Optimal timing of surgery for locally advance rectal cancer: how we choose

doi:10.16139/j.1007-9610.2024.03.04

Abstract

Abstract:

Locally advanced rectal cancer (LARC) is associated with a high risk of local recurrence and distant metastasis, making it difficult to be cured by surgery alone. Neoadjuvant chemoradiotherapy followed by surgery is the standard treatment for LARC, with reduced local recurrence rates. However, neoadjuvant chemoradiotherapy is associated with patients' urogenital and sexual dysfunction, which severely affecting their quality of life. Therefore, determining the optimal timing of surgery to balance oncologic and functional outcomes is crucial and challenging. We proposed that choosing the optimal timing of surgery based on preoperative risk assessment of LARC is an effective strategy. The patients with low to moderate risk of recurrence can be considered to perform surgery directly or have preoperative chemotherapy followed by radical surgery. Patients with high risk of recurrence should extend neoadjuvant therapy before surgery to improve oncologic outcomes. In this study we explored the optimal timing of radical surgery for LARC, providing a new idea for individualized and precise treatment of LARC.

Key words: Locally advanced rectal cancer(LARC), Radical surgery, Timing for surgery, Neoadjuvant chemoradiotherapy

CLC Number:

R735.37

XIE Haiting, HU Yeting, LI Jun, DING Kefeng. Optimal timing of surgery for locally advance rectal cancer: how we choose[J]. Journal of Surgery Concepts & Practice, 2024, 29(03): 206-210.

