Abstract
Patients with locally advanced rectal cancer (LARC) that have a complete clinico-radiological response after neoadjuvant chemoradiation (NACRT) can be offered nonoperative or watch and wait (W&W) management. This study assessed the compliance and outcomes of such patients at our institute. Thirty-six patients with locally advanced low-lying rectal cancers treated between December 2013 and November 2018 and had a near-complete clinical response (ncCR) or complete clinical response (cCR) after completing NACRT and were reluctant to undergo surgery were included. They were followed up at 3 monthly intervals with a combination of pelvic MRI, digital rectal examination, and sigmoidoscopy. Twelve weeks after chemoradiation, 24 (67%) patients had cCR and 12 (33%) had ncCR. All the 36 patients were kept on the W&W protocol. At a median follow-up of 35 (range 17–72) months, six (17%) patients developed local regrowth, one from the cCR group, while five were from the ncCR group. Four of the six patients underwent surgery for local disease (three had sphincter preserving resections and one had abdominoperineal resection), and one of these also had liver metastatectomy. Two of the six patients refused surgery, giving a compliance rate of 94.5%. Three of the 36 patients (8%) had distant metastasis, one had liver metastasis, one had leptomeningeal metastasis, and the third who refused surgery at regrowth developed lung metastasis. Thus, of the 36 patients on the W&W protocol, organ preservation rate was 80%. Local regrowth free DFS was 92.4%, and OAS was 96% at 3 years. W&W approach after cCR and ncCR to NACRT in LARC is acceptable with reasonable compliance and with good outcomes.
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van de Velde CJ, Boelens PG, Borras JM et al (2014) EURECCA colorectal: multidisciplinary management: European consensus conference colon & rectum. Eur J Cancer 50(1):e1-1.e34
Habr-Gama A, Perez RO, Nadalin W, et al (2004) Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: Long-term results. Ann Surg 240:711–717, discussion 717–718
Maas M, Beets-Tan RG, Lambregts DM et al (2011) Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer. J Clin Oncol 29:4633–4640
Li J, Liu H, Yin J et al (2015) Wait-and-see or radical surgery for rectal cancer patients with a clinical complete response after neoadjuvant chemoradiotherapy: A cohort study. Oncotarget 6:42354–42361
Sammour T, Price BA, Krause KJ, Chang GJ (2017) Nonoperative Management or “Watch and Wait” for Rectal Cancer with Complete Clinical Response After Neoadjuvant Chemoradiotherapy: A Critical Appraisal. Ann Surg Oncol 24(7):1904–1915
Dossa F et al (2017) A watch-and-wait approach for locally advanced rectal cancer after a clinical complete response following neoadjuvant chemoradiation: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol 2(7):501–513
Glynne-Jones R et al (2017) Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 28(suppl_4):iv22–iv40
Patil PS, Saklani A, Gambhire P et al (2017) Colorectal cancer in India: an audit from a tertiary center in a low prevalence area. Indian J Surg Oncol 8(4):484–490
Shinde RS, Katdare N, Kumar NAN, Bhamre R, Desouza A, Ostwal V, Engineer R, Saklani A (2018) Impact of histological subtype on treatment outcomes in locally advanced rectal adenocarcinoma treated with neoadjuvant chemoradiation. Acta Oncol. 57(12):1721–1723
Renehan AG, Malcomson L, Emsley R, Gollins S, Maw A, Myint AS, Rooney PS, Susnerwala S, Blower A, Saunders MP, Wilson MS, Scott N, O’Dwyer ST (2016) Watch-and-wait approach versus surgical resection after chemoradiotherapy for patients with rectal cancer (the OnCoRe project): a propensity-score matched cohort analysis. Lancet Oncol 17(2):174–183. https://doi.org/10.1016/S1470-2045(15)00467-2
