Is Local Excision After Complete Pathological Response to Neoadjuvant Chemoradiation for Rectal Cancer an Acceptable Treatment Option?

Kundel, Yulia; Brenner, Ronen; Purim, Ofer; Peled, Nir; Idelevich, Efraim; Fenig, Eyal; Sulkes, Aarón; Brenner, Baruch

doi:10.1007/dcr.0b013e3181f5b64d

Cited by 74 publications

(43 citation statements)

References 32 publications

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“…Kundel [36] compared outcomes of patients with pCR after nCRT who had undergone radical surgery (Group 1, n=37) versus LE only (Group 2; n=14). Group 2 had a higher percentage of distal tumors and a lower post nCRT clinical stage, with 6 patients (43%) characterized as T0N0.…”

Section: Local Excisionmentioning

confidence: 99%

Complete Clinical Response in Rectal Adenocarcinoma: Review of Treatment Options

Scully¹,

C²,

Lee-Kong³

2017

J Clin Gastroenterol Hepatol

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The standard treatment for locally advanced rectal cancer is neoadjuvant chemoradiation followed by radical proctectomy with total mesorectal excision. A significant percentage of patients exhibit a pathological complete response with associated survival benefit. The management of patients who exhibit a complete clinical response after neoadjuvant chemoradiation, and could potentially avoid major resection, is a topic of great interest in colorectal surgery today. This paper reviews treatment options for this population.

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Section: Local Excisionmentioning

confidence: 99%

Complete Clinical Response in Rectal Adenocarcinoma: Review of Treatment Options

Scully¹,

C²,

Lee-Kong³

2017

J Clin Gastroenterol Hepatol

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“…The indications for TAMIS can also be broadened to include local excision of clinical T0 (cT0) lesions in patients with locally advanced rectal cancer after neoadjuvant therapy for the purpose of confirming mural complete pathologic response (cPR) or ypT0. [47][48][49] This approach is acceptable given that the risk of occult node positivity for ypT0 lesions is predictably low, at 3-6%. [50][51][52] The discussion with the patient should highlight the benefits and risks of preservation of rectal function and avoiding functional consequences of a pelvic dissection with the understanding that they still need close follow-up postoperatively.…”

Section: Image 1 Depth Of Submucosal Invasion: Submucosa Divided Intomentioning

confidence: 99%

Transanal Minimally Invasive Surgery (TAMIS): a clinical spotlight review

2017

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Teresa deBeche-Adams, Imran Hassan, and the SAGES Guidelines Committee PreambleThe following clinical spotlight review regarding Transanal Minimally Invasive Surgery (TAMIS) is intended for physicians who manage and treat rectal pathology. It is meant to critically review this technique and the available evidence supporting its safety and efficacy. Based on the level of evidence, recommendations may or may not be given for its use in clinical practice. DisclaimerGuidelines for clinical practice and spotlight reviews are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Spotlight reviews are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to convey recommendations based on a focused topic; within the defined scope of the review, they indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines and recommendations are intended to be flexible. Given the wide range of specifics in any healthcare problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines, spotlight reviews, and recommendations are developed under the auspices of the Society of American Gastrointestinal Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical spotlight review has been systematically researched, reviewed and revised by the guidelines committee, and, when appropriate, reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of production based on the data available. Literature reviewA systematic literature search was performed using PubMed for Transanal Minimally Invasive Surgery (TAMIS). The literature was reviewed from September 1, 2010 through May 31, 2016. Both the quality of the evidence and the strength of the recommendation for each of the guidelines were assessed according to the GRADE system. This uses a 4-tiered system for denoting the quality of evidence (very low (+), low (+ +), moderate (+ + +), or high (+ + + +)) and a 2-tiered system for strength of recommendation (weak, or strong).

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“…Kundel et al [35] compared outcomes of patients with locally advanced rectal cancer who underwent neoadjuvant CRT followed either by radical surgery after pCR or by local excision only (91 vs. 6%). Patients who underwent local excision had a cCR and preference to local excision or clinical residual disease and refusal of abdominoperineal resection.…”

Section: Alternatives To Radical Resection For Complete Respondersmentioning

confidence: 99%

Complete Response after Neoadjuvant Therapy in Rectal Cancer: To Operate or Not to Operate?

Dedemadi¹,

Wexner²

2012

Dig Dis

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Background/Aims: Evidence exists to support both surgical and nonoperative observational approaches to the management of patients with distal rectal cancer who achieve a complete response following neoadjuvant chemoradiotherapy (CRT). This article summarizes findings from key studies on management strategies for complete pathologic and clinical responders after neoadjuvant CRT for rectal cancer. Methods: A comprehensive literature review was undertaken comparing complete responders to neoadjuvant CRT who underwent surgical procedures or nonoperative observation. Results: The sensitivity and specificity of clinical assessment tools following neoadjuvant CRT are generally low. Endoscopic ultrasound and MRI are widely used for rectal cancer staging; PET/CT is applied for detecting residual cancer, although limitations exist in assessing mesorectal disease. In patients with rectal cancer who receive neoadjuvant CRT, rates of complete pathologic response vary from 5 to 44%. Rates of nodal disease in patients with complete pathologic response vary from 0 to 15%. In patients with stage 0 rectal cancer, excellent long-term oncologic results have been reported for both surgical resection and nonoperative observation; therefore, some authors consider that surgical resection may result in unnecessary morbidity. Whereas neoadjuvant CRT followed by total mesorectal excision (TME) reduces local recurrence and improves 5-year survival, TME is associated with significant morbidity and suboptimal functional results. Conclusion: Informed consent in patients with distal rectal cancer who achieve a complete response to neoadjuvant CRT must address both the potential risks of recurrence following nonoperative observation and the increased risks of postoperative morbidity and compromised function following extirpative surgery.

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Is Local Excision After Complete Pathological Response to Neoadjuvant Chemoradiation for Rectal Cancer an Acceptable Treatment Option?

Abstract: In this retrospective study, nodal metastases were rare in patients with mural complete pathological response following neoadjuvant chemoradiation (3%), and local excision did not compromise their outcome. Therefore, local excision may be an acceptable option in these patients.

Cited by 74 publications

References 32 publications

Complete Clinical Response in Rectal Adenocarcinoma: Review of Treatment Options

Complete Clinical Response in Rectal Adenocarcinoma: Review of Treatment Options

Transanal Minimally Invasive Surgery (TAMIS): a clinical spotlight review

Complete Response after Neoadjuvant Therapy in Rectal Cancer: To Operate or Not to Operate?

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