Non-operative Management Following Concurrent Chemoradiotherapy for Rectal Cancer

Purpose. Neoadjuvant chemoradiotherapy combined with total mesorectal excision has become the standard of care for most rectal cancers. A clinically complete response may develop following concurrent chemoradiotherapy. The potential clinical effectiveness of non-operative management is highlighted by pathologic response rates from neoadjuvant trials. This is of concern for elderly patients and for those with significant medical comorbidities. Another potential concern is the perceived reduction in quality of life with a permanent stoma. Therefore, we performed a retrospective study to evaluate the results of non-operative management after chemoradiotherapy, especially in clinically incomplete response patients with non-operative management. Methods. Patients with stage II or III rectal cancer, treated between January 1, 2009 and December 31, 2017, were included in a retrospective study. Clinical data were acquired from computer databases and information concerning survival from the outpatient department follow-up and/or telephone questionnaire. Patients with nonmetastatic rectal cancer treated by neoadjuvant chemoradiation therapy, including 50.4 Gy and concomitant 5-fluorouracil and leucovorin or capecitabine, were assessed for tumor response six to eight weeks after chemoradiation therapy completion. Complete and incomplete clinical responses were defined based on clinical, image and endoscopic findings. After fully informed the patient and families about the risk of non-operative management, both groups of patients have adopted the policy of no surgery with a surveillance program. Results. Ten of 20 patients experienced a clinically complete response at initial assessment after chemoradiotherapy (50%). Median follow-up time was 38.2 months. Two patients (20%) experienced local recurrence (median recurrence time, 20.0 months). Two patients (20%) experienced systemic recurrence. (median recurrence time, 8.0 months). By contrast, patients that experienced a clinically incomplete response had higher systemic recurrence (40%, median recurrence time, 11.0 months). Conclusion. The local recurrence rate in clinically complete response patients is similar to previous study. The optimal tools and follow-up interval for assessing a clinically complete response remain to be determined. Although non-operative management is a promising, innovative approach in previous study, it should not be adopted into routine care until it has been proven to be an equivalent or superior treatment approach in multicenter prospective clinical trials.