Preoperative Concurrent Chemoradiation Therapy Research Articles

Retrospective Evaluation of the Impact of Dose Escalation Using Pre-operative Simultaneous Integrated Boost Volumetric Modulated Arc Therapy on the Outcome of Locally Advanced Rectal Cancer Patients.

Evaluating the outcome of pre-operative simultaneous integrated boost volumetric modulated arc therapy (SIB-VMAT) concomitant with capecitabine in patients diagnosed with locally advanced rectal cancer (LARC) at King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia, during the period January 2013-December 2019. A total of 134 patients were enrolled. The median age at diagnosis was 59years. All patients received pre-operative concurrent chemo-radiation therapy (CCRT) using SIB-VMAT with oral capecitabine. Neoadjuvant chemotherapy was administered prior to CCRT in 32 patients (23.9%). The dose of radiation was 55Gy in 94 patients (70.1%), while 40 patients (29.9%) received 50Gy. All patients completed the CCRT treatment without breaks. No records of acute and late grade III and IV toxicities. Curative surgery was performed in all patients with a median interval of 11 (6-52) weeks between the end of CCRT and the date of surgery. No reported 30-day postoperative mortality and no grade III and IV Clavien-Dindo complications. PCR was reported in 26 patients (19.4%), while pathologically negative nodes (pN0) were achieved in 103 patients (76.9%). Adjuvant chemotherapy was utilized in 57 patients (42.5%). The 5-year local recurrence-free survival (LRFS), disease-free survival (DFS), and overall survival (OS) were 93.2%, 67.1%, and 87.3%, respectively. Only tumor regression grade (TRG) was significantly correlated with LRFS, (p value 0.043). On multivariate analysis, only TRG and achievement of pN0 were significantly correlated with DFS (p value < 0.001). Dose escalation utilization (SIB-VMAT) in the pre-operative treatment of LARC is well tolerated and provides effective local control.

A rare case of multiple endocrine neoplasia type 1 initially presenting as an asymptomatic, huge mediastinal mass: case report

BackgroundMultiple endocrine neoplasia type 1 (MEN1) is a rare inherited syndrome that concurrently involves various endocrine glands. We report a rare case of MEN1 in a 43-year-old man whose first manifestation was an asymptomatic mediastinal mass.Case presentationA 13-cm-sized mediastinal mass was diagnosed as an atypical thymic carcinoid by computed tomography and percutaneous needle biopsy. In addition, hypercalcemia from a left inferior parathyroid hyperplasia, and a non-functioning gastric neuroendocrine tumor seen on esophagogastroduodenoscopy were found. Therefore, the patient was clinically diagnosed with MEN1 syndrome, and underwent surgical resection of thymic carcinoid tumor after pre-operative concurrent chemoradiation therapy to decrease tumor size and volume. Parathyroid lesion and gastric neuroendocrine tumor were also removed. Finally, a MEN1 gene mutation was observed in the patient and his 7-year-old son.ConclusionDespite its rare occurrence, thymic carcinoid tumor should be considered as a MEN1-associated tumor and necessitates screening of other endocrine glands. Thymic carcinoid tumor carries a poor prognosis in patients with MEN1, and thus it needs to be carefully monitored even after radical excision.

비중격에서 발생한 재발성 기저세포선암종 1예

Basal cell adenocarcinoma of the nasal cavity is a rare lesion of the head and neck, besides it is often misdiag-nosed as adenoid cystic carcinoma and other tumor disease. We encountered a 65-year-old patient with a recurred basal cell adenocarcinoma arising from the nasal septum and hard palate. This patient was treated with preoperative concurrent chemo-radiation therapy (CCRT), the tumor was radically removed through midfacial degloving approach and postoperative additional radiation therapy. We present this rare case with a review of related literatures. (J Clinical Otolaryngol 2019;30:261-265)

Prognostic factors and treatment results of preoperative intra-arterial concurrent chemoradiation therapy in locally advanced head and neck cancer

