The treatment of early rectal cancer in the era of adjuvant and neo-adjuvant therapy

Katherine Gash,Michael G Thomas,David E Messenger

doi:10.20517/2574-1225.2018.25

Abstract

The accurate staging of rectal cancer improves the stratification of patients for adjuvant therapy. Staging of tumor with endoluminal ultrasonography (EUS) shows a good correlation with histology (κ = 0.85; 95% confidence interval 0.76-0.95). Overall pT and pN stage accuracy of EUS was 92% and 65% respectively. The staging of local disease can be further augmented by EUS guided fine needle aspiration of extra rectal lesions lying within or outside of the mesorectum. In a systematic review of local excision after neoadjuvant therapy a total of 22 unique studies reporting on 1068 patients were analysed. At a median follow-up of 54 months, ypT0 tumours had a pooled local recurrence rate of 4% and a median disease-free survival rate of 95%. Outcomes for ≥ ypT1 tumours were much worse with pooled local recurrence and disease-free survival of 22% and 68%, respectively. In a review of 22 studies, 804 patients who underwent local excision followed by adjuvant therapy either for unfavourable histology, prohibitive comorbidity or patient choice. the pooled local recurrence was 5.8% for pT1 tumours, 13.8% for pT2 tumours and 33.7% for pT3 tumours. In addition, the response to radiotherapy may be enhanced by aspirin, metformin and statins.

Highlights

The treatment of rectal cancer has advanced considerably during the last 30 years
Despite the difficulties in predicting pathological complete response (pCR) based on clinical and radiological findings, there appears to be increasing evidence that patients who exhibit an apparent clinical response (cCR) could be safely managed by local procedures, such as TEMS, transanal endoscopic operation (TEO) or transanal minimally invasive surgery (TAMIS), to the tumour site or intensive surveillance, the so called “watch and wait” strategy, to avoid the morbidity associated with radical surgery and enable organ preservation[36,37,38]
We provide treatment for early rectal cancer that is both patient-centred and based on the available evidence

Summary

Introduction

The treatment of rectal cancer has advanced considerably during the last 30 years. It is widely accepted that surgery should be based on sound oncological principles where the aim is to completely excise the surrounding mesorectum in order to achieve a resection margin free from microscopic disease, together with an adequate lymph node harvest. In this article we describe our approach to the management of early rectal cancer, its staging and our evidence-based rationale for the use of neoadjuvant and adjuvant therapies. The accuracy of colonoscopic EUS was assessed in the selection of patients with rectal neoplasia suitable for local excision by TEM.

Results

Conclusion