Post-chemoradiotherapy microsurgery acceptable in early rectal cancer

Last Updated: 2018-10-18

By David Douglas

NEW YORK (Reuters Health) - In patients with early-stage rectal cancer, chemoradiotherapy (CRT) followed by local excision appears to be a feasible rectum-preserving strategy but still requires refinement, according to Dutch researchers.

In an October 10 online paper in JAMA Surgery, Dr. Johannes H. W. de Wilt of Radboud University Medical Centre, Nijmegen, and colleagues sought to determine whether this approach might be an alternative to conventional total mesorectal excision (TME).

The researchers prospectively studied 55 patients with cT1-3N0M0 rectal cancer. They were treated with CRT. Two died at this point, two stopped CRT and one of these patients was lost to follow-up.

In all, 47 patients subsequently underwent transanal endoscopic microsurgery (TEM) and 35 were initially successfully treated with local excision alone and the rectum was preserved.

However, the researchers note, 50% of patients in the preservation group experienced major symptoms similar to low anterior resection syndrome - such as soiling and fecal incontinence. In addition, 28% of the patients experienced minor symptoms, with only 22% overall having no symptoms.

Nevertheless, health-related quality of life (HRQL) during a median of 53 months of follow-up was equal to baseline, with improved emotional well-being in patients treated with local excision.

The actuarial five-year local recurrence rate was 7.7%. The five-year disease-free survival rate was 81.6% and for overall survival, it was 82.8%.

Commenting by email, Dr. de Wilt told Reuters Health, "These results demonstrate that in rather early distal rectal cancer, chemoradiation followed by local excision can result in organ preserving in approximately two out of three patients. Although long-term oncological safety seems as good as in patients treated with standard surgery, several issues are still to be addressed."

"First of all," he added, "one third of patients are overtreated with this regimen, because they fail on chemoradiation and still need major TME surgery. These patients could have been operated on straight away, without the short- and long-term morbidity of chemoradiation. Secondly, not all patients need to be treated with a local excision because almost 40% have a complete response. These patients could have been treated with a wait-and-see strategy after chemoradiation. Thirdly, the quality of life of patients was not as good as expected."

"Therefore," Dr. de Wilt concluded, "we still need more research to identify those patients who are excellent candidates for organ-preserving treatments and to study the quality of life in patients who are treated with organ preserving strategies. We are currently conducting an international randomized trial (STAR-TREC) which addresses several of the above-mentioned questions."

In accompanying editorial, Dr. Julio Garcia-Aguilar of Memorial Sloan Kettering Cancer Center in New York City notes, "Evidence for the safety of a watch-and-wait approach in patients with a clinical complete response to chemoradiotherapy is accumulating, and it seems reasonable to speculate whether such patients require surgery at all."

In fact, Dr. Garcia-Aguilar told Reuters Health by telephone that the current study is probably among the last to be done in that area and what "we are now working on is a protocol in which we'll do local incisions if there is something visible left but we'll probably not do surgery - even local incision - if we see that the tumor is completely gone." Another area being investigated he added, "is making the chemoradiation less toxic."

SOURCE: http://bit.ly/2yoa26d and http://bit.ly/2yrdRr9

JAMA Surgery 2018.