Advertisement

International Journal of Colorectal Disease

, Volume 34, Issue 12, pp 2129–2136 | Cite as

Local excision in rectal cancer patients with major or complete clinical response after neoadjuvant therapy: a case-matched study

  • M. Bushati
  • S. PucciarelliEmail author
  • N. Gennaro
  • I. Maretto
  • P. Toppan
  • A. Perin
  • E. D. L. Urso
  • A. Bagatella
  • G. Spolverato
Original Article

Abstract

Purpose

To assess the long-term oncological outcomes in patients with locally advanced rectal cancer who underwent neoadjuvant therapy followed by local or total mesorectal excision.

Methods

Patients with locally advanced rectal adenocarcinoma who received neoadjuvant therapy from 2005 to 2017 were evaluated. Those with major or complete clinical response underwent a full-thickness local excision. Kaplan-Meier estimates were used to evaluate overall, disease-free, and local recurrence-free survival of patients who underwent local excision (LE group) and were compared with a matched cohort of patients who underwent total mesorectal excision (TME group).

Results

Among 252 patients who received neoadjuvant therapy for rectal cancer, 51 (20.2%) underwent a local excision. At a median follow-up of 61 months, patients who underwent local excision were stoma-free in 88.2% of cases and with rectum preserved in 78.5% of cases, respectively. The estimated 5-year local, disease-free, and overall survival was 91.8% vs 97.6% (95% CI: 79.5–96.8 vs 84.6–99.6), 86.7% vs 86.4% (95% CI: 72.5–93.9 vs 70.1–94.1), and 85% vs 90% (95% CI: 69.0–93.0% vs 75.3–96.2), in the study and matched control group, respectively. None of the differences was statistically significant.

Conclusions

One-fifth of patients with locally advanced rectal cancer are manageable with a rectum-sparing approach after neoadjuvant therapy. With this strategy, about 80% patients will have their rectum preserved and 90% will be without stoma at long term.