Background: To retrospectively evaluate the prognostic factors and treatment outcomes of patients treated with intra-arterial concurrent chemo-radiation therapy (IACCRT). Methods: We retrospectively analyzed patients treated with intra-arterial concurrent chemo-radiation therapy between 2010 and 2016. Intra-arterial catheters were placed in superficial temporal arteries. Two different radiotherapy techniques were used, conventional and simultaneous integrated boost (SIB). The significance of each prognostic factor was estimated using survival analysis. Results: 31 patients were sequentially reviewed with median follow-up time of 11.6 months. There was no renal toxicity. Different radiotherapy techniques, conventional dose fraction versus SIB, did not differ significantly, in terms of locoregional-recurrence-free survival (P=0.057) and overall survival (P=0.069). Better overall survival was found in patients receiving salvage surgery than no surgery (P=0.001) as well as in treatment-naïve patients than recurrent ones (P=0.001). Conclusions: Preoperative concurrent intra-arterial chemoradiation therapy is feasible and effective, has lower toxicity when compare to reports from intravenous chemoradiotherapy. SIB may seemly increase the conversion of inoperable tumor into operable tumor when compare the conventional dose fraction, but this may require further prospective study with more patient accrual. Prognostic factor that significantly improves the overall survival is if the patients receive the salvage surgery.

Feasibility Analysis of Involved-Field Irradiation in Patients With Locally Advanced Adenocarcinoma of the Gastroesophageal Junction in Siewert’s Type 2 and 3 Undergoing Preoperative Concurrent Chemoradiation Therapy

To analyze the feasibility of involved-field irradiation (IFI) in patients with locally advanced adenocarcinoma of gastroesophageal junction (AEG) in Siewert’s type II and III underwent preoperative concurrent chemoradiotherapy. A total of 45 cases were involved into this study. Patients received two cycles of chemotherapy with XELOX and concurrent radiotherapy (45Gy/25f, five fractions per week). After 6 to 8 weeks, they underwent operation. Patients were filled with 800 to 1000 ml water before CT simulation, and more than 5mm of stomach wall on the CT images was delineated as GTV-primary, with the reference of upper gastrointestinal barium meal, esophagus endoscopy, and MRI simultaneously. CTV provided a proximal margin of 2.0cm and distal margin of 1.5 to 2.0cm and radial of 0.8cm around the GTV-primary. GTV-nd was drawn on each relevant slice of the planning CT, and we just regarded GTV-nd and its involved area of metastasis (IFI) as CTV-nd. PTV was defined as 0.8 to 1.0cm of external expansion. The feasibility of IFI was analyzed via the postoperative pathology response and toxicity of chemoradiotherapy. Of the 45 patients, 39 completed preoperative concurrent chemoradiotherapy (CCRT), 6 underwent one cycle of chemotherapy with irradiotherapy. The R0 resection rate was 93.3% (42/45). The rate of pathological complete response (pCR) was 22.2% (10/45). The patients with tumor regression grade 0 to grade 3 were 10 (22.2%), 17 (37.8%), 15 (33.3%), 3 (6.7%), respectively. The lymph node metastasis rate and ratio were 37.8% (17/45) and 4.3% (46/1062). After neoadjuvant chemoradiotherapy, down-staging of T and N were observed in 24 and 26 patients, respectively. The proportion of pathological of stage T3∼4 had a decline by 51.1%, N positive by 42.2%, and stage III-IV by 37.8% (c2=30.896, P=0.000, c2=16.568, P=0.000, c2=17.822, P=0.000). The incidence of esophagitis/gastritis was 44.4% (20/45), and grade 1-3 were 17.8%, 22.2%, 4.4%, respectively. The rate of grade 1-2 pneumonitis was 6.6% (3/45). One patient died of treatment toxicity. A total dose of 45Gy irradiation with concurrent 2 cycles of XELOX regiment before surgery for locally advanced AEG with Siewert’s type II and III could achieve a preferable pCR and higher R0 resection. The rate of lymph node metastasis is decreased obviously, as well as T and N stage. In addition to mild toxicity, concurrent chemotherapy with IFI is worthy to be studied further.

