Objective: This study aimed to compare the oncologic outcomes between treatment strategies for rectal cancer [radical surgery, local excision (LE), and the wait-and-see approach] in radiologic complete responders after neoadjuvant chemoradiation (nCRT). Methods: We retrospectively reviewed rectal cancer patients and included 52 radiologic complete responders after nCRT defined as no residual tumor or residual fibrosis and no suspicious metastatic lymph nodes on magnetic resonance imaging (MRI). Clinicopathologic features and oncologic outcomes were compared according to the treatment strategies. Results: The median follow-up period was 41 months (range, 6-80). Twenty-eight patients underwent radical surgery, whereas 16 underwent LE, and 8 were closely monitored without initial surgery. The pathologic complete response rate was 40.9%. Patients who underwent radical surgery showed better prognosis compared to those who underwent LE or wait-and-see (3-year disease-free survival: radical surgery 85.0% vs. LE 62.5%, wait-and-see 75.0%, p = 0.019; 3-year local recurrence-free survival: radical surgery 96.4% vs. LE 67.0%, wait-and-see 75.0%, p = 0.009). After recurrence, patients who underwent salvage surgery showed a relatively good oncologic outcome. Conclusion: Pursuing LE or the wait-and-see approach instead of radical surgery in rectal cancer patients undergoing nCRT may bring about a detrimental oncologic outcome if clinical complete response is solely determined by MRI.

Keywords:
Rectal cancer, Local excision, Wait-and-see approach, Prognosis
1.
Sauer R, Becker H, Hohenberger W, Rodel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens JH, Liersch T, Schmidberger H, Raab R: Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351:1731-1740.
2.
National Comprehensive Cancer Network. Rectal cancer clinical practice guidelines in oncology. http://www.nccn.org/default.aspx (accessed April 22, 2015).
3.
Pucciarelli S, Gagliardi G, Maretto I, Lonardi S, Friso ML, Urso E, Toppan P, Nitti D: Long-term oncologic results and complications after preoperative chemoradiotherapy for rectal cancer: a single-institution experience after a median follow-up of 95 months. Ann Surg Oncol 2009;16:893-899.
4.
Rodel C, Martus P, Papadoupolos T, Fuzesi L, Klimpfinger M, Fietkau R, Liersch T, Hohenberger W, Raab R, Sauer R, Wittekind C: Prognostic significance of tumor regression after preoperative chemoradiotherapy for rectal cancer. J Clin Oncol 2005;23:8688-8696.
5.
Kuo LJ, Liu MC, Jian JJ, Horng CF, Cheng TI, Chen CM, Fang WT, Chung YL: Is final TNM staging a predictor for survival in locally advanced rectal cancer after preoperative chemoradiation therapy? Ann Surg Oncol 2007;14:2766-2772.
6.
Maas M, Nelemans PJ, Valentini V, Das P, Rodel C, Kuo LJ, Calvo FA, Garcia-Aguilar J, Glynne-Jones R, Haustermans K, Mohiuddin M, Pucciarelli S, Small W Jr, Suarez J, Theodoropoulos G, Biondo S, Beets-Tan RG, Beets GL: Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data. Lancet Oncol 2010;11:835-844.
7.
Patel UB, Taylor F, Blomqvist L, George C, Evans H, Tekkis P, Quirke P, Sebag-Montefiore D, Moran B, Heald R, Guthrie A, Bees N, Swift I, Pennert K, Brown G: Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience. J Clin Oncol 2011;29:3753-3760.
8.
Kim CJ, Yeatman TJ, Coppola D, Trotti A, Williams B, Barthel JS, Dinwoodie W, Karl RC, Marcet J: Local excision of T2 and T3 rectal cancers after downstaging chemoradiation. Ann Surg 2001;234:352-358; discussion 358-359.
9.
Bonnen M, Crane C, Vauthey JN, Skibber J, Delclos ME, Rodriguez-Bigas M, Hoff PM, Lin E, Eng C, Wong A, Janjan NA, Feig BW: Long-term results using local excision after preoperative chemoradiation among selected T3 rectal cancer patients. Int J Radiat Oncol Biol Phys 2004;60:1098-1105.
10.
Huh JW, Jung EJ, Park YA, Lee KY, Sohn SK: Preoperative chemoradiation followed by transanal excision for rectal cancer. J Surg Res 2008;148:244-250.
11.
Nair RM, Siegel EM, Chen DT, Fulp WJ, Yeatman TJ, Malafa MP, Marcet J, Shibata D: Long-term results of transanal excision after neoadjuvant chemoradiation for T2 and T3 adenocarcinomas of the rectum. J Gastrointest Surg 2008;12:1797-1805; discussion 1805-1796.
12.
