Non-operative Management Of Rectal Cancer Research Articles

Non-operative management of rectal cancer: future perspectives turning into reality?

The management of rectal cancer has considerably changed over the last decades and complete response to neoadjuvant chemoradiotherapy is becoming a common clinical entity. There is still no consensus on the definition of complete response to neoadjuvant treatment prior to surgery. Treatment programs are mostly heterogeneous and non-randomized. In addition, techniques to diagnose complete response are still unclear and there is no uniformity in surveillance modality of those patients managed without operative intervention. We review the most recent evidences reported in literature.

Update on advances and controversy in rectal cancer treatment.

Changes in the multidisciplinary treatment of rectal cancer have been recently proposed. We performed a comprehensive review of the current data on neoadjuvant and adjuvant treatment of rectal cancer, focussing on chemoradiotherapy treatment and timing of surgery. Six components were proposed as the framework for the treatment of rectal cancer: neoadjuvant therapy and changing patterns in patient selection, long- or short-course radiotherapy, adverse effects of radiotherapy, timing of surgery, non-operative management of rectal cancer and postoperative adjuvant therapy. Lack of a consistent difference in terms of local recurrence has been observed between short-course radiotherapy and long-course chemoradiotherapy. Indications for preoperative radiotherapy have been reconsidered in the last years. An interval of 10-11 weeks seemed to be the optimal timing, with no impact on patient safety. Since assessment criteria of clinical complete response are not well defined, and the basis for non-operative management of rectal cancer is still not clear, further investigations are required. There is controversy about standard treatments for patients with locally advanced rectal cancer that are being analyzed by ongoing studies. Tailored treatments could avoid over-treatment for a large number of patients without any impairment of the oncologic results.

Nonoperative management of rectal cancer.

Surgery has long been the primary curative modality for localized rectal cancer. Neoadjuvant chemoradiation has significantly improved local control rates and, in a significant minority, eradicated all disease. Patients who achieve a pathologic complete response to neoadjuvant therapy have an excellent prognosis, although the combination treatment is associated with long-term morbidity. Because of this, a nonoperative management (NOM) strategy has been pursued to preserve sphincter function in select patients. Clinical and radiographic findings are used to identify patients achieving a clinical complete response to chemoradiation, and they are then followed with intensive surveillance. Incomplete, nonresponding and those demonstrating local progression are referred for salvage with standard surgery. Habr-Gama and colleagues have published extensively on this treatment strategy and have laid the groundwork for this approach. This watch-and-wait strategy has evolved over time, and several groups have now reported their results, including recent prospective experiences. Although initial results appear promising, several significant challenges remain for NOM of rectal cancer. Further study is warranted before routine implementation in the clinic.

Nonoperative management of rectal cancer after chemoradiation opposed to resection after complete clinical response. A comparative study

IntroductionSurgery is the standard treatment of rectal cancer after neoadjuvant therapy. Some authors advocate a nonoperative management (NOM) after complete clinical response (cCR) following chemoradiotherapy (CRT). We compare our results with NOM to standard resection in a retrospective analysis. MethodsRectal adenocarcinomas submitted to NOM after CRT between September 2002 and December 2013 were compared to surgical patients that had pathological complete response (pCR) during the same period. Endpoints were Overall Survival (OS), Disease Free Survival (DFS), Local Relapse (LR) and Distant Relapse (DR). ResultsForty-two NOM patients compared to 69 pCR patients operated after a median interval of 35 weeks after CRT. NOM tumors were distal (83.3% vs 59.4%, p = 0.011), less obstructive (26.2% vs 54.4%, p = 0.005) and had a lower digital rectal score (p = 0.024). Twelve (28.0%) recurrences in NOM group and eight (11.5%) in the surgical group occurred after a follow-up of 47.7 and 46.7 months respectively. Isolated LR occurred in five (11%) NOM patients and one (1.4%) in the surgical group. Four (80%) LR were surgically salvaged in NOM group. No difference in OS was found (71.6% vs 89.9%, p = 0.316) but there was a higher DFS favoring surgical group (60.9% vs 82.8%, p = 0.011). Distal tumors had worse OS compared to proximal tumors in surgical group (5-year OS of 85.5% vs 96.2%, p = 0.038). ConclusionThe NOM achieved OS comparable to surgical treatment and spared patients from surgical morbidity but it resulted in more recurrences. This approach cannot be advocated routinely and controlled trials are warranted.