Efficacy and Safety Analysis of Preoperative Concurrent Chemoradiation Therapy for Patients With Locally Advanced Adenocarcinoma of Gastroesophageal Junction in Siewert’s Type II III

Efficacy and Safety Analysis of Preoperative Concurrent Chemoradiation Therapy for Patients With Locally Advanced Adenocarcinoma of Gastroesophageal Junction in Siewert’s Type II III

Objective Assessment of Surgical Restaging after Concurrent Chemoradiation for Locally Advanced Pancreatic Cancer

The role of neoadjuvant chemoradiation therapy in locally advanced pancreatic cancer (LAPC) is still controversial. The aim of this study was to evaluate surgical downstaging after concurrent chemoradiation therapy (CCRT) for LAPC by measuring the objective changes after treatment. From January 2003 through July 2011, 54 patients with LAPC underwent neoadjuvant CCRT. Computed tomography findings of the tumor size, including major vessel invasion, were analyzed before and after CCRT. Among the total recruited patients, 14 had borderline resectable malignancy and another 40 were unresectable before CCRT. After CCRT, a partial response was achieved in four patients. Stable disease and further disease progression were achieved in 36 and 14 patients, respectively. Tumor size showed no significant difference before and after CCRT (3.6 ± 1.1 vs. 3.6 ± 1.0 cm, P = 0.61). Vessel invasion showed improvement in two patients, while 13 other patients showed further tumor progression. Thirty-nine patients with unresectable malignancy and 11 patients with borderline resectable malignancy at time of initial diagnosis remained unchanged after CCRT. Four patients with borderline pancreatic malignancy progressed to an unresectable stage, whereas one unresectable pancreatic malignancy improved to a borderline resectable stage. Only one patient with borderline resectable disease underwent operation after CCRT; however, curative resection failed due to celiac artery invasion and peritoneal seeding. The adverse events associated with CCRT were tolerable. In conclusion, preoperative CCRT in LAPC rarely leads to surgical downstaging, and it could lower resectability rates.

Prognostic Impact of the Nodal Level Involvement in Advanced Oral Cancer Treated With Preoperative Concurrent Chemoradiation Therapy

Prognostic Impact of the Nodal Level Involvement in Advanced Oral Cancer Treated With Preoperative Concurrent Chemoradiation Therapy

Assessment of Cervical Nodal-Level Involvement in Patients With Advanced Oral Cancer Treated With Preoperative Concurrent Chemoradiation Therapy

Assessment of Cervical Nodal-Level Involvement in Patients With Advanced Oral Cancer Treated With Preoperative Concurrent Chemoradiation Therapy

The prognostic value of circumferential resection margin in esophageal squamous cell carcinoma after concurrent chemoradiation therapy and surgery

BackgroundDespite the significant advances in surgical techniques and multimodality treatments for esophageal cancer, the overall survival remains unsatisfactory. During the past years, efforts were made to determine the prognostic factors that would help in identifying patients suitable for surgery or guiding adjuvant therapy. Positive circumferential resection margins (CRMs) in esophageal cancer have been previously linked with poor prognosis, but their impact on survival remains controversial in patients treated by a multimodality protocol. The aim of our study was to examine the significance of tumor involvement of CRM in patients with esophageal squamous cell carcinoma after concurrent chemoradiation therapy followed by esophagectomy. MethodsBetween 2000 and 2010, 94 esophageal squamous cell carcinoma patients who received preoperative concurrent chemoradiation therapy followed by surgery were enrolled in our study. We focused on the CRM, which was defined microscopically as clear (negative) or involved (positive). Univariate and multivariate survival analyses were performed with overall survival as the endpoint. ResultsOur cohort was predominantly male (94.7%) with a median age of 57 years. All of them received concurrent chemoradiation therapy followed by esophagectomy. Overall, 17 patients (18.1%) had positive CRM. Kaplan–Meier survival analysis demonstrated that the 5-year overall survival of patients with clear and involved CRM is 60.1% and 11.8%, respectively (log rank p < 0.001). Multivariate analysis with the Cox proportional hazard model demonstrated that CRM involvement is a significant prognostic factor for overall survival (p < 0.001). ConclusionIn patients with esophageal squamous cell carcinoma who underwent trimodality treatment, CRM involvement is a significant risk factor predicting survival. Additional effort is required to achieve a clear CRM in esophageal cancer treatment.

