role of neoadjuvant therapy for upper LARC (≥10-15 cm), and they suggested that patients with T3 N0 tumors would not likely benefit from neoadjuvant RT and that treatment of patients with T4 N0 should be individualized. 30 Rosenberg et al presented that upper rectal cancers have more similarities with rectal cancers of the middle rectum than with sigmoid cancers.…”

“…Studies have proposed up‐front surgery for upper rectal tumors because of the low LR risk and the sphincter preservation advantage . In 2017, a multidisciplinary team of European cancer experts achieved consensus on risk‐adapted treatment in those patients with recurring cT4 tumors in the pelvis might benefit from NCRT .…”

“…Studies have proposed up-front surgery for upper rectal tumors because of the low LR risk and the sphincter preservation advantage. 15,[28][29][30][31] In 2017, a multidisciplinary team of European cancer experts achieved consensus on risk-adapted treatment in those patients with recurring cT4 tumors in the pelvis might benefit from NCRT. 32 Nevertheless, they did not recommend applying this treatment model uniformly to all rectal cancer patients regardless of tumor location.…”