Aim There is significant international variation in the use of neoadjuvant radiation prior to total mesorectal excision. The MERCURY group advocate selective neoadjuvant chemoradiotherapy (CRT). We have performed a retrospective, single‐centre study of patients treated with CRT, where only the circumferential resection margin is threatened, with the aim of identifying whether a more selective approach to CRT provides acceptable local relapse rates (LRRs). Method All consecutive patients who underwent radical surgery for rectal adenocarcinoma over a 5‐year period (2007–2012) in the Oxford University Trust were considered. Electronic hospital systems were reviewed to obtain patient and tumour demographics, treatment and follow‐up information. All patients were classified into risk categories according to National Institute for Health and Care Excellence guidance. Data were analysed using Microsoft Excel and R. Results Two hundred and seventy‐two patients were identified: 123, 89 and 60 in the high‐, intermediate‐ and low‐risk categories, respectively. Seventy‐nine per cent of those in the high‐risk group, 6% in the intermediate and 5% in the low‐risk group underwent CRT. The overall 5‐year LRR and distant recurrence rate (DRR) were 5.2% and 17.8%, respectively. The 5‐year LRR for those who went straight to surgery was 2.0% and for those who had neoadjuvant CRT it was 7.4%. The DRR for these two groups was 8.5% and 18.9%, respectively. Conclusion Our series demonstrates that the use of CRT only in margin‐threatening tumours, results in an exceptionally low LRR for those without margin‐threatening disease. In routine clinical care, this strategy can minimize the significant morbidity of multimodal treatment and allow earlier introduction of systemic therapy to minimize distant recurrence.

Background: Infusional 5-fluorouracil (5-FU) has been the standard radiation sensitizer in patients undergoing preoperative long-course chemoradiotherapy (CRT) for locally advanced rectal cancer in Australia. Capecitabine (Xeloda) is an oral 5-FU prodrug of comparable pharmacodynamic activity, currently preferred in place of 5-FU infusion, its established counterpart in neoadjuvant CRT for rectal cancer. The few studies quantifying pathological complete response (pCR) of Xeloda versus 5-FU have produced inconsistent results. We reviewed our own data to determine if the rates of pCR of oral capecitabine were non-inferior to intravenous 5-FU in patients undergoing neoadjuvant CRT for rectal cancer. Methods: A retrospective study was performed from a prospectively kept database. Four hundred and fifty-two patients received preoperative CRT from January 2006 to January 2016. Pelvic radiotherapy was delivered concurrently with capecitabine (n = 42) or infusional 5-FU (n = 341). The remaining received different chemotherapy regimens. Surgery was performed 6-12 weeks of CRT completion. Pathological responses were assessed using Dworak regression grading score (0-4). Clinical outcomes were evaluated in terms of local control and recurrence-free survival. Results: The proportion of patients who had a tumour regression score of 4 (pCR) after CRT was 4/42 (9.5%) in the capecitabine group and 71/341 (20%) in the infusional 5-FU group (P = 0.082). pCR was an independent predictor for survival in this group of patients (hazard ratio: 0.002, P = 0.0001, 95% confidence interval: 0.0001-0.027). Conclusion: The use of capecitabine as neoadjuvant chemotherapy in patients with rectal cancer was associated with a reduced rate of pCR. However this difference did not achieve statistical significance.

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