Organ‐saving surgery for rectal cancer after neoadjuvant chemoradiation: Analysis of failures and long‐term results

Abstract

BackgroundTo analyze long‐term results and risk of relapse in the clinical TNM stages II and III, mid‐low rectal cancer patients (RC pts), treated with transanal local excision (LE) after major response to neoadjuvant chemoradiation (n‐CRT).MethodsThirty‐two out of 345 extraperitoneal cT3–4 or N+ RC pts (9.3%) underwent LE. Inclusion criteria: extraperitoneal RC, adenocarcinoma, ECOG Performance Status ≤2. Pts with distant metastases were excluded.ResultsAll pts showed histologically clear margins of resection and 81.2% were restaged ypT0/mic/1. Nine out of 32 (28.1%) pts relapsed: 7 (21.8%) showed a local recurrence, of which 5 (15.6%) at the endorectal suture, 1 (3.1%) pelvic and 1 (3.1%) mesorectal. Two pts (6.2%) relapsed distantly. Among the pT0/1, 11.5% relapsed vs 100% of the pT2 and pT4 ones. The six pts relapsing locally or in the mesorectal fat underwent a salvage total mesorectal excision surgery. The old patient with pelvic recurrence relapsed after 108 months and underwent a re‐irradiation; the two pts with distant metastases were treated with chemotherapy followed by radical surgery.ConclusionsPresently combined approach seems a valid option in major responders, confirming its potential curative impact in the ypT0/mic/1 pts. A strict selection of pts is basic to obtain favourable results.

Multidisciplinary treatment of esophageal cancer: The role of active surveillance after neoadjuvant chemoradiation

“…This justifies initiating studies looking at the benefit and harm of "surgery as needed" since avoiding an esophagectomy will not put the patient at risk for a reduced quality of life. Secondly, there is no risk of morbidity and mortality related to the surgical intervention as previously reported in other malignancies 20,62‐63 …”

“…Secondly, there is no risk of morbidity and mortality related to the surgical intervention as previously reported in other malignancies. 20,[62][63] Another argument towards delaying surgery after nCRT and opting for an organ-sparing approach is that patients have more time to recover after therapies with improvement of physical, social, and selfcare. Surgical trauma and its consequences also impair the immune system.…”

“…Another argument towards delaying surgery after nCRT and opting for an organ‐sparing approach is that patients have more time to recover after therapies with improvement of physical, social, and self‐care. Surgical trauma and its consequences also impair the immune system 63‐66 . Hence, avoidance of surgery may provide time for the immune function to self‐ reinforce and attack any possibly remaining viable tumor cells.…”

“…Surgical trauma and its consequences also impair the immune system. [63][64][65][66] Hence, avoidance of surgery may provide time for the immune function to self-reinforce and attack any possibly remaining viable tumor cells. Finally, as already discussed, prolonged time to surgery was associated with a better histopathological assessment of tumor response to neoadjuvant treatment and prognostication.…”

Editorial: Multimodal treatment of recurrence and distant metastases of colorectal cancer

“…Since the first milestone intervention proposed by Miles more than one hundred years ago, for the treatment of low rectal tumors, surgery has made great progress with the introduction of low anterior resection with Knight and Griffits anastomosis, colonic pouches, intersphincteric resection, the introduction of the minimally invasive approach by laparoscopy or by robot, the use of transanal device, or the use of fluorescence angiography and lymphangiography, up to the use of artificial intelligence intraoperatively ( 1 – 3 ). However, we must not forget maybe the most important advance in the treatment of rectal cancer such as the description by Heald in the 80’s of the concept of total mesorectal excision (TME) ( 4 ). In fact the introduction of this new paradigm was a sliding door for the oncological results allowing to reduce drastically the recurrence rate after surgery ( 4 ).…”