Nonoperative Approaches to Rectal Cancer: A Critical Evaluation

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A neoadjuvant multimodality approach with chemoradiation therapy (CRT) is the preferred treatment strategy for most distal rectal cancers. Significant downstaging and complete pathologic response may develop after this strategy, and there is still controversy regarding the management of these patients. In this setting, a nonoperative approach has been suggested in select patients with complete clinical response after thorough clinical, endoscopic, and radiologic assessment. However, the assessment of these patients is not straightforward and remains complex. Available data regarding this approach are limited to a single institution's experience from retrospective analyses. Standardization of the assessment of tumor response and the development of radiological/molecular tools may clarify the role of no immediate surgery in patients with complete clinical response after neoadjuvant CRT. Advances in radiation and medical oncology could potentially lead to significant improvements in complete tumor regression rates, leading to an increase in importance of a minimally invasive approach in patients with rectal cancer.

Section snippets

Complete Tumor Regression

Several factors have been implicated in the prediction of complete pathologic response development after neoadjuvant CRT. A review of phase II and III studies using different regimens of neoadjuvant CRT for rectal cancer identified several predictive factors of a complete pathologic response, including the dose of radiation therapy delivered, the method of 5-fluorouracil (5-FU) infusion, and the use of additional drugs to standard 5-FU–based regimens. After reviewing 71 studies with over 4,000

Tumor Response Assessment

The efforts in identifying patients with tumors undergoing complete regression are important because the achievement of such is associated with excellent oncologic outcomes. Additionally, alternative treatment strategies, other than radical total mesorectal excision, may suffice in these patients.16 A major obstacle is that complete pathologic response can only be determined after full pathologic examination of the resected specimen after TME. In this setting, response assessment of tumors

Authors' Experience

Between 1991 and 2009, 475 patients with distal rectal cancer were managed at 2 collaborating Institutions (University of São Paulo School of Medicine/Angelita and Joaquim Gama Institute). All patients were enrolled in this watch and wait strategy after achieving a complete clinical response. Here we present updated data from one of these instituions (Angelita and Joaquim Gama Institute and Hospital Alemão Oswaldo Cruz). In this experience, 173 patients with rectal cancers located no more than

Conclusions

The fact that a proportion of patients with distal rectal cancer may develop complete pathological and clinical response is one of the great advantages of a neoadjuvant CRT approach. The management of such patients remains highly controversial. The development of molecular and new radiologic tools may aid in the accurate clinical identification of such patients in the future. Currently, no immediate surgery may be considered as a safe alternative in highly selected patients using very stringent

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