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The Approach to the Rectal Cancer Patient with a Suspected Complete Clinical Response: Selection of Patients to the Watch and Wait Strategy

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Complexities in Colorectal Surgery

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Abstract

Incorporation of new treatment modalities has significantly increased complexity of locally advanced rectal cancer. Neoadjuvant chemoradiation is considered as one of the preferred treatment strategies for these patients. In addition, this treatment strategy may lead to significant tumor regression, ultimately leading to complete pathological response in up to 42 % of patients. Assessment of tumor response following CRT and prior to radical surgery may identify patients with complete clinical response that could be managed nonoperatively with strict follow-up (watch and wait strategy). This chapter deals with critical issues in appropriate selection of patients for this approach.

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References

  1. Kosinski L, Habr-Gama A, Ludwig K, Perez R. Shifting concepts in rectal cancer management: a review of contemporary primary rectal cancer treatment strategies. CA Cancer J Clin. 2012;62(3):173–202.

    Article  PubMed  Google Scholar 

  2. Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351(17):1731–40.

    Article  CAS  PubMed  Google Scholar 

  3. Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;345(9):638–46.

    Article  CAS  PubMed  Google Scholar 

  4. Sauer R, Liersch T, Merkel S, et al. Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. J Clin Oncol. 2012;30(16):1926–33.

    Article  CAS  PubMed  Google Scholar 

  5. Peeters KC, van de Velde CJ, Leer JW, et al. Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients – a Dutch colorectal cancer group study. J Clin Oncol. 2005;23(25):6199–206.

    Article  CAS  PubMed  Google Scholar 

  6. van Gijn W, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial. Lancet Oncol. 2011;12(6):575–82.

    Article  PubMed  Google Scholar 

  7. Bosset JF, Calais G, Mineur L, et al. Enhanced tumoricidal effect of chemotherapy with preoperative radiotherapy for rectal cancer: preliminary results–EORTC 22921. J Clin Oncol. 2005;23(24):5620–7.

    Article  CAS  PubMed  Google Scholar 

  8. Schrag D, Weiser MR, Goodman KA, et al. Neoadjuvant FOLFOX-bev, without radiation, for locally advanced rectal cancer. J Clin Oncol. 2010;28(15s):(suppl; abstr 3511).

    Google Scholar 

  9. 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):835–44.

    Article  PubMed  Google Scholar 

  10. Smith FM, Waldron D, Winter DC. Rectum-conserving surgery in the era of chemoradiotherapy. Br J Surg. 2010;97(12):1752–64.

    Article  CAS  PubMed  Google Scholar 

  11. Habr-Gama A, Perez RO. Non-operative management of rectal cancer after neoadjuvant chemoradiation. Br J Surg. 2009;96(2):125–7.

    Article  CAS  PubMed  Google Scholar 

  12. Perez RO, Habr-Gama A, Gama-Rodrigues J, et al. Accuracy of positron emission tomography/computed tomography and clinical assessment in the detection of complete rectal tumor regression after neoadjuvant chemoradiation: long-term results of a prospective trial (National Clinical Trial 00254683). Cancer. 2012;118(14):3501–11.

    Article  PubMed  Google Scholar 

  13. Sanghera P, Wong DW, McConkey CC, et al. Chemoradiotherapy for rectal cancer: an updated analysis of factors affecting pathological response. Clin Oncol (R Coll Radiol). 2008;20(2):176–83.

    Article  CAS  Google Scholar 

  14. Garcia-Aguilar J, Shi Q, Thomas Jr CR, 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):384–91.

    Article  PubMed  Google Scholar 

  15. Lezoche E, Baldarelli M, Lezoche G, et al. Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br J Surg. 2012;99(9):1211–8.

    Article  CAS  PubMed  Google Scholar 

  16. 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):711–7; discussion 717–8.

    PubMed Central  PubMed  Google Scholar 

  17. Radu C, Berglund A, Pahlman L, Glimelius B. Short-course preoperative radiotherapy with delayed surgery in rectal cancer – a retrospective study. Radiother Oncol. 2008;87(3):343–9.

    Article  PubMed  Google Scholar 

  18. Bujko K, Nowacki MP, Nasierowska-Guttmejer A, et al. Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg. 2006;93(10):1215–23.

    Article  CAS  PubMed  Google Scholar 

  19. Habr-Gama A, Sabbaga J, Gama-Rodrigues J, et al. Watch and Wait Approach Following Extended Neoadjuvant Chemoradiation for Distal Rectal Cancer: Are We Getting Closer to Anal Cancer Management? Dis of Colon Rectum. 2013;56(10):1109–17.

    Google Scholar 

  20. Habr-Gama A, Perez RO, Sabbaga J, et al. Increasing the rates of complete response to neoadjuvant chemoradiotherapy for distal rectal cancer: results of a prospective study using additional chemotherapy during the resting period. Dis Colon Rectum. 2009;52(12):1927–34.

    Google Scholar 

  21. 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):1692–8.

    Article  PubMed  Google Scholar 

  22. Hiotis SP, Weber SM, Cohen AM, et al. Assessing the predictive value of clinical complete response to neoadjuvant therapy for rectal cancer: an analysis of 488 patients. J Am Coll Surg. 2002;194(2):131–5; discussion 135–6.

    Article  PubMed  Google Scholar 

  23. Smith FM, Chang KH, Sheahan K, et al. The surgical significance of residual mucosal abnormalities in rectal cancer following neoadjuvant chemoradiotherapy. Br J Surg. 2012;99(7):993–1001.

    Article  CAS  PubMed  Google Scholar 

  24. Kalady MF, de Campos-Lobato LF, Stocchi L, et al. Predictive factors of pathologic complete response after neoadjuvant chemoradiation for rectal cancer. Ann Surg. 2009;250(4):582–9.

    PubMed  Google Scholar 

  25. Tulchinsky H, Shmueli E, Figer A, et al. An interval >7 weeks between neoadjuvant therapy and surgery improves pathologic complete response and disease-free survival in patients with locally advanced rectal cancer. Ann Surg Oncol. 2008;15(10):2661–7.

    Article  PubMed  Google Scholar 

  26. Francois Y, Nemoz CJ, Baulieux J, et al. Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: the Lyon R90-01 randomized trial. J Clin Oncol. 1999;17(8):2396.

    CAS  PubMed  Google Scholar 

  27. Evans J, Tait D, Swift I, et al. Timing of surgery following preoperative therapy in rectal cancer: the need for a prospective randomized trial? Dis Colon Rectum. 2011;54(10):1251–9.

    Article  PubMed  Google Scholar 

  28. Perez RO, Habr-Gama A, Sao Juliao GP, et al. Optimal timing for assessment of tumor response to neoadjuvant chemoradiation in patients with rectal cancer: do all patients benefit from waiting longer than 6 weeks? Int J Radiat Oncol Biol Phys. 2012;84(5):1159–65.

    Article  PubMed  Google Scholar 

  29. Perez RO, Habr-Gama A, Pereira GV, et al. Role of biopsies in patients with residual rectal cancer following neoadjuvant chemoradiation after downsizing: can they rule out persisting cancer? Colorectal Dis. 2012;14(6):714–20.

    Article  CAS  PubMed  Google Scholar 

  30. Perez RO, Habr-Gama A, Lynn PB, et al. Transanal endoscopic microsurgery for residual rectal cancer (ypT0-2) following neoadjuvant chemoradiation therapy: another word of caution. Dis Colon Rectum. 2013;56(1):6–13.

    Article  PubMed  Google Scholar 

  31. Mignanelli ED, de Campos-Lobato LF, Stocchi L, et al. Downstaging after chemoradiotherapy for locally advanced rectal cancer: is there more (tumor) than meets the eye? Dis Colon Rectum. 2010;53(3):251–6.

    Article  PubMed  Google Scholar 

  32. Bujko K, Nowacki MP, Nasierowska-Guttmejer A, et al. Prediction of mesorectal nodal metastases after chemoradiation for rectal cancer: results of a randomised trial: implication for subsequent local excision. Radiother Oncol. 2005;76(3):234–40.

    Article  PubMed  Google Scholar 

  33. Kim DW, Kim DY, Kim TH, et al. Is T classification still correlated with lymph node status after preoperative chemoradiotherapy for rectal cancer? Cancer. 2006;106(8):1694–700.

    Article  PubMed  Google Scholar 

  34. Lambregts DM, Beets GL, Maas M, et al. Accuracy of gadofosveset-enhanced MRI for nodal staging and restaging in rectal cancer. Ann Surg. 2011;253(3):539–45.

    Article  PubMed  Google Scholar 

  35. 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):1081–7.

