“Watch and wait“ strategy in the treatment of patients with rectal carcinoma
Authors:
P. Ihnát
Authors‘ workplace:
Katedra chirurgických oborů Lékařské fakulty Ostravské univerzity
; Chirurgická klinika, Fakultní nemocnice Ostrava
Published in:
Rozhl. Chir., 2021, roč. 100, č. 11, s. 517-521.
Category:
Review
doi:
https://doi.org/10.33699/PIS.2021.100.11.517–521
Overview
Innovative treatment strategies which do not involve oncosurgical radical rectal resection have been explored within the last decades in the management of patients with rectal carcinoma. Resection of the rectum with total mesorectal excision is burdened not only with significant postoperative morbidity, but also with symptoms of bowel, urinary and sexual dysfunctions, which can significantly affect patients’ quality of life. The aim of these alternative strategies is to preserve the anatomy and function of the rectum (so called organ preservation approach). This approach includes three innovative strategies: “watch and wait” strategy, neoadjuvant radiochemotherapy completed with transanal rectal carcinoma excision (or excision of the scar remaining after neoadjuvant therapy) and neoadjuvant radiochemotherapy of an early rectal carcinoma.
So far, evidence supporting the organ preservation approach is highly insufficient in the available literature. There are no clear indication criteria for these strategies, no unequivocal criteria for complete clinical response detection and vague recommendations regarding an optimal neoadjuvant regimen or patients’ follow-up. Organ preservation approach is therefore considered to be an experimental treatment strategy, which should be offered only to patients within clinical trials with a high-quality design and very careful long-term follow-up. Patients considered for “watch and wait” must be informed properly about the benefits and drawbacks of the strategy including the risk of rectal carcinoma recurrence in 30% of the patients.
Keywords:
rectal carcinoma – radiotherapy – complete pathological response – organ preservation approach – transanal excision
Sources
1. Tseng M, Soon YY, Vellayappan B, et al. Radiation therapy for rectal cancer. J Gastrointest Oncol. 2019;10(6):1238–1250. doi:10.21037/jgo.2018.12.04.
2. Vošmik M. Postavení radioterapie v léčbě kolorektálního karcinomu. In: Petruželka L, et al. Kolorektální karcinom. 1. vyd. Praha, Farmakon Press 2018:97–102. ISBN 978-80-906589-7-4.
3. On J, Aly EH‚ Watch and wait‘ in rectal cancer: summary of the current evidence. Int J Colorectal Dis. 2018;33(9):1159−1168. doi:10.1007/s00384-018-3116-5.
4. Mullaney TG, Lightner AL, Johnston M, et al. ‚Watch and wait‘ after chemoradiotherapy for rectal cancer. ANZ J Surg. 2018;88(9):836−841. doi:10.1111/ ans.14352.
5. Habr-Gama A, Perez RO, Nadalin W, et al. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg. 2004;240(4):711−717. doi:10.1097/01. sla.0000141194.27992.32.
6. Smith JJ, Strombom P, Chow OS, et al. Assessment of a watch-and-wait strategy for rectal cancer in patients with a complete response after neoadjuvant therapy. JAMA Oncol. 2019;5(4):e185896. doi:10.1001/jamaoncol.2018.5896.
7. Rullier E, Rouanet P, Tuech JJ, et al. Organ preservation for rectal cancer (GRECCAR 2): a prospective, randomised, open-label, multicentre, phase 3 trial. Lancet 2017;390(10093):469−479. doi:10.1016/S0140-6736(17)31056-5.
8. Habr-Gama A, Gama-Rodrigues J, São Julião GP, et al. Local recurrence after complete clinical response and watch and wait in rectal cancer after neoadjuvant chemoradiation: impact of salvage therapy on local disease control. Int J Radiat Oncol Biol Phys. 2014;88(4):822−828. doi:10.1016/j.ijrobp.2013.12.012.
9. Guillem JG, Ruby JA, Leibold T, et al. Neither FDG-PET Nor CT can distinguish between a pathological complete response and an incomplete response after neoadjuvant chemoradiation in locally advanced rectal cancer: a prospective study. Ann Surg. 2013;258(2):289−295. doi:10.1097/SLA.0b013e318277b625.
10. Maffione AM, Marzola MC, Capirci C, et al. Value of (18)F-FDG PET for predicting response to neoadjuvant therapy in rectal cancer: Systematic review and meta-analysis. AJR Am J Roentgenol. 2015;204(6):1261–8. doi:10.2214/ AJR.14.13210.
11. Patel UB, Blomqvist LK, Taylor F, et al. MRI after treatment of locally advanced rectal cancer: how to report tumor response--the MERCURY experience. AJR Am J Roentgenol. 2012;199(4):W486−495. doi:10.2214/ AJR.11.8210.
12. Martens MH, Maas M, Heijnen LA, et al. Long-term outcome of an organ preservation program after neoadjuvant treatment for rectal cancer. J Natl Cancer Inst. 2016;108(12). doi:10.1093/jnci/ djw171.
13. Gani C, Kirschniak A, Zips D. Watchful waiting after radiochemotherapy in rectal cancer: when is it feasible? Visc Med. 2019;35(2):119−123. doi:10.1159/000499167.
14. Habr-Gama A, Perez RO, Wynn G, et al. Complete clinical response after neoadjuvant chemoradiation therapy for distal rectal cancer: characterization of clinical and endoscopic findings for standardization. Dis Colon Rectum 2010;53(12):1692−1698. doi:10.1007/DCR.0b013e3181f42b89.
15. Marks JH, Valsdottir EB, DeNittis A, et al. Transanal endoscopic microsurgery for the treatment of rectal cancer: comparison of wound complication rates with and without neoadjuvant radiation therapy. Surg Endosc. 2009;23(5):1081−1087. doi:10.1007/s00464-009-0326-5.
16. Perez RO, Habr-Gama A, São Julião GP, et al. Transanal endoscopic microsurgery for residual rectal cancer after neoadjuvant chemoradiation therapy is associated with significant immediate pain and hospital readmission rates. Dis Colon Rectum 2011;54(5):545−551. doi:10.1007/ DCR.0b013e3182083b84.
17. Garcia-Aguilar J, Shi Q, Thomas CR Jr, et al. A phase II trial of neoadjuvant chemoradiation and local excision for T2N0 rectal cancer: preliminary results of the ACOSOG Z6041 trial. Ann Surg Oncol. 2012;19(2):384−391. doi:10.1245/ s10434-011-1933-7.
18. Gornicki A, Richter P, Polkowski W, et al. Anorectal and sexual functions after preoperative radiotherapy and full-thickness local excision of rectal cancer. Eur J Surg Oncol. 2014;40(6):723−730. doi:10.1016/j.ejso.2013.11.010.
19. Maas M, Nelemans PJ, Valentini V, et al. 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(9):835−844. doi:10.1016/S1470-2045(10)70172-8.
20. Pucciarelli S, Capirci C, Emanuele U, et al. Relationship between pathologic T-stage and nodal metastasis after preoperative chemoradiotherapy for locally advanced rectal cancer. Ann Surg Oncol. 2005;12(2):111−116. doi:10.1245/ ASO.2005.03.044.
21. Park IJ, You YN, Skibber JM, et al. Comparative analysis of lymph node metastases in patients with ypT0-2 rectal cancers after neoadjuvant chemoradiotherapy. Dis Colon Rectum 2013;56(2):135−141. doi:10.1097/DCR.0b013e318278ff8a.
22. Bujko K, Richter P, Smith FM, et al. Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders: a prospective multicentre study. Radiother Oncol. 2013;106(2):198−205. doi:10.1016/j.radonc.2012.12.005.
23. Rullier E, Vendrely V, Asselineau J, et al. Organ preservation with chemoradiotherapy plus local excision for rectal cancer: 5-year results of the GRECCAR 2 randomised trial. Lancet Gastroenterol Hepatol. 2020;5(5):465−474. doi:10.1016/ S2468-1253(19)30410-8.
24. Smith JD, Ruby JA, Goodman KA, et al. Nonoperative management of rectal cancer with complete clinical response after neoadjuvant therapy. Ann Surg. 2012; 256(6): 965−972. doi:10.1097/ SLA.0b013e3182759f1c.
25. Dossa F, Chesney TR, Acuna SA, et al. A watch-and-wait approach for locally advanced rectal cancer after a clinical complete response following neoadjuvant chemoradiation: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2017;2(7):501−513. doi:10.1016/ S2468-1253(17)30074-2.
26. Park IJ, You YN, Agarwal A, et al. Neoadjuvant treatment response as an early response indicator for patients with rectal cancer. J Clin Oncol. 2012;30(15):1770−1776. doi:10.1200/ JCO.2011.39.7901.
Labels
Surgery Orthopaedics Trauma surgeryArticle was published in
Perspectives in Surgery
2021 Issue 11
Most read in this issue
- Total mesorectal excision for rectal cancer – laparoscopic versus robotic approach
- Současné trendy v chirurgické léčbě karcinomu rekta
- TaTME (transanal total mesorectal excision) – state of the art
- Quality of life after transanal total mesorectal excision – our experience