Summary
Total neoadjuvant therapy is a novel approach for locally advanced rectal cancer. The optimal treatment sequence is, however, a matter of debate and until now, no overall survival benefit has been reported. This review is a critical, objective summary viewed from different perspectives of the available literature of previous milestones that have been achieved in the treatment of locally advanced rectal cancer, of current recommendations, and of future perspectives.
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References
Enker WE, Laffer UT, Block GE. Enhanced survival of patients with colon and rectal cancer is based upon wide anatomic resection. Ann Surg. 1979;190(3):350–60.
Pollett WG, Nicholls RJ. The relationship between the extent of distal clearance and survival and local recurrence rates after curative anterior resection for carcinoma of the rectum. Ann Surg. 1983;198(2):159–63.
Buyse M, Zeleniuch-Jacquotte A, Chalmers TC. Adjuvant therapy of colorectal cancer. Why we still don’t know. JAMA. 1988;259(24):3571–8.
Heald RJT. “Holy Plane” of rectal surgery. J R Soc Med. 1988;81(9):503–8.
Cedermark B, et al. Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med. 1997;336(14):980–7.
Sauer R, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351(17):1731–40.
Kapiteijn E, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;345(9):638–46.
Brown G, et al. Effectiveness of preoperative staging in rectal cancer: digital rectal examination, endoluminal ultrasound or magnetic resonance imaging? Br J Cancer. 2004;91(1):23–9.
Brown G. Local radiological staging of rectal cancer. Clin Radiol. 2004;59(3):213–4.
Beets-Tan RG, Beets GL. Local staging of rectal cancer: a review of imaging. J Magn Reson Imaging. 2011;33(5):1012–9.
Beets-Tan RG. MRI in rectal cancer: the T stage and circumferential resection margin. Colorectal Dis. 2003;5(5):392–5.
Maughan NJ, Quirke P. Modern management of colorectal cancer—a pathologist’s view. Scand J Surg. 2003;92(1):11–9.
Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol. 2008;26(2):303–12.
Nagtegaal ID, et al. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol. 2005;23(36):9257–64.
Quirke P. Training and quality assurance for rectal cancer: 20 years of data is enough. Lancet Oncol. 2003;4(11):695–702.
van den Broek CB, et al. Differences in pre-operative treatment for rectal cancer between Norway, Sweden, Denmark, Belgium and the Netherlands. Eur J Surg Oncol. 2014;40(12):1789–96.
van Gijn W, 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.
Breugom AJ, et al. Adjuvant chemotherapy after preoperative (chemo)radiotherapy and surgery for patients with rectal cancer: a systematic review and meta-analysis of individual patient data. Lancet Oncol. 2015;16(2):200–7.
Bosset J‑F, et al. Fluorouracil-based adjuvant chemotherapy after preoperative chemoradiotherapy in rectal cancer: long-term results of the EORTC 22921 randomised study. Lancet Oncol. 2014;15(2):184–90.
Schmoll HJ, et al. Pre- and postoperative capecitabine without or with oxaliplatin in locally advanced rectal cancer: PETACC 6 trial by EORTC GITCG and ROG, AIO, AGITG, BGDO, and FFCD. J Clin Oncol. 2021;39(1):17–29.
Rödel C, et al. Preoperative chemoradiotherapy and postoperative chemotherapy with fluorouracil and oxaliplatin versus fluorouracil alone in locally advanced rectal cancer: initial results of the German CAO/ARO/AIO-04 randomised phase 3 trial. Lancet Oncol. 2012;13(7):679–87.
Kim TW, et al. Randomized trial of postoperative adjuvant therapy in Stage II and III rectal cancer to define the optimal sequence of chemotherapy and radiotherapy: 10-year follow-up. Int J Radiat Oncol Biol Phys. 2011;81(4):1025–31.
Marijnen CA, et al. Radiotherapy does not compensate for positive resection margins in rectal cancer patients: report of a multicenter randomized trial. Int J Radiat Oncol Biol Phys. 2003;55(5):1311–20.