Preoperative Short-Course Concurrent Chemoradiation Therapy Followed by Delayed Surgery for Locally Advanced Rectal Cancer: A Phase 2 Multicenter Study (KROG 10-01)

A prospective phase 2 multicenter trial was performed to investigate the efficacy and safety of preoperative short-course concurrent chemoradiation therapy (CRT) followed by delayed surgery for patients with locally advanced rectal cancer. Seventy-three patients with cT3-4 rectal cancer were enrolled. Radiation therapy of 25 Gy in 5 fractions was delivered over 5 consecutive days using helical tomotherapy. Concurrent chemotherapy was administered on the same 5 days with intravenous bolus injection of 5-fluorouracil (400 mg/m(2)/day) and leucovorin (20 mg/m(2)/day). After 4 to 8 weeks, total mesorectal excision was performed. The primary endpoint was the pathologic downstaging (ypStage 0-I) rate, and secondary endpoints included tumor regression grade, tumor volume reduction rate, and toxicity. Seventy-one patients completed the planned preoperative CRT and surgery. Downstaging occurred in 20 (28.2%) patients, including 1 (1.4%) with a pathologic complete response. Favorable tumor regression (grade 4-3) was observed in 4 (5.6%) patients, and the mean tumor volume reduction rate was 62.5 ± 21.3%. Severe (grade ≥3) treatment toxicities were reported in 27 (38%) patients from CRT until 3 months after surgery. Preoperative short-course concurrent CRT followed by delayed surgery for patients with locally advanced rectal cancer demonstrated poor pathologic responses compared with conventional long-course CRT, and it yielded considerable toxicities despite the use of an advanced radiation therapy technique.

Clinical Nodal Staging and Clinical Target Volume for Preoperative Concurrent Chemoradiation Therapy in Patients With Advanced Oral Cancer

Clinical Nodal Staging and Clinical Target Volume for Preoperative Concurrent Chemoradiation Therapy in Patients With Advanced Oral Cancer

Pancreatoduodenectomy Following Neoadjuvant Chemoradiation Therapy in Uncinate Process Pancreatic Cancer

The objective of the study was to delineate surgical outcomes of pancreatoduodenectomy following neoadjuvant concurrent chemoradiation therapy (CCRT) in uncinate process pancreatic cancer (UPC). We reviewed 97 patients with resected usual pancreatic head cancer (PHC) and UPC and analyzed clinicopathologic characteristics and survival outcomes of PHC and UPC with a review of the reported literature regarding UPC. Twenty-five patients (27.8%) had UPC, and 72 patients had PHC. Pylorus-preserving pancreatoduodenectomy was performed in 67 patients (69.1%) and conventional pancreatoduodenectomy in 28 patients (28.9%), and 2 patients needed total pancreatectomies. When comparing UPCs with PHCs, less frequent jaundice (P = 0.009) and more advanced stages of cancers at the time of diagnosis (linear-to-linear association, P = 0.03) were found in UPCs, and CCRT was administered more frequently in UPCs (P = 0.013). Survival outcomes between PHC and UPC were similar, with median survival rates of 25.9 and 30.5 months, respectively (P = 0.702). In addition, disease-free survival was similar between the 2 groups (15.6 and 15.2 months, respectively; P = 0.4503). Our oncologic outcome of pancreatectomy for UPC is likely to be more acceptable compared with those previously reported in the literature. Although UPCs are found in relatively advanced clinical stages, favorable oncologic outcomes may be obtained by pancreatectomy following preoperative CCRT.

Technical Feasibility of Laparoscopic Lateral Pelvic Lymph Node Dissection for Patients with Low Rectal Cancer after Concurrent Chemoradiation Therapy

To test the technical feasibility of laparoscopic lateral pelvic lymph node dissection for patients with clinically positive lateral node(s) after preoperative concurrent chemoradiation therapy for lower rectal cancer. The operation procedures are detailed in the attached video. Forty-five procedures of laparoscopic lateral pelvic lymphadenectomy were performed in 34 patients, with dissection over bilateral lateral node foci in 11 patients and dissection over unilateral lateral node station in 23. There were four procedures in which the metastatic node was very close to or even encased the adjacent iliac vessel and therefore the lymphadenectomy was done with a surgical margin of less than 1 mm. The median (range) number of lymph nodes harvested in each lateral station was 6 (2-14). Lympho-adipose tissues from 32 (71.1%, 32/45) lateral node dissections were confirmed by histopathology to harbor metastatic adenocarcinoma. For unilateral lateral pelvic lymph node dissection, median (range) blood loss was 44 (20-240) ml and median (range) operation time was 58 (42-94) min. There was one (2.9%) operative mortality and seven (20.6%) postoperative complications. Postoperatively, most patients presented with mild postoperative pain and quick convalescence. During follow-up (mean 24 months), nine patients (27.3%) developed recurrent disease. Remarkably, all four patients with surgical margin less than 1 mm developed cancer recurrence. Laparoscopic lateral pelvic lymphadenectomy is technically feasible for some selected patients. To date, laparoscopic approach is still underdeveloped to treat the complex clinical condition in which the metastatic node involves the iliac vessel and combined resection of the vessel is required to obtain sufficient margin.

