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CC BY-NC-ND 4.0 · Clin Colon Rectal Surg 2023; 36(04): 290-294
DOI: 10.1055/s-0042-1758808
Letter to the Editor

The Role of Local Excision after Neoadjuvant Therapy for Locally Advanced Rectal Cancer: A Different Perspective

Amr Aref
1   Rectal Cancer Group, Van Elslander Cancer Center, Ascension St. John Hospital, Detroit, Michigan
2   Department of Radiation Oncology, Van Elslander Cancer Center, Ascension St. John Hospital, Detroit, Michigan
,
Ahmed Abdalla
3   Department of Interdisciplinary Oncology, Mitchell Cancer Center, University of South Alabama, Mobile, Alabama
,
Ernesto Raul Drelichman
4   Department of Rectal Surgery, Ascension St. John Hospital, Detroit, Michigan
› Author Affiliations Funding None.
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The concept of using preoperative radiation to downstage locally advanced rectal cancer (LARC) before limiting surgical resection to only local excision (LE) was introduced more than 30 years ago.[1] [2] Initially, this strategy was reserved for patients not suitable for total mesorectal excision (TME). However, the clinical indications for this approach have been refined and it is applied now as a method of organ preservation, even for patients who are fit to undergo radical resection, to avoid the long-term sequelae of TME.[3] [4] [5] [6] In addition, concurrent chemotherapy, usually 5-fluorouracil (5-FU) or capecitabine, is now added to radiation therapy to improve the response rate. In some circumstances, LE is performed as an alternative to TME, even when significant residual disease persists after neoadjuvant therapy. This is often either due to patients' refusal of TME or patients' frailty. A discussion of the role of LE under these circumstances is beyond the scope of this commentary and we will consider only the role of LE when it is reserved for patients with complete clinical response (CCR) or near CCR (nCCR) following neoadjuvant treatment. Several prospective, retrospective, and one randomized studies confirmed the safety of this approach when compared with TME. When LE is performed for patients with CCR or nCCR and subsequent histological examination confirms the ypT0 status, the expected local control rate is approximately 95%.[7] [8] Completion TME is recommended when histological examination reveals more extensive disease than ypT1-R0. Eradication of the residual cancer is accomplished within a few weeks following LE, through completion TME, thus avoiding the potential risk of undetected malignancy for a prolonged period, which may increase the risk of distant metastasis.[9] The recently published OPRA trial indicated high regrowth rates in both the induction and consolidation arms (40 and 27.5%). In addition, a high rate of pelvic failure (24%) was reported following salvage TME in cases of regrowth.[10] These results reflect the difficulty of post-neoadjuvant therapy clinical restaging, even when patients are managed in large centers with a clear interest in the conservative management of rectal cancer, and under strict protocol guidelines and quality assurance procedures. The high regrowth rate necessitates close follow-up and the availability of experienced physicians and high-quality imaging capabilities.

These requirements can be particularly challenging in a high mobility society as in the U.S. or in the current health care environment where physicians have to struggle frequently to secure preauthorization for patients' imaging studies and also when institutions' and physicians' “participation” in various health insurance programs are changing continuously.

Despite these clear advantages, LE is currently not included in either the National Comprehensive Cancer Network or American Society of Colon and Rectal Surgeons guidelines as an acceptable organ preservation strategy for patients diagnosed with LARC.[11] [12] In addition, there are no U.S.-based active trials currently listed on the Clinicaltrials.gov Web site that is conducted by a cooperative group or major institutions aiming to define and further refine the role of LE in the management of LARC. We will attempt to address the perceived shortcomings of LE commonly cited in the literature and are probably the cause of its underutilization.[13] [14] [15] [16] [17] [18]



Publication History

Article published online:
29 November 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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