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.
Hughes
Robert
R
Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex HA6 2RN, UK. robert.hughes@nhs.net
Harrison
Mark
M
Glynne-Jones
Robert
R
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