Watch and Wait Approach for Rectal Cancer Following Neoadjuvant Treatment: The Experience of a High Volume Cancer Center.

Daniela Rega,Ugo Pace,Fabiana Tatangelo,Carmela Cervone,Antonio Avallone,Antonella Petrillo,Valentina D’Angelo,Vincenza Granata,Vincenzo Ravo,Carmela Romano,Paolo Delrio,Roberta Fusco

doi:10.3390/diagnostics11081507

Abstract

Multimodal treatments for rectal cancer, along with significant research on predictors to response to therapy, have led to more conservative surgical strategies. We describe our experience of the rectal sparing approach in rectal cancer patients with clinical complete response (cCR) after neoadjuvant treatment. We also specifically highlight our clinical and imaging criteria to select patients for the watch and wait strategy (w&w). Data came from 39 out of 670 patients treated for locally advanced rectal cancer between January 2016 until February 2020. The selection criteria were a clinical complete response after neoadjuvant chemotherapy managed with a watch and wait (w&w) strategy. A strict follow-up period was adopted in these selected patients and follow-ups were performed every three months during the first two years and every six months after that. The median follow-up time was 28 months. Six patients had a local recurrence (15.3%); all were salvageable by total mesorectal excision (TME). Five patients had a distant metastasis (12.8%). There was no local unsalvageable disease after w&w strategy. The rectal sparing approach in patients with clinical complete response after neoadjuvant treatment is the best possible treatment and is appropriate to analyze from this perspective. The watch and wait approach after neoadjuvant treatment for rectal cancer can be successfully explored after inflexible and strict patient selection.

Highlights

Total mesorectal excision (TME) is the current standard of care for mid and low locally advanced rectal cancers (LARC), defined as tumors staged T3 or above, or with lymph node involvement
We describe our experience of the rectal sparing approach in rectal cancer patients with clinical complete response after neoadjuvant treatment
We selected 128 patients with no signs of residual tumor at restaging exams and/or histopathologic exam out of 670 patients treated with neoadjuvant therapy for locally advanced rectal adenocarcinoma from January 2016 to February 2020

Summary

Introduction

Total mesorectal excision (TME) is the current standard of care for mid and low locally advanced rectal cancers (LARC), defined as tumors staged T3 or above, or with lymph node involvement. Surgical techniques continue to improve, TME is correlated with a 1–2% rate of perioperative mortality, which increases with old age, frailty, and comorbidity [4]; it is associated with a 31% rate of major complications (Clavien–Dindo grade 3–4) [5] such as anastomotic leaks, a 25% risk of a permanent stoma, chronic altered bowel function, or anorectal and sexual dysfunction in more than 60% of patients [6,7]. The role and accuracy of imaging in the detection of the primary tumor, residual rectal cancer or local recurrence appears crucial

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