Technical feasibility of laparoscopic total mesorectal excision for patients with low rectal cancer after concurrent radiation and chemotherapy with bevacizumab plus FOLFOX

This study aimed to evaluate the technical feasibility of laparoscopic total mesorectal excision (TME) for the treatment of low rectal cancer after concurrent chemoradiation therapy (CCRT) with bevacizumab and FOLFOX. Patients with clinical T3, T4, or N1-2 rectal cancer were subjected to a preoperative CCRT protocol with FOLFOX and bevacizumab (5 mg/kg) biweekly for 6 cycles followed by a standardized laparoscopic TME procedure, as detailed in the attached video. The treatment protocol was completed by 28 patients. Scrutiny of the video indicated that the dissection plane was a little blurred due to preoperative CCRT, but this did not significantly increase the technical difficulties. Laparoscopic TME was efficiently performed with acceptable operation time (214.4 ± 44.4 min). However, the median blood loss (420 ml; range, 120-1,200 ml) in this series was significantly greater than in the historic series without bevacizumab therapy. Bevacizumab seems not to increase the severity of FOLFOX-related liver steatosis and sinusoidal dilation. One operative mortality (3.6%) occurred. Six patients (21.4%) presented with postoperative complications including upper gastrointestinal bleeding, deep vein thrombosis, pelvic abscess, wound infection, enterocutaneous fistula, and perineal fistula. The patients presented with mild postoperative pain and had a quick convalescence. The addition of bevacizumab to FOLFOX achieved a superior pathologic response for 78.3% of the patients, whose residual tumor cells were very few (< 10% microscopic field). Based on the controllable surgical complications and minimal invasiveness in the current patient series, laparoscopic TME is shown to be technically feasible and can be recommended for patients with advanced lower rectal cancer requiring preoperative CCRT using bevacizumab as the additional therapeutic agent.

Phase II Study of Preoperative Concurrent Chemoradiation Therapy with S-1 in Patients with T4 Oral Squamous Cell Carcinoma

Phase II Study of Preoperative Concurrent Chemoradiation Therapy with S-1 in Patients with T4 Oral Squamous Cell Carcinoma

Phase II Study of Preoperative Concurrent Chemoradiation Therapy With S-1 in Patients With T4 Oral Squamous Cell Carcinoma

To determine the feasibility and efficacy of preoperative concurrent chemoradiation therapy (CCRT) with S-1, an oral fluoropyrimidine derivative, in patients with T4 oral squamous cell carcinoma (SCC). Only patients with histologically proven T4 oral SCC were included. Radiotherapy (total dose, 30 Gy) was delivered in 2-Gy daily fractions over a period of 3 weeks. Concurrently, S-1 (80 mg/m(2)/day) was administered orally twice daily for 14 consecutive days. We enrolled 46 patients. All underwent radiotherapy as planned; however, oral S-1 was discontinued in 3 patients who manifested acute toxicity. Grade 3 toxicities were mucositis (20%), anorexia (9%), and neutropenia (4%). We encountered no Grade 4 adverse events or serious postoperative morbidity requiring surgical intervention. After CCRT, 32 of the 46 patients underwent radical resection; in 17 (53%) of the operated patients, the pathologic response was complete. During follow-up ranging from 7 to 58 months (median, 22 months), tumor control failed in 5 (16%) of the 32 operated patients; there were 3 local and 2 regional failures. Of the 14 non-operated patients, 8 (57%) manifested local (n = 7) or regional failure (n = 1). The 3-year overall survival rate for all 46 patients was 69%; it was significantly higher for operated than for non-operated patients (82% vs. 48%; p = 0.0288). Preoperative CCRT with S-1 is feasible and effective in patients with T4 oral SCC. Even in inoperable cases, CCRT with S-1 provides adequate tumor control.