PTH-331 Non-operative management of low rectal cancer with complete response to standard neoadjuvant chemoradiotherapy

<h3>Introduction</h3> 20% of low rectal cancers respond extremely well to standard long course radiotherapy and on clinical examination apparently disappear from the rectal lumen after chemoradiotherapy; an apparent complete response. There are two dilemmas which follow this: Can we be sure about the complete response and that there is no viable residual tumour tissue? If we believe there is no tumour tissue left, how do we then manage these patients? Our Trust started to suggest non-operative management to ‘complete responders’ in January 2007, and the results were remarkable. <h3>Method</h3> Ongoing study looking at 14 complete responders. Surveillance has been MRI/EUS/EUA under GA during years 0–2 every three months. MRI/EUS/EUA under GA during years 3–5 every six months. MRI/EUS/EUA under GA after 5 years every year. A CT scan and colonoscopy were performed at the two and five year marks. These are the Trust’s local guidelines. <h3>Results</h3> 14 patients in total. Seven are still disease-free and still under surveillance. Three had recurrence; two underwent APR and one underwent ultra low anterior resection; all had R0 resections and are still disease-free. Four were suspected to have recurrence but were not fit for major resections therefore had transanal procedures; all had tumour-free specimens and are still disease-free and under surveillance. <h3>Conclusion</h3> There are an important cohort of patients who have low rectal cancer who may not need an operation. We are still unsure exactly how to manage these patients and it is therefore important for each unit to follow them up and share experiences. As a Trust, we will continue to manage these patients with the diagnosis of low rectal cancer, who are ‘disease-free’ following long course chemoradiotherapy, non-operatively. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Smith JD, <i>et al</i>. Non-operative management of rectal cancer with complete response to neoadjvant therapy. Ann Surg. 2012;256:965–972 Habr-Gama A, <i>et al</i>. Non-operative management of distal rectal cancer after chemoradiation: experience with the “watch and wait” policy. Dis. Colon Rectum. 2010;52:1137–1143 Habr-Gama A, <i>et al</i>. Operative versus non-operative treatment for stage 0 distal rectal cancer following chemoradiation therapy. Ann Surg. 2004;240(4):711–718 Tennyson MD, <i>et al</i>. Transanal excision with radiation therapy for rectal cancer. Clin Med Res. 2012;10(4):224–229 Schmoll HJ, <i>et al</i>. ESMO concensus guideline for management of patients with colon and rectal cancer: a personalised approach to clinical decision making. Ann Oncol. 2012;23:2479–2516 Deferral of Surgery (Watch And Wait) Study. Royal Marsden Hospital, Pelican Cancer Foundation, Phase II Multicentre Single-Arm Study, Cancer Research Trial Number CRUK/10/006

Predicting complete response: is there a role for non-operative management of rectal cancer?

Pre-operative chemoradiotherapy followed by a total mesorectal excision (TME) is the standard of care for patients with locally advanced (stage II or III) rectal cancer. Approximately 20% of patients may achieve a pathologic complete response after chemoradiation therapy (CRT), which has been shown to be associated with better oncologic outcomes. Whether surgery can be avoided in this population is an area of active investigation. Recent studies demonstrated feasibility and safety of non-operative management in patients with clinical complete response (cCR) after chemoradiotherapy. In this article, we set out to review the current data on non-operative management and to identify areas requiring further investigation, including improvement in imaging for reassessment after CRT and identifying the optimal time frame for restaging. As the field moves forward with non-operative management in select patients with rectal cancer, there continues to be a need to better understand the prognostic factors and biomarkers that may more accurately characterize patients who are qualified for this "wait-and-see" approach and thereby avoid overtreatment, potentially leading to improvements in long-term quality of life.

Nonoperative Management of Rectal Cancer With Complete Clinical Response After Neoadjuvant Therapy

Nonoperative management (NOM) of rectal cancer after a complete clinical response (cCR) to neoadjuvant therapy is controversial. In this article, we retrospectively reviewed the outcomes of patients managed with selective NOM after a cCR to neoadjuvant treatment and compared these with patients who underwent standard rectal resection with a pathological complete response (pCR). Patients completing neoadjuvant chemoradiotherapy (CRT) for stage I to III rectal cancer between January 2006 and August 2010 were retrospectively reviewed. Median follow-up was calculated in months after completion of CRT. Thirty-two patients (median follow-up 28 months) were treated by NOM after a cCR. Among 265 treated by CRT and rectal resection, 57 patients (22%) had a pCR and formed the control group (median follow-up 43 months). Factors associated with selective use of NOM included lower pretreatment stage, older age, and distal tumor location (P < 0.05). In the NOM group, 6 recurred locally (median 11 months, range 7-14), 3 of whom also had concurrent distant recurrence. All 6 local failures were controlled by salvage rectal resection with no further local recurrence of disease (median follow-up 17 months). In the rectal resection/pCR group, there were no local failures. The 2-year distant disease-free survival (88% vs 98%, P = 0.27) and overall survival (96% vs 100%, P = 0.56) were similar for NOM and rectal resection/pCR groups. Rectal resection was successfully avoided in 81% of patients selected for NOM. When combined with salvage surgery, NOM appears to achieve similar local and distant disease control compared with patients with a pCR treated by rectal resection. Longer follow-up and prospective trials are warranted to evaluate this promising treatment option.

Nonoperative Management of Rectal Cancer: Current Perspectives

While surgery plays a central role in the management of all stages of operable rectal cancer, nonoperative approaches for both early-stage and locally advanced disease are being explored. This comprehensive review summarizes the current literature regarding the nonoperative management of rectal cancer and discusses caveats and controversies to such an approach.

Non-operative management of rectal cancer after neoadjuvant chemoradiation

A problem of patient selection