Strassburg J, et al. MRI-based indications for neoadjuvant radiochemotherapy in rectal carcinoma: interim results of a prospective multicenter observational study. Ann Surg Oncol. 2011;18(10):2790–9.
Junginger T, et al. Rectal carcinoma: is too much neoadjuvant therapy performed? Proposals for a more selective MRI based indication. Zentralbl Chir. 2006;131(4):275–84.
Kreis ME, et al. Use of preoperative magnetic resonance imaging to select patients with rectal cancer for neoadjuvant chemoradiation—interim analysis of the German OCUM trial (NCT01325649). J Gastrointest Surg. 2016;20(1):25–32. discussion 32–33.
Ruppert R, et al. Oncological outcome after MRI-based selection for neoadjuvant chemoradiotherapy in the OCUM rectal cancer trial. Br J Surg. 2018;105(11):1519–29.
Ruppert R, et al. Avoidance of overtreatment of rectal cancer by selective chemoradiotherapy: results of the optimized surgery and MRI-based multimodal therapy trial. J Am Coll Surg. 2020;231(4):413–425.e2.
Maas M, 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.
Petrelli F, et al. Pathologic complete response and disease-free survival are not surrogate endpoints for 5‑year survival in rectal cancer: an analysis of 22 randomized trials. J Gastrointest Oncol. 2017;8(1):39–48.
Sargent D, et al. Two or three year disease-free survival (DFS) as a primary end-point in stage III adjuvant colon cancer trials with fluoropyrimidines with or without oxaliplatin or irinotecan: data from 12,676 patients from MOSAIC, X‑ACT, PETACC‑3, C‑06, C‑07 and C89803. Eur J Cancer. 2011;47(7):990–6.
Merkel S, et al. Time to locoregional recurrence after curative resection of rectal carcinoma is prolonged after neoadjuvant treatment: a systematic review and meta-analysis. Colorectal Dis. 2011;13(2):123–31.
Allegra CJ, et al. Neoadjuvant 5‑FU or capecitabine plus radiation with or without oxaliplatin in rectal cancer patients: a phase III randomized clinical trial. J Natl Cancer Inst. 2015;107(11):djv248. https://doi.org/10.1093/jnci/djv248.
Aschele C, et al. Primary tumor response to preoperative chemoradiation with or without oxaliplatin in locally advanced rectal cancer: pathologic results of the STAR-01 randomized phase III trial. J Clin Oncol. 2011;29(20):2773–80.
Deng HY, et al. Neoadjuvant chemoradiotherapy or chemotherapy? A comprehensive systematic review and meta-analysis of the options for neoadjuvant therapy for treating oesophageal cancer. Eur J Cardiothorac Surg. 2017;51(3):421–31.
Wiśniowska K, et al. Does the addition of oxaliplatin to preoperative chemoradiation benefit cT4 or fixed cT3 rectal cancer treatment? A subgroup analysis from a prospective study. Eur J Surg Oncol. 2016;42(12):1859–65.
Gerard JP, et al. Comparison of two neoadjuvant chemoradiotherapy regimens for locally advanced rectal cancer: results of the phase III trial ACCORD 12/0405-Prodige 2. J Clin Oncol. 2010;28(10):1638–44.
Rödel C, et al. Oxaliplatin added to fluorouracil-based preoperative chemoradiotherapy and postoperative chemotherapy of locally advanced rectal cancer (the German CAO/ARO/AIO-04 study): final results of the multicentre, open-label, randomised, phase 3 trial. Lancet Oncol. 2015;16(8):979–89.
Bittner R, et al. Report on the workshop “workflow rectal cancer II” in Burghausen. Zentralbl Chir. 2007;132(2):95–8.
Buhr HJ, et al. Clinical pathway (workflow) for diagnostic, therapy and follow-up in patients with rectal cancer. Zentralbl Chir. 2006;131(4):285–97.
