Limitation of surgical radicality in rectal cancer responding to neoadjuvant therapy.

The basic principle in the treatment of rectal cancer is the complete surgical removal of the tumor together with the lymphatic drainage region, i.e. the mesorectum encased by the mesorectal 'fascia pelvis visceralis' according to Westhues. It was shown in the 1990s that the results of surgery alone could be improved by additional adjuvant and neoadjuvant therapy. Because of less toxicity and a lower rate of local recurrence, neoadjuvant therapies in International Union Against Cancer (UICC) stage II and III disease are now preferred over adjuvant strategies. The German Rectal Cancer study CAO/ARO/AIO-94 showed a full remission rate of 8% after a 5-fluorouracil (5-FU)based chemotherapy added to a conventional fractional radiation therapy (50.4 Gy). This figure, together with similar results of others, leads to the question whether surgical radicality in rectal cancer treatment could be limited in case of a good remission after neoadjuvant therapy. There are several promising possibilities under investigation, e.g. local excision instead of radical resection, or even no resection at all. Nevertheless, up to now these strategies did not prove to give comparable results to standard surgical procedures. Therefore, reduction of radicality in curable rectal cancer should be limited to accurately designed randomized clinical trials.

Incidence of Metachronous Distant Metastasis and ypN Classification Influence Patient Survival in Endosonographically Confirmed uT3 Rectal Cancer after Neoadjuvant Therapy and R0 Resection: A Historical Cohort Analysis.

BACKGROUND: Tumor response after neoadjuvant radiochemotherapy (NRC) prior to surgery and other parameters are likely to have an influence on the survival rate of patients suffering from T3 rectal cancer. METHODS: 51 patients (17 female, 34 male; 59.0 years; Apache < 9 points: 95.1%; ASA I-II 88.3% and ASA III 11.8%) were treated with NRC (50.4 Gy; 5-fluorouracil/folinic acid) 4-6 weeks prior to surgery because of uT3 rectal cancer (G2: 96%; adenocarcinoma 86.3%; cUICC II 62.7%). NRC led to a tumor response (TR) (ypT0-ypT2) in 45.1% (ypT0N0M0 7.8%). RESULTS: Neither the age of patients nor Apache/ASA score, histology, UICC staging, ypTNM, Dukes staging, infiltration of vessels, surgical procedure, local recurrence nor TR had a significant influence on the patients' survival time. Patients with metachronous distant metastasis (MDM) during the follow-up period (mean: 8.2 years; 1 month to 14.5 years) and patients with ypN1-ypN2 had a significantly shorter survival time. CONCLUSIONS: NRC prior to surgery leads to a remarkable TR rate but has no significant impact of TR on the patients' survival time. Occurrence of MDM during the follow-up period and ypN1/N2 status do have a greater influence. It is necessary to investigate larger cohorts of patients in the future to obtain more conclusive results and to define factors with influence on survival.