ASO Author Reflections: Decline in Unnecessary Surgery by Structural Restaging After Neoadjuvant Chemoradiation for Loca
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Decline in Unnecessary Surgery by Structural Restaging After Neoadjuvant Chemoradiation for Locally Advanced Rectal Cancer Jelle F. Huisman, MD1, Wouter H. de Vos tot Nederveen Cappel, MD, PhD1, and Henderik L. van Westreenen, MD, PhD2 1
Department of Gastroenterology and Hepatology, Isala Hospital, Zwolle, The Netherlands; 2Department of Surgery, Isala Hospital, Zwolle, The Netherlands
PAST Standard therapy for locally advanced rectal cancer is neoadjuvant chemoradiotherapy (nCRT) followed by total mesorectal excision (TME); however, TME is often accompanied by morbidity and mortality.1 Furthermore, the disappearance of malignant tumors and lymph nodes in the surgical specimen—a pathologic complete response (pCR)—has been reported in 15–20% of patients.2 Therefore, nowadays a watch and wait (W&W) policy instead of TME surgery is proposed for selected patients with an apparent clinical complete response (cCR) after nCRT.3 We started a W&W and structural multidisciplinary response evaluation in 2015 to identify patients with an apparent complete response and to discuss the option of organ preservation.
with pCR after TME, even with our liberal policy of a longer observational period. In the majority of cases, this is caused by residual abnormalities found during endoscopy, as also reported by others.5 Our reported oncological outcome and local regrowth rate seems reasonable, however the study was underpowered to perform adequate survival analysis. FUTURE We recommend structural multidisciplinary response evaluation following nCRT in all patients with locally advanced rectal cancer. Future studies should investigate the long-term oncological outcomes and the optimal timing and strategy of restaging, as well as repeated response assessment, since near-complete responders can evolve in complete responders.
PRESENT Since the implementation of this structural multidisciplinary response evaluation with the option of W&W for patients with good response, we have found significant less TME resections without residual tumor (pCR).4 On the one hand, this implicates the efficacy of structural multidisciplinary response evaluation and the importance for clinical practice, while on the other hand, we still have patients
Ó Society of Surgical Oncology 2020 First Received: 17 September 2020 Accepted: 18 September 2020 J. F. Huisman, MD e-mail: [email protected]
DISCLOSURES Jelle F. Huisman, Wouter H. de Vos tot Nederveen Cappel, and Henderik L. van Westreenen declare no conflicts of interest.
REFERENCES 1. Shearer R, Gale M, Aly OE, Aly EH. Have early postoperative complications from laparoscopic rectal cancer surgery improved over the past 20 years? Colorectal Dis. 2013;15(10):1211–26. 2. Maas M, Nelemans PJ, Valentini V, Das P, Rodel C, Kuo LJ, et al. Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data. Lancet Oncol. 2010;11(9):835–44. 3. Dossa F, Chesney TR, Acuna SA, Baxt
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