Effectiveness of preoperative concurrent chemoradiation therapy (CCRT) for locally advanced adenocarcinoma of cervix

Aim To determine the efficacy of preoperative concurrent chemoradiation therapy (CCRT) to improve the prognosis of locally advanced adenocarcinoma of the uterine cervix. Methods Twenty-five patients with clinical stage IB2–IVB adenocarcinoma of the cervix were received preoperative CCRT. The CCRT protocol included: external radiotherapy to the pelvis: 39.6 Gy; intra-arterial or intravenous infusion of 70 mg/m 2 cisplatin, days 1 and 22; 24-h continuous intravenous infusion of 700 mg/m 2 5-FU, days 1–4 and 22–25. Two weeks after the end of CCRT, patients underwent restaging followed by appropriate surgery with pelvic lymphadenectomy. Results The overall clinical response rate was 96% (24/25), with a complete response (CR) in 12/25 patients and partial response (PR) in 12/25. On pathological examination, 5 of 19 patients (26%) undergoing surgery showed a pathological CR, 13 patients showed a PR, and 1 patient no change (NC) in their disease. Grade 3 or 4 hematological toxicity was observed in 15 patients. Grade 3 gastrointestinal toxicity was observed in 8 patients. The median follow-up period was 34 months (range, 6–69). The 5-year overall survival (OS) rate was 84%, and the progression-free survival (PFS) rate was 76%. Conclusions Preoperative CCRT improves the survival of patients with locally advanced adenocarcinoma of the cervix, with manageable toxicities.

A modern regimen of pre‐operative concurrent chemo‐radiation therapy in locally advanced rectal cancer

To evaluate the efficacy and toxicity of preoperative concurrent capecitabine and radiotherapy in the treatment of resectable locally advanced rectal cancer (LARC). We conducted a phase II trial to assess pathological complete response, tumor downstaging, toxicity and survival of capecitabine (825 mg/m(2) orally, twice daily) with radiotherapy (50.4 Gy/28 fractions) in 31 patients with LARC (cT3/T4 or N+) staged by endoscopic ultrasound (EUS). Median age was 53 years; with M:F ratio of 1:1.58; 77.4% had Eastern Cooperative Oncology Group performance status of 1. EUS showed that 67.7% of tumors were T3, 19.4% were T4, and 58% were node positive. Of 30 patients who had surgery, 6.5% achieved pathological complete remission (pCR). Tumor and nodal downstaging were achieved in 53.9% and 50% of patients, respectively. Grade 3/4 toxicities were mainly diarrhea (35.5%) and proctitis (32.3%). Sphincter preservation was achieved in 4/21 (15%) of patients initially planned for abdominoperineal resection. The median follow-up was 46 months (Range: 1.47-63.9), and the 3-year disease-free and overall survival were 59.8% and 76.6%, respectively. Capecitabine given concurrently with radiation therapy is generally well tolerated, and proved to be an effective radiosensitizer in the neoadjuvant treatment of locally advanced rectal cancer, yielding results comparable to those reported with 5-FU.

Transanal Local Excision for Preoperative Concurrent Chemoradiation Therapy for Distal Rectal Cancer in Selected Patients

To evaluate the clinical course and outcomes of patients with T2 or T3 rectal cancer treated by transanal local excision after preoperative chemoradiation therapy (CRT). Between June 2000 and August 2004, seven patients underwent local excision of T2 or T3 rectal cancer after preoperative CRT. Preoperative clinical staging was on the basis of the findings of endorectal ultrasound. Computed tomography (CT) and digital rectal examination consisted of radiation therapy with 4 500 cGy/25 fractions, given over 5 weeks with 5-FU-based chemosensitization. Local excision was performed 4-7 weeks later. The mean age of the patients was 54.9 (35-70) years and the median follow-up period was 23 (5-57) months. The lesions were located 2-6 cm above the anal verge (median 3.0 cm). Pretreatment T staging was estimated as T3 in one patient, and T2 in six patients. Post-treatment T staging was estimated as complete remission (CR) in two patients, T1 in three patients, and T2 in two patients. Pathologic evaluation revealed tumor downstaging in six patients, including three (42.9%) with CR. No tumor cells were seen in the resection margin and there was no sign of recurrence in any of the patients. These findings support local excision after preoperative CRT as an effective alternative to radical resection in carefully selected patients with T2 and T3 distal rectal cancer.