Roxburgh CSD, et al. Changes in the multidisciplinary management of rectal cancer from 2009 to 2015 and associated improvements in short-term outcomes. Colorectal Dis. 2019;21(10):1140–50.
Conroy T, 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. Lancet Oncol. 2021;22(5):702–15.
Bahadoer RR, 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. Lancet Oncol. 2021;22(1):29–42.
Garcia-Aguilar J, et al. Organ preservation in patients with rectal adenocarcinoma treated with total neoadjuvant therapy. J Clin Oncol. 2022;40(23):2546–56.
Fokas E, et al. Chemoradiotherapy plus induction or consolidation chemotherapy as total neoadjuvant therapy for patients with locally advanced rectal cancer: long-term results of the CAO/ARO/AIO-12 randomized clinical trial. JAMA Oncol. 2022;8(1):e215445.
Jin J, et al. Multicenter, randomized, phase III trial of short-term radiotherapy plus chemotherapy versus long-term chemoradiotherapy in locally advanced rectal cancer (STELLAR). J Clin Oncol. 2022; https://doi.org/10.1200/JCO.21.01667.
Benson AB, et al. Rectal cancer, version 2.2018, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2018;16(7):874–901.
Cercek A, et al. Adoption of total neoadjuvant therapy for locally advanced rectal cancer. JAMA Oncol. 2018;4(6):e180071.
Smith JJ, et al. Organ preservation in rectal adenocarcinoma: a phase II randomized controlled trial evaluating 3‑year disease-free survival in patients with locally advanced rectal cancer treated with chemoradiation plus induction or consolidation chemotherapy, and total mesorectal excision or nonoperative management. BMC Cancer. 2015;15:767.
Ludmir EB, et al. Total neoadjuvant therapy for rectal cancer: an emerging option. Cancer. 2017;123(9):1497–506.
Wang X, et al. Total neoadjuvant treatment (CAPOX plus radiotherapy) for patients with locally advanced rectal cancer with high risk factors: a phase 2 trial. Radiother Oncol. 2018;129(2):300–5.
Riesco-Martinez MC, et al. Impact of total neoadjuvant therapy vs. standard chemoradiotherapy in locally advanced rectal cancer: a systematic review and meta-analysis of randomized trials. Cancers (Basel). 2020;12(12):3655.
Liu S, et al. Total neoadjuvant therapy (TNT) versus standard neoadjuvant chemoradiotherapy for locally advanced rectal cancer: a systematic review and meta-analysis. Oncologist. 2021;26(9):e1555–e66.
Valadão M, et al. Do we have to treat all T3 rectal cancer the same way? Clin Colorectal Cancer. 2020;19(4):231–5.
Lee JB, et al. Role of preoperative chemoradiotherapy in clinical stage II/III rectal cancer patients undergoing total mesorectal excision: a retrospective propensity score analysis. Front Oncol. 2020;10:609313.
Bujko K, et al. Long-course oxaliplatin-based preoperative chemoradiation versus 5 × 5 Gy and consolidation chemotherapy for cT4 or fixed cT3 rectal cancer: results of a randomized phase III study. Ann Oncol. 2016;27(5):834–42.
Ciseł B, et al. Long-course preoperative chemoradiation versus 5 × 5 Gy and consolidation chemotherapy for clinical T4 and fixed clinical T3 rectal cancer: long-term results of the randomized Polish II study. Ann Oncol. 2019;30(8):1298–303.
Benson AB, et al. NCCN guidelines insights: rectal cancer, version 6.2020. J Natl Compr Canc Netw. 2020;18(7):806–15.
Harrison JD, et al. Patient and physician preferences for surgical and adjuvant treatment options for rectal cancer. Arch Surg. 2008;143(4):389–94.
Breugom AJ, et al. Adjuvant chemotherapy for rectal cancer patients treated with preoperative (chemo)radiotherapy and total mesorectal excision: a Dutch Colorectal Cancer Group (DCCG) randomized phase III trial. Ann Oncol. 2015;26(4):696–701.
Goodman KA. Definitive chemoradiotherapy (“watch-and-wait” approach). Semin Radiat Oncol. 2016;26(3):205–10.
Lopez-Campos F, et al. Watch and wait approach in rectal cancer: current controversies and future directions. World J Gastroenterol. 2020;26(29):4218–39.
Xu Q, et al. MRI evaluation of complete response of locally advanced rectal cancer after neoadjuvant therapy: current status and future trends. Cancer Manag Res. 2021;13:4317–28.
Dattani M, et al. Oncological and survival outcomes in watch and wait patients with a clinical complete response after neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and pooled analysis. Ann Surg. 2018;268(6):955–67.
Habr-Gama A, 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.
Habr-Gama A, 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.
Glynne-Jones R, et al. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2017;28:iv22–iv40.
Yu M, et al. Does a long interval between neoadjuvant chemoradiotherapy and surgery benefit the clinical outcomes of locally advanced rectal cancer? A systematic review and meta analyses. Int J Colorectal Dis. 2022;37(4):855–68.
Petrelli F, et al. Increasing the interval between neoadjuvant chemoradiotherapy and surgery in rectal cancer: a meta-analysis of published studies. Ann Surg. 2016;263(3):458–64.
Deidda S, et al. Association of delayed surgery with oncologic long-term outcomes in patients with locally advanced rectal cancer not responding to preoperative Chemoradiation. JAMA Surg. 2021;156(12):1141–9.
Dizdarevic E, Hansen TF, Jakobsen A. The Prognostic Importance of ctDNA in Rectal Cancer: A Critical Reappraisal. Cancers (Basel). 2022;14(9):2252.
Murahashi S, et al. Serial circulating tumour DNA analysis for locally advanced rectal cancer treated with preoperative therapy: prediction of pathological response and postoperative recurrence. Br J Cancer. 2020;123(5):803–10.
Vidal J, et al. Clinical impact of presurgery circulating tumor DNA after total neoadjuvant treatment in locally advanced rectal cancer: a biomarker study from the GEMCAD 1402 trial. Clin Cancer Res. 2021;27(10):2890–8.
Kotaka M, et al. Association of circulating tumor DNA dynamics with clinical outcomes in the adjuvant setting for patients with colorectal cancer from an observational GALAXY study in CIRCULATE-Japan. J Clin Oncol. 2022;40(4_suppl):9.
Bach SP, et al. STAR-TREC phase II: Can we save the rectum by watchful waiting or transanal surgery following (chemo)radiotherapy versus total mesorectal excision for early rectal cancer? J Clin Oncol. 2022;40(16_suppl):3502–3502.
Hearn N, et al. Neoadjuvant radiotherapy dose escalation in locally advanced rectal cancer: a systematic review and meta-analysis of modern treatment approaches and outcomes. Clin Oncol. 2021;33(1):e1–e14.
Cercek A, et al. Mismatch repair-deficient rectal cancer and resistance to neoadjuvant chemotherapy. Clin Cancer Res. 2020;26:3271–9.
André T, et al. Pembrolizumab in microsatellite-instability-high advanced colorectal cancer. N Engl J Med. 2020;383:2207–18.
Overmann MJ, et al. Durable clinical benefit with nivolumab plus ipilimumab in DNA mismatch repair-deficient/microsatellite instability-high metastatic colorectal cancer. J Clin Oncol. 2018;36:773–9.
Cercek A, et al. PD‑1 blockade in mismatch repair-deficient, locally advanced rectal cancer. N Eng J Med. 2022;386:2363–76.
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G. Piringer and A. De Vries declare that they have no competing interests.
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Piringer, G., De Vries, A. Total neoadjuvant therapy in rectal cancer. memo 16, 21–30 (2023). https://doi.org/10.1007/s12254-022-00854-1
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DOI: https://doi.org/10.1007/s12254-022-00854-1