Ayloor Seshadri R, Kondaveeti SS, Jayanand SB, John A, Rajendranath R, Arumugam V, Raj Ellusamy H, Sagar TG (2013) Complete clinical response to neoadjuvant chemoradiation in rectal cancers: can surgery be avoided? Hepatogastroenterology 60(123):410–414
Habr-Gama A, São Julião GP, Fernandez LM, Vailati BB, Andrade A, Araújo SEA, Gama-Rodrigues J, Perez RO (2019) achieving a complete clinical response after neoadjuvant chemoradiation that does not require surgical resection: it may take longer than you think! Dis Colon Rectum 62(7):802–808
Hupkens BJP et al (2018) Organ preservation in rectal cancer after chemoradiation: should we extend the observation period in patients with a clinical near-complete response? Ann Surg Oncol 25(1):197–203
Habr-Gama A, São Julião GP, Gama-Rodrigues J et al (2017) Baseline T classification predicts early tumor regrowth after nonoperative management in distal rectal cancer after extended neoadjuvant chemoradiation and initial complete clinical response. Dis Colon Rectum 60:586–594
Bitterman DS, Resende Salgado L, Moore HG, Sanfilippo NJ, Gu P, Hatzaras I, Du KL (2015) Predictors of complete response and disease recurrence following chemoradiation for rectal cancer. Front Oncol 5:286
Habr-Gama A, São Julião GP, Vailati BB, Fernandez LM, Ortega CD, Figueiredo N, Gama-Rodrigues J, Perez RO (2019) Organ preservation among patients with clinically node-positive rectal cancer: is it really more dangerous? Dis Colon Rectum 62(6):675–683
Bipat S, Glas AS, Slors FJ, Zwinderman AH, Bossuyt PM, Stoker J (2004) Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging–a metaanalysis. Radiology 232:773–783
Sammour T, Malakorn S, Bednarski BK, Kaur H, Shin US, Messick C, You YN, Chang GJ (2018) Oncological outcomes after robotic proctectomy for rectal cancer: analysis of a prospective database. Ann Surg 267(3):521–526
Kong JC et al (2017) Outcome and salvage surgery following “watch and wait” for rectal cancer after neoadjuvant therapy: a systematic review. Dis Colon Rectum 60(3):335–345
van der Valk MJM, Hilling DE, Bastiaannet E, Meershoek-Klein Kranenbarg E, Beets GL, Figueiredo NL et al (2018) Long-term outcomes of clinical complete responders after neoadjuvant treatment for rectal cancer in the International Watch & Wait Database (IWWD): an international multicentre registry study. Lancet 391(10139):2537e45
P Bulens, A Debucquoy, I Joye, A Wolthuis et al, Comparison of surgical data and survival outcome of rectal cancer patients that need upfront surgery after chemoradiotherapy versus salvage surgery after watch-and-wait PD _ 032 Annals of Oncology
Pang K, Rao Q, Qin S, Jin L, Yao H, Zhang Z (2019) Prognosis comparison between wait and watch and surgical strategy on rectal cancer patients after treatment with neoadjuvant chemoradiotherapy: a meta-analysis. Therap Adv Gastroenterol 12:1756284819892477. https://doi.org/10.1177/1756284819892477
Hupkens BJP, Martens MH, Stoot JH, Berbee M, Melenhorst J, Beets-Tan RG, Beets GL, Breukink SO (2017) Quality of life in rectal cancer patients after chemoradiation: watch-and-wait policy versus standard resection - a matched-controlled study. Dis Colon Rectum 60(10):1032–1040
Yeom SS, Lee SY, Kim CH, Kim YJ, Nam TK, Kim HR (2019) Non-operative treatment outcome for the rectal cancer patient with clinical complete response after neoadjuvant chemoradiotherapy. Asian J Surg 42(8):823–831. https://doi.org/10.1016/j.asjsur.2018.12.007
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Engineer, R., Saklani, A., D’souza, A. et al. Watch and Wait Approach After Neoadjuvant Chemoradiotherapy in Rectal Cancer: Initial Experience in the Indian subcontinent. Indian J Surg Oncol 12, 664–670 (2021). https://doi.org/10.1007/s13193-021-01421-6
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DOI: https://doi.org/10.1007/s13193-021-01421-6