Could a wait and see policy be justified in T3/4 rectal cancers after chemo-radiotherapy?
Chemoradiotherapy (CRT) followed by total mesorectal excision is the standard when MRI staging demonstrates threatened surgical margins in locally advanced rectal cancer (LARC). Interest in non-surgical management of LARC as an alternative to a resection has been provoked by published excellent long-term outcomes of patients who achieve clinical complete responses (cCR) after CRT. The present retrospective study aimed to determine whether similar rates of local disease control are seen in a UK cancer centre in patients with T3-4 tumours, who obtained a cCR after preoperative CRT, but did not undergo surgery.


METHODS
The outcome and treatment details of 266 patients who underwent CRT for clinically staged T3-4 rectal adenocarcinomas between 1993 and 2005 were reviewed.


RESULTS
Fifty-eight patients did not proceed to surgery, 10 of whom were identified as having a cCR. Six of these 10 patients subsequently developed intrapelvic recurrent disease with a median time to local progression of 20 months. Local relapse preceded the development of metastatic disease or occurred simultaneously. No patients underwent salvage resection.


CONCLUSIONS
CRT alone in cT3/T4 rectal cancers has a high rate of local relapse even after cCR. Delaying or avoiding surgery might be appropriate for cT1 or cT2 tumours, or elderly and frail patients with co-morbidity, but these results do not support the current uncritical move to extrapolate this approach to all surgically fit patients with rectal cancer.
Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex HA6 2RN, UK. robert.hughes@nhs.net
Robert
R
Hughes
Mark
M
Harrison
Robert
R
Glynne-Jones
D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D017024:Chemotherapy, Adjuvant; D015897:Comorbidity; D013505:Digestive System Surgical Procedures / Q000379:methods; D019583:Dose Fractionation, Radiation; D005260:Female; D016330:Frail Elderly; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000379:methods*; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D009367:Neoplasm Staging; D011446:Prospective Studies; D018714:Radiotherapy, Adjuvant; D012004:Rectal Neoplasms / Q000188:drug therapy / Q000453:epidemiology / Q000473:pathology* / Q000532:radiotherapy / Q000601:surgery / Q000628:therapy*; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology