Читать книгу Surgical Management of Advanced Pelvic Cancer - Группа авторов - Страница 47

In addition to event‐free survival and local control outcomes, preservation of bowel function and quality of life continue to represent significant challenges in the management of LARC. The prevalence of low anterior resection syndrome (LARS) is 60–90% following low or ultra‐low sphincter‐sparing surgery for rectal cancer [38]. The syndrome is associated with a significant and sustained reduction in quality of life [39, 40]. A potential advantage of improved tumor regression and downstaging with TNT is the selective practice of non‐operative management and avoidance of a stoma. A multinational experience (1009 patients) of conventional nCRT and a “watch and wait” approach found two‐year local tumor regrowth was 25% [41].

A retrospective single‐center analysis of 628 patients with LARC observed more complete responders at one year with TNT compared with conventional nCRT and adjuvant chemotherapy [42]. This was the subject of a recently presented multicenter, randomized, phase II trial assessing if TNT increases the proportion of patients managed with organ preservation. Patients were randomized to induction or consolidation FOLFOX (before or after long‐course chemoradiation), followed by restaging with magnetic resonance imaging (MRI)/endoscopy 8–12 weeks later. Incomplete responders proceeded to TME, while complete clinical responders were managed non‐operatively [43]. Three‐year disease‐ and metastasis‐free survival rates were similar in the OPRA (organ preservation of rectal adenocarcinoma) trial arms, but the rate of organ preservation was improved by consolidation (58%) rather than induction (43%) chemotherapy.

In patients with early disease (cT1–2N0), the standard of care currently is surgery without neoadjuvant therapy. Systemic therapy with curative intent may be an alternative to surgery if long‐term disease‐specific outcomes were comparable. Those who achieve a clinical complete response (cCR) may be eligible for organ preservation, with salvage surgery reserved for cases of locoregional recurrence. A retrospective analysis of 81 patients with cT2N0 disease reported an increased likelihood of a cCR and avoidance of definitive surgery at five years with consolidation chemotherapy (six cycles of 5‐FU) with high‐dose radiotherapy (54 Gy) compared with standard nCRT (67 vs. 30%; p = 0.001) [44].