Kundel Y, Brenner R, Purim O, Peled N, Idelevich E, Fenig E, Sulkes A, Brenner B: Is local excision after complete pathological response to neoadjuvant chemoradiation for rectal cancer an acceptable treatment option? Dis Colon Rectum 2010;53:1624-1631.
13.
Perez RO, Habr-Gama A, Lynn PB, Sao Juliao GP, Bianchi R, Proscurshim I, Gama-Rodrigues J: Transanal endoscopic microsurgery for residual rectal cancer (ypT0-2) following neoadjuvant chemoradiation therapy: another word of caution. Dis Colon Rectum 2013;56:6-13.
14.
Yu CS, Yun HR, Shin EJ, Lee KY, Kim NK, Lim SB, Oh ST, Kang SB, Choi WJ, Lee WY; Colorectal Cancer Study Group KSoC: Local excision after neoadjuvant chemoradiation therapy in advanced rectal cancer: a national multicenter analysis. Am J Surg 2013;206:482-487.
15.
Lee NK, Kim DY, Kim SY, Oh JH, Park W, Choi DH, Nam TK, Lee KJ: Clinical outcomes of local excision following preoperative chemoradiotherapy for locally advanced rectal cancer. Cancer Res Treat 2014;46:158-164.
16.
Habr-Gama A, Perez RO, Nadalin W, Sabbaga J, Ribeiro U Jr, Silva e Sousa AH Jr, Campos FG, Kiss DR, Gama-Rodrigues J: Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg 2004;240:711-717; discussion 717-718.
17.
Maas M, Beets-Tan RG, Lambregts DM, Lammering G, Nelemans PJ, Engelen SM, van Dam RM, Jansen RL, Sosef M, Leijtens JW, Hulsewe KW, Buijsen J, Beets GL: Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer. J Clin Oncol 2011;29:4633-4640.
18.
Nakagawa WT, Rossi BM, de O Ferreira F, Ferrigno R, David Filho WJ, Nishimoto IN, Vieira RA, Lopes A: Chemoradiation instead of surgery to treat mid and low rectal tumors: is it safe? Ann Surg Oncol 2002;9:568-573.
19.
Hughes R, Harrison M, Glynne-Jones R: Could a wait and see policy be justified in T3/4 rectal cancers after chemo-radiotherapy? Acta Oncol 2010;49:378-381.
20.
Dalton RS, Velineni R, Osborne ME, Thomas R, Harries S, Gee AS, Daniels IR: A single-centre experience of chemoradiotherapy for rectal cancer: is there potential for nonoperative management? Colorectal Dis 2012;14:567-571.
21.
Jung SH, Heo SH, Kim JW, Jeong YY, Shin SS, Soung MG, Kim HR, Kang HK: Predicting response to neoadjuvant chemoradiation therapy in locally advanced rectal cancer: diffusion-weighted 3 Tesla MR imaging. J Magn Reson Imaging 2012;35:110-116.
22.
Park IJ, You YN, Skibber JM, Rodriguez-Bigas MA, Feig B, Nguyen S, Hu CY, Chang GJ: Comparative analysis of lymph node metastases in patients with ypT0-2 rectal cancers after neoadjuvant chemoradiotherapy. Dis Colon Rectum 2013;56:135-141.
23.
dos Santos LV, dos Anjos Jacome AA, Carcano FM, da Silveira Nogueira Lima JP, Serrano SV: Watch and wait policy remains experimental for the management of rectal cancer. Colorectal Dis 2010;12:833.
24.
Glynne-Jones R, Hughes R: Critical appraisal of the ‘wait and see' approach in rectal cancer for clinical complete responders after chemoradiation. Br J Surg 2012;99:897-909.
25.
Hanly AM, Ryan EM, Rogers AC, McNamara DA, Madoff RD, Winter DC: Multicenter Evaluation of Rectal cancer ReImaging pOst Neoadjuvant (MERRION) Therapy. Ann Surg 2014;259:723-727.
26.
Suppiah A, Hunter IA, Cowley J, Garimella V, Cast J, Hartley JE, Monson JR: Magnetic resonance imaging accuracy in assessing tumour down-staging following chemoradiation in rectal cancer. Colorectal Dis 2009;11:249-253.
27.
Franklin JM, Anderson EM, Gleeson FV: MRI features of the complete histopathological response of locally advanced rectal cancer to neoadjuvant chemoradiotherapy. Clin Radiol 2012;67:546-552.
28.
Del Vescovo R, Trodella LE, Sansoni I, Cazzato RL, Battisti S, Giurazza F, Ramella S, Cellini F, Grasso RF, Trodella L, Beomonte Zobel B: MR imaging of rectal cancer before and after chemoradiation therapy. Radiol Med 2012;117:1125-1138.
© 2015 S. Karger AG, Basel
2015
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.