ASO Author Reflections: Local Excision Following Neoadjuvant Therapy for Rectal Cancer: A Compromise Between TME and Wat
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Local Excision Following Neoadjuvant Therapy for Rectal Cancer: A Compromise Between TME and Watch-and-Wait in Patients with Major Response Quoc Riccardo Bao, MD, Giulia Capelli, MD, Gaya Spolverato, MD, and Salvatore Pucciarelli, MD Department of Surgical, Oncological, and Gastroenterological Sciences, First Surgical Clinic, University of Padua, Padua, Italy
PAST Total mesorectal excision (TME) after neoadjuvant chemoradiotherapy is correlated with good long-term outcomes. However, this approach carries considerable morbidity and can determine an impairment of bowel function and quality of life. Acknowledging these issues, rectal-sparing approaches (i.e., local excision, watch-andwait) have been proposed for the treatment of patients achieving major or complete response to neoadjuvant chemoradiotherapy. Rectal-sparing approaches are associated with better bowel function and quality of life compared with TME.1 Conversely, a higher risk of recurrence has been reported, which may impact on patients’ long-term oncologic outcomes. PRESENT The purpose of our study was to validate the use of local excision following neoadjuvant chemoradiotherapy.2,3 In highly selected patients, this approach was associated with encouraging long-terms outcomes with a 10-year OS of 79% and a 10-year RFS of 82%. In particular, patients with a major pathologic response showed excellent long-term oncologic outcomes. Only a few of them experienced local
recurrence, occurring within 50 months. Pathological response remains the most important prognostic factor in these patients. FUTURE A highly accurate clinical staging after neoadjuvant therapy is pivotal to select the best candidates to rectal sparing approaches. Compared with watch-and-wait, local excision provides a histological proof of pathological complete response. The possibility to obtain such proof is particularly relevant, because up to one-third of the patients undergoing local excision require a completion radical surgery on the base of histopathological report.4,5 Thus, local excision could be implemented in patients with complete or near complete clinical response to validate a correct staging. In conclusion, rectal-sparing strategies should be proposed based on clinical response to neoadjuvant therapy instead of clinical baseline staging to reduce the risk of recurrences.
FUNDING
No external funding for this manuscript.
DISCLOSURE All the authors have indicated they have no conflicts of interest to declare. The authors declare that no honorarium, grant nor other form of payment was given to anyone to produce the manuscript.
REFERENCES Ó Society of Surgical Oncology 2020 First Received: 7 September 2020 Accepted: 10 September 2020 G. Spolverato, MD e-mail: [email protected]
1. Pucciarelli S, Giandomenico F, De Paoli A, et al. Bowel function and quality of life after local excision or total mesorectal excision following chemoradiotherapy for rectal cancer. Br J Surg. 2017;104(1):138–47. 2. Pucciarelli S, De Paoli A, Gue
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