Role of Preoperative Chemoradiotherapy in Clinical Stage II/III Rectal Cancer Patients Undergoing Total Mesorectal Excision: A Retrospective Propensity Score Analysis

Abstract

BackgroundAlthough the current standard preoperative chemoradiotherapy (PCRT) for stage II/III rectal cancer decreases the risk of local recurrence, it does not improve survival and increases the likelihood of preoperative overtreatment, especially in patients without circumferential resection margin (CRM) involvement.MethodsStage II/III rectal cancer without CRM involvement and lateral lymph node metastasis was radiologically defined by preoperative magnetic resonance imaging (MRI). Patients who received PCRT followed by total mesorectal excision (TME) (PCRT group) and upfront surgery (US) with TME (US group) between 2010 and 2016 were analyzed. We derived cohorts of PCRT group versus US group using propensity-score matching for stage, age, and distance from the anal verge. Three-year relapse-free survival rate, disease-free survival (DFS), and overall survival (OS) were compared between the two groups.ResultsA total of 202 patients were analyzed after propensity score matching. There were no differences in baseline characteristics. The median follow-up duration was 62 months (interquartile range, 46–87). There was no difference in the 3-year disease-free survival rate between the PCRT and US groups (83 vs. 88%, respectively; p=0.326). Likewise, there was no significant difference in the 3-year OS (89 vs. 91%, respectively; p=0.466). The 3-year locoregional recurrence rates (3 vs. 2% with US, p=0.667) and distant metastasis rates (16 vs. 11%, p=0.428) were not significantly different between the two groups. Time to completion of curative treatment was significantly shorter in the US group (132 days) than in the PCRT group (225 days) (p<0.001).ConclusionUsing MRI-guided selection for better risk stratification, US without neoadjuvant therapy can be considered in early stage patients with good prognosis. PCRT may not be required for all stage II/III rectal cancer patients, especially for the MRI-proven intermediate-risk group (cT1-2/N1, cT3N0) without CRM involvement and lateral lymph node metastasis. Further prospective studies are warranted.

Surgical Treatment of Low-Lying Rectal Cancer: Updates

“…For cT1–2/N1, cT3N patients without CRM involvement nor lateral LN metastasis, upfront surgery without neoadjuvant therapy can be considered in early-stage patients with a good prognosis [ 80 ]. In our experience, oncologic outcomes of LAR and uLAR are significantly affected by positive ypN stage (hazard ratio [HR], 2.110; 95% confidence interval [CI], 1.144–3.892; P = 0.017) and tumor regression grade of 3 or more (HR, 2.962; 95% CI, 1.434–6.119; P = 0.003) with a recurrence rate of 20.0% in our locally advanced rectal cancer patients, coinciding with National Comprehensive Cancer Network guidelines where a recurrence rate of 20.8% is reported [ 81 ].…”

Precision Identification of Locally Advanced Rectal Cancer in Denoised CT Scans Using EfficientNet and Voting System Algorithms

“…The rate of permanent stoma following low anterior resection is 13%. Reducing neoadjuvant therapy to chemotherapy with FOLFOX alone [8] or opting for direct surgery [9] for rectal cancer with an adequate surgical margin has been proven to offer comparable efficacy. Hence, the rapid identification of LARC with margin-threatening characteristics is crucial at the outset of rectal cancer therapy.…”