References 24

[1]	BRAY F, FERLAY J, SOERJOMATARAM I, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin, 2018, 68(6):394-424.
[2]	HAN B, ZHENG R, ZENG H, et al. Cancer incidence and mortality in China, 2022[J]. J Natl Cancer Cent, 2024, 4(1):47-53.
[3]	MA B, GAO P, WANG H, et al. What has preoperative radio(chemo)therapy brought to localized rectal cancer patients in terms of perioperative and long-term outcomes over the past decades? A systematic review and meta-analysis based on 41,121 patients[J]. Int J Cancer, 2017, 141(5):1052-1065. doi: 10.1002/ijc.30805 pmid: 28560805
[4]	SEBAG-MONTEFIORE D, STEPHENS R J, STEELE R, et al. Preoperative radiotherapy versus selective post-operative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial[J]. Lancet, 2009, 373(9666):811-820.
[5]	SAUER R, BECKER H, HOHENBERGER W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer[J]. N Engl J Med, 2004, 351(17):1731-1740.
[6]	SIEGEL R L, TORRE L A, SOERJOMATARAM I, et al. Global patterns and trends in colorectal cancer incidence in young adults[J]. Gut, 2019, 68(12):2179-2185. doi: 10.1136/gutjnl-2019-319511 pmid: 31488504
[7]	HEALD R J. A new approach to rectal cancer[J]. Br J Hosp Med, 1979, 22(3):277-281.
[8]	JIANG W Z, XU J M, XING J D, et al. Short-term outcomes of laparoscopy-assisted vs. open surgery for patients with low rectal cancer: the LASRE randomized clinical trial[J]. JAMA Oncol, 2022, 8(11):1607-1615.
[9]	FENG Q, YUAN W, LI T, et al. Robotic versus laparoscopic surgery for middle and low rectal cancer (REAL): short-term outcomes of a multicentre randomised controlled trial[J]. Lancet Gastroenterol Hepatol, 2022, 7(11):991-1004.
[10]	MERCURY STUDY GROUP. Extramural depth of tumor invasion at thin-section MR in patients with rectal cancer: results of the MERCURY study[J]. Radiology, 2007, 243(1):132-139. doi: 10.1148/radiol.2431051825 pmid: 17329685
[11]	MERCURY STUDY GROUP. Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study[J]. BMJ, 2006, 333(7572):779.
[12]	KENNEDY E D, SIMUNOVIC M, JHAVERI K, et al. Safety and feasibility of using magnetic resonance imaging criteria to identify patients with "good prognosis" rectal cancer eligible for primary surgery: the phase 2 nonrandomized quicksilver clinical trial[J]. JAMA Oncol, 2019, 5(7):961-966. doi: 10.1001/jamaoncol.2019.0186 pmid: 30973610
[13]	RUPPERT R, JUNGINGER T, KUBE R, et al. Risk-adapted neoadjuvant chemoradiotherapy in rectal cancer: final report of the OCUM study[J]. J Clin Oncol, 2023, 41(24):4025-4034.
[14]	LI J, HU Y T, LIU C C, et al. Primary surgery followed by selective chemoradiotherapy versus preoperative chemoradiotherapy followed by surgery for locally advanced rectal cancer: a randomized clinical trial[J]. Int J Radiat Oncol Biol Phys, 2024, 119(3):884-895.
[15]	SCHRAG D, SHI Q, WEISER M R, et al. Preoperative treatment of locally advanced rectal cancer[J]. N Engl J Med, 2023, 389(4):322-334.
[16]	DING P R, WANG X, LI Y, et al. Neoadjuvant chemotherapy with CAPOX versus chemoradiation for locally advanced rectal cancer with uninvolved mesorectal fascia (CONVERT): final results of a phase Ⅲ trial[J]. Ann Oncol, 2023, 34(suppl 2):S1267-S1268.
[17]	JIAO Y, LI J, KONG X, et al. Effectiveness and safety of rectal arterial infusion chemotherapy combined with anti-PD1 antibody for microsatellite stable locally advanced rectal cancer: early outcome report of a two-stage, single armed, phase Ⅱ study (RAIC)[J]. Ann Oncol, 2023,34,S433.
[18]	WANG L, ZHANG X Y, ZHAO Y M, et al. Intentional watch and wait or organ preservation surgery following neoadjuvant chemoradiotherapy plus consolidation CAPEOX for MRI-defined low-risk rectal cancer: findings from a prospective phase 2 trial (PKUCH-R01 trial, NCT02860234)[J]. Ann Surg, 2023, 277(4):647-654.
[19]	CERCEK A, LUMISH M, SINOPOLI J, et al. PD-1 blockade in mismatch repair-deficient, locally advanced rectal cancer[J]. N Engl J Med, 2022, 386(25):2363-2376.
[20]	CHEN G, JIN Y, GUAN W L, et al. Neoadjuvant PD-1 blockade with sintilimab in mismatch-repair deficient, locally advanced rectal cancer: an open-label, single-centre phase 2 study[J]. Lancet Gastroenterol Hepatol, 2023, 8(5):422-431.
[21]	BAHADOER R R, DIJKSTRA E A, VAN ETTEN B, et al. Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomised, open-label, phase 3 trial[J]. Lancet Oncol, 2021, 22(1):29-42.
[22]	DIJKSTRA E A, NILSSON P J, HOSPERS G A P, et al. Locoregional failure during and after short-course radiotherapy followed by chemotherapy and surgery compared with long-course chemoradiotherapy and surgery: a 5-year follow-up of the RAPIDO trial[J]. Ann Surg, 2023, 278(4):e766-e772.
[23]	CONROY T, BOSSET J F, ETIENNE P L, et al. Neoadjuvant chemotherapy with FOLFIRINOX and preoperative chemoradiotherapy for patients with locally advanced rectal cancer (UNICANCER-PRODIGE 23): a multicentre, randomised, open-label, phase 3 trial[J]. Lancet Oncol, 2021, 22(5):702-715. doi: 10.1016/S1470-2045(21)00079-6 pmid: 33862000
[24]	LIN Z Y, ZHANG P, CHI P, et al. Neoadjuvant short-course radiotherapy followed by camrelizumab and chemotherapy in locally advanced rectal cancer (UNION): early outcomes of a multicenter randomized phase Ⅲ trial[J]. Ann Oncol, 2024,S0923- 7534(24)00746-4.