Role of Preoperative Chemoradiotherapy in Clinical Stage II/III Rectal Cancer Patients Undergoing Total Mesorectal Excision: A Retrospective Propensity Score Analysis.

Jii Bum Lee,Kang Young Lee,Nam Kyu Kim,Woong Sub Koom,Ahrong Ham,Yu Rang Park,Hyuk Hur,Dai Hoon Han,Taeil Kim,Jee Suk Chang,Han Sang Kim,Joon Seok Lim,Sang Jun Shin,Byung Soh Min,Joong Bae Ahn,Yoon Dae Han,Seung-Hoon Beom

doi:10.3389/fonc.2020.609313

Jii Bum Lee, Kang Young Lee + Show 15 more

Open Access

https://doi.org/10.3389/fonc.2020.609313

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Abstract

BackgroundAlthough the current standard preoperative chemoradiotherapy (PCRT) for stage II/III rectal cancer decreases the risk of local recurrence, it does not improve survival and increases the likelihood of preoperative overtreatment, especially in patients without circumferential resection margin (CRM) involvement.MethodsStage II/III rectal cancer without CRM involvement and lateral lymph node metastasis was radiologically defined by preoperative magnetic resonance imaging (MRI). Patients who received PCRT followed by total mesorectal excision (TME) (PCRT group) and upfront surgery (US) with TME (US group) between 2010 and 2016 were analyzed. We derived cohorts of PCRT group versus US group using propensity-score matching for stage, age, and distance from the anal verge. Three-year relapse-free survival rate, disease-free survival (DFS), and overall survival (OS) were compared between the two groups.ResultsA total of 202 patients were analyzed after propensity score matching. There were no differences in baseline characteristics. The median follow-up duration was 62 months (interquartile range, 46–87). There was no difference in the 3-year disease-free survival rate between the PCRT and US groups (83 vs. 88%, respectively; p=0.326). Likewise, there was no significant difference in the 3-year OS (89 vs. 91%, respectively; p=0.466). The 3-year locoregional recurrence rates (3 vs. 2% with US, p=0.667) and distant metastasis rates (16 vs. 11%, p=0.428) were not significantly different between the two groups. Time to completion of curative treatment was significantly shorter in the US group (132 days) than in the PCRT group (225 days) (p<0.001).ConclusionUsing MRI-guided selection for better risk stratification, US without neoadjuvant therapy can be considered in early stage patients with good prognosis. PCRT may not be required for all stage II/III rectal cancer patients, especially for the MRI-proven intermediate-risk group (cT1-2/N1, cT3N0) without CRM involvement and lateral lymph node metastasis. Further prospective studies are warranted.

Highlights

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide and the second cause of cancer related death [1]
This study suggested the possibility of omitting preoperative chemoradiotherapy (PCRT) in subjects with a negative circumferential resection margin (CRM) and no lateral lymph node metastasis in stage II/III rectal cancer
This was a retrospective study of stage II and III rectal cancer patients who received either PCRT followed by total mesorectal excision (TME) or underwent upfront radical surgery in Yonsei Cancer Center

Summary

Introduction

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide and the second cause of cancer related death [1]. The standard treatment for stage II/III rectal cancer is preoperative chemoradiotherapy (PCRT) followed by surgery and adjuvant chemotherapy [3]. PCRT is effective in reducing local recurrence and down staging locally advanced rectal cancer [4, 5]. It is associated with complications such as bowel [6], anorectal [7], and sexual dysfunctions [8, 9] and delay from surgical recovery [10]. The current standard preoperative chemoradiotherapy (PCRT) for stage II/III rectal cancer decreases the risk of local recurrence, it does not improve survival and increases the likelihood of preoperative overtreatment, especially in patients without circumferential resection margin (CRM) involvement

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