Keywords

Rectal cancer Neoadjuvant therapy Local excision Total mesorectal excision 

Abbreviations

LARC

locally advanced rectal cancer

LE

local excision

TME

total mesorectal excision

TEM

transanal endoscopic microsurgery

nCRT

neoadjuvant (chemo)radiotherapy

pCR

pathologic complete response

cCR

complete clinical response

mCR

major clinical response

WW

watch-and-wait

LR

local recurrence

DR

distant recurrence

LAR

low anterior resection

APR

abdominoperineal resection

QoL

quality of life

MRI

magnetic resonance imaging

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Sauer R, Becker H, Hohenberger W et al (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. New Engl J Med 35:1731–1740CrossRefGoogle Scholar
  2. 2.
    Pucciarelli S, Del Bianco P, Efficace F et al (2011) Patient-reported outcomes after neoadjuvant chemoradiotherapy for rectal cancer: a multicenter prospective observational study. Ann Surg 253:71–77CrossRefGoogle Scholar
  3. 3.
    Juul T, Ahlberg M, Biondo S, Espin E, Jimenez LM, Matzel KE, Palmer GJ, Sauermann A, Trenti L, Zhang W, Laurberg S, Christensen P (2014) Low anterior resection syndrome and quality of life: an international multicenter study. Dis Colon Rectum 57:585–591CrossRefGoogle Scholar
  4. 4.
    Smith FM, Waldron D, Winter DC (2010) Rectum-conserving surgery in the era of chemoradiotherapy. Br J Surg 97:1752–1764CrossRefGoogle Scholar
  5. 5.
    Maas M, Nelemans PJ, Valentini V, Das P, Rödel C, Kuo LJ, Calvo FA, García-Aguilar J, Glynne-Jones R, Haustermans K, Mohiuddin M, Pucciarelli S, Small W Jr, Suárez J, Theodoropoulos G, Biondo S, Beets-Tan RG, Beets GL (2010) Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data. Lancet Oncol. 11:835–844CrossRefGoogle Scholar
  6. 6.
    Perez RO (2016) Complete clinical response in rectal cancer: a turning tide. Lancet Oncol. 17:125–126CrossRefGoogle Scholar
  7. 7.
    Gani C, Bonomo P, Zwirner K, Schroeder C, Menegakis A, Rödel C, Zips D (2017) Organ preservation in rectal cancer - challenges and future strategies. Clin Transl Radiat Oncol 3:9–15CrossRefGoogle Scholar
  8. 8.
    Smith JJ, Chow OS, Gollub MJ et al (2015) Organ preservation in rectal adenocarcinoma: a phase II randomized controlled trial evaluating 3-year disease-free survival in patients with locally advanced rectal cancer treated with chemoradiation plus induction or consolidation chemotherapy, and total mesorectal excision or nonoperative management. BMC Cancer 15:767CrossRefGoogle Scholar
  9. 9.
    Habr-Gama A (2006) Assessment and management of the complete clinical response of rectal cancer to chemoradiotherapy. Color Dis 8:21–24CrossRefGoogle Scholar
  10. 10.
    Pucciarelli S, De Paoli A, Guerrieri M et al (2013) Local excision after preoperative chemoradiotherapy for rectal cancer: results of a multicenter phase II clinical trial. Dis Colon Rectum 56:1349–1356CrossRefGoogle Scholar
  11. 11.
    Aschele C, Cionini L, Lonardi S, Pinto C, Cordio S, Rosati G, Artale S, Tagliagambe A, Ambrosini G, Rosetti P, Bonetti A, Negru ME, Tronconi MC, Luppi G, Silvano G, Corsi DC, Bochicchio AM, Chiaulon G, Gallo M, Boni L (2011) Primary tumour response to preoperative chemoradiation with or without oxaliplatin in locally advanced rectal cancer: pathologic results of the STAR-01 randomized phase III trial. J Clin Oncol 29:2773–2780CrossRefGoogle Scholar
  12. 12.
    Bujko K, Richter P, Smith FM, Polkowski W, Szczepkowski M, Rutkowski A, Dziki A, Pietrzak L, Kołodziejczyk M, Kuśnierz J, Gach T, Kulig J, Nawrocki G, Radziszewski J, Wierzbicki R, Kowalska T, Meissner W, Radkowski A, Paprota K, Polkowski M, Rychter A (2013) Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders: a prospective multicentre study. Radiother Oncol 106:198–205CrossRefGoogle Scholar
  13. 13.
    Stijns RCH, de Graaf EJR, Punt CJA, Nagtegaal ID, Nuyttens JJME, van Meerten E, Tanis PJ, de Hingh IHJT, van der Schelling G, Acherman Y, Leijtens JWA, Bremers AJA, Beets GL, Hoff C, Verhoef C, Marijnen CAM, de Wilt JHW, CARTS Study Group (2019) Long-term oncological and functional outcomes of chemoradiotherapy followed by organ-sparing transanal endoscopic microsurgery for distal rectal cancer: the CARTS study. JAMA Surg 154:47–54CrossRefGoogle Scholar
  14. 14.
    Martens MH, Maas M, Heijnen LA et al (2016) Long-term outcome of an organ preservation program after neoadjuvant treatment for rectal cancer. J Natl Cancer Inst 10:108Google Scholar
  15. 15.
    Rullier E, Rouanet P, Tuech JJ, Valverde A, Lelong B, Rivoire M, Faucheron JL, Jafari M, Portier G, Meunier B, Sileznieff I, Prudhomme M, Marchal F, Pocard M, Pezet D, Rullier A, Vendrely V, Denost Q, Asselineau J, Doussau A (2017) Organ preservation for rectal cancer (GRECCAR 2): a prospective, randomised, open-label, multicentre, phase 3 trial. Lancet. 390:469–479CrossRefGoogle Scholar
  16. 16.
    Lezoche G, Baldarelli M, Guerrieri M, Paganini AM, de Sanctis A, Bartolacci S, Lezoche E (2008) A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc 22:352–358CrossRefGoogle Scholar
  17. 17.
    Garcia-Aguilar J, Renfro LA, Chow OS et al (2015) Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol 16:1537–1546CrossRefGoogle Scholar
  18. 18.
    Smith FM, Wiland H, Mace A, Pai RK, Kalady MF (2014) Clinical criteria underestimate complete pathological response in rectal cancer treated with neoadjuvant chemoradiotherapy. Dis Colon Rectum 57:311–315CrossRefGoogle Scholar
  19. 19.
    Friel CM, Cromwell JW, Marra C, Madoff RD, Rothenberger DA, Garcia-Aguílar J (2002) Salvage radical surgery after failed local excision for early rectal cancer. Dis Colon Rectum 45:875–879CrossRefGoogle Scholar
  20. 20.
    Bulut O, Levic K, Hesselfeldt P, Bülow S (2014) The outcome of rectal cancer after early salvage TME following TEM compared with primary TME: a case-matched study. Tech Coloproctol 18:83–84CrossRefGoogle Scholar
  21. 21.
    Smith JJ, Strombom P, Chow OS et al (2019) Assessment of a watch-and-wait strategy for rectal cancer in patients with a complete response after neoadjuvant therapy. JAMA Oncol.  https://doi.org/10.1001/jamaoncol.2018.5896 CrossRefGoogle Scholar
  22. 22.
    Creavin B, Ryan E, Martin ST et al (2017) Organ preservation with local excision or active surveillance following chemoradiotherapy for rectal cancer. Br J Cancer 116:169–174CrossRefGoogle Scholar
  23. 23.
    Lezoche E, Baldarelli M, Lezoche G, Paganini AM, Gesuita R, Guerrieri M (2012) Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br J Surg 99:1211–1218CrossRefGoogle Scholar
  24. 24.
    Maretto I, Pomerri F, Pucciarelli S, Mescoli C, Belluco E, Burzi S, Rugge M, Muzzio PC, Nitti D (2007) The potential of restaging in the prediction of pathologic response after preoperative chemoradiotherapy for rectal cancer. Ann Surg Oncol 14:455–461CrossRefGoogle Scholar
  25. 25.
    Glynne-Jones R, Hughes R (2012) Critical appraisal of the ‘wait and see’ approach in rectal cancer for clinical complete responders after chemoradiation. B J Surg 99:897–909CrossRefGoogle Scholar
  26. 26.
    Barina A, De Paoli A, Delrio P et al (2017) Rectal sparing approach after preoperative radio- and/or chemotherapy (RESARCH) in patients with rectal cancer: a multicentre observational study. Tech Coloproctol. 21:633–640CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.1st Surgical Clinic, Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly
  2. 2.Regional Health Service, Epidemiology UnitPaduaItaly

Personalised recommendations