    Article  PubMed  Google Scholar 

  36. Perez RO, Habr-Gama A, Sao Juliao 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):545–51.

    Article  PubMed  Google Scholar 

  37. Bujko K, Richter P, Kolodziejczyk M, et al. Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders. Radiother Oncol. 2009;92(2):195–201.

    Article  PubMed  Google Scholar 

  38. Lambregts DM, Maas M, Bakers FC, et al. Long-term follow-up features on rectal MRI during a wait-and-see approach after a clinical complete response in patients with rectal cancer treated with chemoradiotherapy. Dis Colon Rectum. 2011;54(12):1521–8.

    Article  PubMed  Google Scholar 

  39. Restivo A, Zorcolo L, Cocco IM, et al. Elevated CEA levels and low distance of the tumor from the anal verge are predictors of incomplete response to chemoradiation in patients with rectal cancer. Ann Surg Oncol. 2013;20(3):864–71.

    Article  PubMed  Google Scholar 

  40. Patel UB, Taylor F, Blomqvist L, et al. Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience. J Clin Oncol. 2011;29(28):3753–60.

    Article  PubMed  Google Scholar 

  41. Lambregts DM, Vandecaveye V, Barbaro B, et al. Diffusion-weighted MRI for selection of complete responders after chemoradiation for locally advanced rectal cancer: a multicenter study. Ann Surg Oncol. 2011;18(8):2224–31.

    Article  PubMed Central  PubMed  Google Scholar 

  42. Habr-Gama A, Perez RO, Nadalin W, et al. Long-term results of preoperative chemoradiation for distal rectal cancer correlation between final stage and survival. J Gastrointest Surg. 2005;9(1):90–9; discussion 99–101.

    Article  PubMed  Google Scholar 

  43. Kristiansen C, Loft A, Berthelsen AK, et al. PET/CT and histopathologic response to preoperative chemoradiation therapy in locally advanced rectal cancer. Dis Colon Rectum. 2008;51(1):21–5.

    Article  PubMed  Google Scholar 

  44. Das P, Skibber JM, Rodriguez-Bigas MA, et al. Predictors of tumor response and downstaging in patients who receive preoperative chemoradiation for rectal cancer. Cancer. 2007;109(9):1750–5.

    Article  CAS  PubMed  Google Scholar 

  45. Perez RO, Sao Juliao GP, Habr-Gama A, et al. The role of carcinoembriogenic antigen in predicting response and survival to neoadjuvant chemoradiotherapy for distal rectal cancer. Dis Colon Rectum. 2009;52(6):1137–43.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of Colorectal Surgery, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil

    Rodrigo O. Perez MD, PhD

  2. Angelita and Joaquim Gama Institute, São Paulo, Brazil

    Rodrigo O. Perez MD, PhD

  3. Department of Colorectal Surgery, Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, Brazil

    Angelita Habr-Gama MD

  4. Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil

    Angelita Habr-Gama MD

Authors
  1. Rodrigo O. Perez MD, PhD
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  2. Angelita Habr-Gama MD
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Corresponding author

Correspondence to Rodrigo O. Perez MD, PhD .

Editor information

Editors and Affiliations

  1. Division of Colon and Rectal Surgery Department of Surgery, Madigan Army Medical Center, Fort Lewis, WA, USA

    Scott R. Steele MD

  2. Division of Colorectal Surgery Department of Surgery, UMass Memorial Medical Center University of Massachusetts Medical School, Worcester, MA, USA

    Justin A. Maykel MD

  3. Division of Colon and Rectal Surgery Department of Surgery, Case Western Reserve University School of Medicine University Hospitals, Cleveland, OH, USA

    Bradley J. Champagne MD

  4. Division of Colon and Rectal Surgery Department of Surgery, Louisiana State University Health Science Center LSU School of Medicine, New Orleans, LA, USA

    Guy R. Orangio MD

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Perez, R.O., Habr-Gama, A. (2014). The Approach to the Rectal Cancer Patient with a Suspected Complete Clinical Response: Selection of Patients to the Watch and Wait Strategy. In: Steele, S.R., Maykel, J.A., Champagne, B.J., Orangio, G.R. (eds) Complexities in Colorectal Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-9022-7_16

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  • DOI: https://doi.org/10.1007/978-1-4614-9022-7_16

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  • Print ISBN: 978-1-4614-9021-0

  • Online ISBN: 978-1-4614-9022-7

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