Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders: A prospective multicentre study

Abstract

PurposeTo assess local control after preoperative radiation and local excision and to determine an optimal radiotherapy regimen. MethodsEighty-nine patients with G1–2 rectal adenocarcinoma <3–4cm; unfavourable cT1N0 (23.6%), cT2N0 (62.9%) or borderline cT2/cT3N0 (13.5%) received 5×5Gy plus 4Gy boost (71.9%) or 55.8Gy in 31 fractions with 5-FU and leucovorin (28.1%). Local excision (traditional technique 56.2%, transanal endoscopic microsurgery 41.6%, Kraske procedure 2.2%) was performed 6–8weeks later. If patients were downstaged to ypT0–1 without unfavourable factors (good responders), this was deemed definitive treatment. Immediate conversion to radical surgery was recommended for remaining patients. ResultsGood response to radiation was seen in 67.2% of patients in the short-course group and in 80.0% in the chemoradiation group, p=0.30. Local recurrence at 2years (median follow-up) in good responders was 11.8% in the short-course group and 6.2% in the chemoradiation group, p=0.53. In the total group, a lower rate of local recurrence at 2years was observed in elderly patients (>69years, median value) when compared to the younger patients; 8.3% vs. 27.7%, Cox analysis hazard ratio 0.232, p=0.016. A total of 18 patients initially managed with local excision required conversion to abdominal surgery but either refused it or were unfit. In this group, local recurrence at 2years was 37.1%. ConclusionsThis study suggests an acceptable local recurrence rate after preoperative radiotherapy and local excision of small, radiosensitive tumours in elderly patients.