title: Watch and wait approach following extended neoadjuvant chemoradiation for distal rectal cancer: are we getting closer to anal cancer management?
abstract: BACKGROUND
  No immediate surgery (Watch and Wait) has been considered in select patients with complete clinical response after neoadjuvant chemoradiation to avoid postoperative morbidity and functional disorders after radical surgery.
  
  
  OBJECTIVE
  The purpose of this study was to demonstrate the long-term results of patients who had a complete clinical response following an alternative chemoradiation regimen and were managed nonoperatively.
  
  
  METHODS
  This is a prospective study.
  
  
  METHODS
  This study was conducted at a single center.
  
  
  METHODS
  Seventy consecutive patients with T2-4N0-2M0 distal rectal cancer were studied. Neoadjuvant chemoradiotherapy included 54 Gy and 5-fluorouracil/leucovorin delivered in 6 cycles every 21 days. Patients were assessed for tumor response at 10 weeks from radiation completion. Patients with incomplete clinical response were referred to immediate surgery. Patients with complete clinical response were not immediately operated on and were monitored.
  
  
  METHODS
  The primary outcomes measured were the initial complete clinical response rates after 10 weeks and the sustained complete clinical response rates after 12 months from chemoradiotherapy.
  
  
  RESULTS
  One patient died during chemoradiotherapy because of cardiac complications. Forty-seven (68%) patients had initial complete clinical response. Of these, 8 developed local regrowth within the first 12 months of follow-up (17%). Thirty-nine sustained complete clinical response at a median follow-up of 56 months (57%). An additional 4 patients (10%) developed late local recurrences (>12 months of follow-up). Overall, 35 patients never underwent surgery (50%).
  
  
  CONCLUSIONS
  This study is limited by the short follow-up and small sample size.
  
  
  CONCLUSIONS
  Extended chemoradiation therapy with additional chemotherapy cycles and 54 Gy of radiation may result in over 50% of sustained (>12 months) complete clinical response rates that may ultimately avoid radical rectal resection. Local failures occur more frequently during the initial 12 months of follow-up in up to 17% of cases, whereas late recurrences are less common but still possible, leading to 50% of patients who never required surgery. Strict follow-up may allow salvage therapy in the majority of these patients (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A113.).
authors.affiliation: 1 Angelita & Joaquim Gama Institute, Sao Paulo, Brazil 2 Clinical Oncology Division, Instituto do Cancer do Estado de São Paulo (ICESP), Sao Paulo, Brazil 3 Department of Gastroenterology, Colorectal Surgery Division, University of São Paulo School of Medicine, Sao Paulo, Brazil 4 Department of Radiology, Radiation Oncology Division, University of São Paulo School of Medicine, Sao Paulo, Brazil 5 Radiation Oncology Division, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil 6 Ludwig Institute for Cancer Research, São Paulo Branch, Sao Paulo, Brazil.
authors.forename: Angelita
authors.initials: A
authors.lastname: Habr-Gama
authors.forename: Jorge
authors.initials: J
authors.lastname: Sabbaga
authors.forename: Joaquim
authors.initials: J
authors.lastname: Gama-Rodrigues
authors.forename: Guilherme P
authors.initials: GP
authors.lastname: São Julião
authors.forename: Igor
authors.initials: I
authors.lastname: Proscurshim
authors.forename: Patricia
authors.initials: P
authors.lastname: Bailão Aguilar
authors.forename: Wladimir
authors.initials: W
authors.lastname: Nadalin
authors.forename: Rodrigo O
authors.initials: RO
authors.lastname: Perez
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D059186:Chemoradiotherapy, Adjuvant; D019583:Dose Fractionation, Radiation; D005260:Female; D005472:Fluorouracil / Q000008:administration & dosage; D006801:Humans; D002955:Leucovorin / Q000008:administration & dosage; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009364:Neoplasm Recurrence, Local / Q000175:diagnosis; D009367:Neoplasm Staging; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000473:pathology / Q000628:therapy*; D013997:Time Factors; D057832:Watchful Waiting
chemical_list: D002955:Leucovorin; D005472:Fluorouracil