Multimodal Treatment of cT3 Rectal Cancer in a Prospective Multi-Center Observational Study: Can Neoadjuvant Chemoradiation Be Omitted in Patients with an MRI-Assessed, Negative Circumferential Resection Margin?

Abstract

<b><i>Background/Aim:</i></b> Neoadjuvant chemoradiation (nCRT) in rectal cancer is associated with significant long-term morbidity. It is unclear whether nCRT in resectable mesorectal fascia circumferential resection margin (mrCRM)-negative rectal cancer treated by adequate total mesorectal excision (TME) is beneficial. The aim was to determine if nCRT can be omitted in patients with MRI-assessed cT3 rectal cancer and a negative mrCRM undergoing good-quality TME. <b><i>Methods:</i></b> By means of a prospective nationwide registry (<i>n</i> = 43.147; prospective multi-center observational study), patients with cT3 rectal cancer <12 cm from the anal verge with a negative (>1 mm) MRI-assessed CRM undergoing radical resection from 2006 to 2008 were selected. Overall, 87 patients were available for the final analysis (TME-alone, <i>n</i> = 25; nCRT+TME, <i>n</i> = 62). Groups were balanced for age, sex, and ASA score, with a nonsignificant predominance of males in the nCRT+TME group. As main outcome measures, local and distant recurrence rates were compared between patients undergoing primary surgery (TME-alone) vs. neoadjuvant chemoradiation + surgery (nCRT+TME). <b><i>Results:</i></b> In the TME-alone group, tumors were located closer to the anal verge (<i>p</i> = 0.018) and demonstrated a smaller minimal circumferential distance from the resection margin (<i>p</i> = 0.036). TME quality was comparable, as was median follow-up (48.9 vs. 44.9 months; <i>p</i> = 0.268). Local recurrences occurred at a similar rate in the TME-alone (<i>n</i> = 1; 5.3%) and nCRT+TME groups (<i>n</i> = 3; 5.5%) (<i>p</i> = 0.994) and were diagnosed at 10 months (TME-alone) and at 8, 13, and 18 months (nCRT+TME). Distant recurrences occurred in 28.9 and 17.4% of the cases, respectively (<i>p</i> = 0.626). The analysis was limited to cT3 cancers with a negative mrCRM. In addition, caution is required when appraising these results because of the limited number of evaluable subjects (especially in the TME-alone group), which adds some uncertainty to the statistical analysis. <b><i>Conclusions:</i></b> In this cohort of patients with rectal cancer located <12 cm from the anal verge and a negative mrCRM undergoing adequate TME, omission of nCRT had no impact onto the local recurrence rate.

Abandonment of Routine Radiotherapy for Nonlocally Advanced Rectal Cancer and Oncological Outcomes

“…Furthermore, patients with tumors with good prognostic features (cT2-3ab CRM − mrEMVI − tumors, regardless of cN-stage) could be safely treated with surgery alone, resulting in a 3% LR rate. Several studies thereafter confirmed that upfront TME surgery was associated with similarly low LR rates compared with n(C)RT as long as the MRF is free, although this might be debated for the distal tumors based on the OCUM trial …”

Vai Trò Hội Chẩn Đa Mô Thức Trong Điều Trị Ung Thư Trực Tràng T3, Diện Cắt Vòng Quanh Âm Tính

“…Chuyển mổ mở, (5). Đã mổ do bệnh ung thư khác, (6) "Nguồn: Glynne-Jones R -ESMO Clinical Guidelines (2017)" 4…”

“…Phẫu tích 4 bình diện trực tràng: Lấy bỏ bán phần MTTT (dưới u 5cm) hoặc toàn bộ MTTT (dưới u ít nhất 2cm), (5). Bảo tồn thần kinh tự động vùng chậu, (6). Thực hiện miệng nối bằng máy khâu nối hoặc nối tay (7).…”

“…pN: Hạch di căn, (5). Xâm nhập mạch Lim-phô có sự hiện diện của cụm tế bào u hoặc tế bào u riêng lẻ trong lòng mạch limphô, (6). Xâm lấn mạch máu, (7).…”

Issue on general and abdominal surgery – an exciting and challenging surgical discipline in the spectrum of operative medicine

“…Studies on quality assurance in clinical medicine, in particular, in “oncosurgery”, have a long tradition at the Magdeburg’s Institute of Quality Assurance in Operative Medicine (Otto von Guericke University; former scientific heads: Profs. Lippert and Gastinger) - see a selection in the reference list [ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ].…”