Chemoradiotherapy alone or chemoradiotherapy followed by surgery in rectal cancer
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memo https://doi.org/10.1007/s12254-020-00586-0
Chemoradiotherapy alone or chemoradiotherapy followed by surgery in rectal cancer Which way to go? Fabian Lunger · Georgios Peros Received: 15 January 2020 / Accepted: 17 February 2020 © Springer-Verlag GmbH Austria, part of Springer Nature 2020
Summary In locally advanced rectal cancer, neoadjuvant chemoradiotherapy provides a significant benefit to local cancer control in addition to total mesorectal excision. However, in 10–40% of all patients, a complete clinical remission can be detected after completion of chemoradiotherapy. Recent studies have shown that those patients omitting radical surgery after successful neoadjuvant pretreatment can be safely managed within a close follow-up network without compromising short-term overall and disease-free survival. However, available data suggest that 20–30% of all patients assigned to a watch and wait regimen will eventually have to be transferred to surgical management due to local recurrence. Careful patient selection is key for a successful watch and wait approach and the choice of non-operative management should not be made after completion of staging but rather after neoadjuvant chemoradiotherapy. Selected patients need to be thoroughly informed that there is still no standardized follow-up protocol and no predefined follow-up period. Keywords Rectal cancer · Locally advanced rectal cancer · Chemoradiotherapy · Watch and wait
The incidence of rectal cancer in the European Union is 15–25/100,000 per year, which corresponds to about 35% of the total incidence of colorectal cancer. The mortality rate is about 4–10/100,000 per year and the mean age at diagnosis is about 70 years [1]. Diagnosis is based on the endoscopy with biopsy. The current classification of rectal cancer is based F. Lunger, MD, PhD · G. Peros, MD () Department of Surgery, Cantonal Hospital of Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland [email protected]
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on ESMO recommendations according to the distance from anal verge into high (10–15 cm), medium (>5–10 cm) and low rectal cancer (up to 5 cm) as assessed by rigid rectoscopy [2]. However, the sigmoid take-off as seen on computed tomography (CT) or magnetic resonance imaging (MRI) has recently been proposed as a consensus landmark for defining the proximal end of the rectum [3]. Due to their anatomic location and possibly also different tumor biology, high rectal cancer behaves more like colon cancer and is therefore not considered in this overview. Tumor staging requires a CT scan of thorax and abdomen in addition to the determination of carcinoembryonic antigen (CEA) serum levels. The endoscopic ultrasound (EUS) is a valid option for locoregional tumor staging, although it does not seem to be sufficient [4]. The pelvic MRI allows the determination of the extramural venous invasion (EMVI), mesorectal fascia involvement (MRF), subclassification of the cT3 stage according to penetration depth and circumferential resection margin (CRM). CT3 subclassification and CRM involvement
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