Avoiding radical surgery after pre-operative chemoradiotherapy: A possible therapeutic option in rectal cancer?

Figures & data

Figure 1. Schematic illustration of methodology employed to identify appropriate studies that had reported on the long-term outcomes following local excision or clinical observation after long-course pre-operative chemoradiotherapy (LCPRT).

Figure 2. Management algorithm for patients with newly diagnosed rectal cancer in the UK. Conservative surgical strategies are employed only in few selected patients who out of personal choice do not want a permanent stoma or are not fit for radical surgery. LCPRT, long-course pre-operative chemoradiotherapy; MDT, multi-disciplinary team; SCPRT, short course pre-operative radiotherapy. LCPRT, long-couse pre-operative chemoradiotherapy.

Table I. Published studies that have evaluated the effects of local excision (LE) after long-course pre-operative radiotherapy (LCPRT).

Study (N=patient number)	Patient selection	Pathological outcome	Long-term outcome	FU and OS
Mohiuddin et al. (1994) [5] N=48	T2-T3; NX good and poor-risk patient sub-groups based on tumour and patient characteristics	ypT0 (n=18); ypT1 (n=12); ypT2 (n=14); ypT3 (n=4)	LR=5	FU=40M 5-yr OS=83.5%
Schell et al. (2002) [8] N=11 from cohort of 75 patients treated with LCPRT	T3; N0-1 CR after LCPRT	ypT0 (n=8); ypT1 (n=3)	LR=0; DM=1	FU=48M OS=100%
Ruo et al. (2002) [9] N=10	T2-3; NX Poor surgical risk Refusal to have colostomy	ypT0 (n=3); residual tumour (n=7)	LR=1; DM=2	FU=28.5M 2-year OS (78%)
Kim et al. (2001) [10] N=26 from cohort of 95 patients treated with LCPRT	T2-3; N0 (n=25); N1 (n=1) CR after LCPRT Poor surgical risk Refusal to have colostomy	ypT0 (n=17); residual tumour (n=9)	LR=1; DM=0	FU= 19M OS=100%
Bonnen et al. (2004) [11] N=26 from cohort of 431 patients treated with LCPRT	T3; N0 (n=25); N1 (n=1) CR after LCPRT Poor surgical risk Refusal to have colostomy	ypT0 (n=14); residual tumour- microscopic (n=9); gross (n=3)	LR=2; DM=2	FU= 46M 5-year OS (85%)
Huh et al. (2008) [12] N=9 from cohort of 73 patients treated with LCPRT	T2-T3; N0 (n=6); N1 (n=3) Poor surgical risk Refusal to have colostomy	ypT0 (n=4); ypT2 (n=4); ypT3 (n=1)	LR=1; DM=1	FU=91M 10-yr OS = 88.9%
Callender et al. (2010) [6] N=47 from cohort of 520 patients treated with LCPRT	T3; N0 (n=34); N1 (n=13) CR after LCPRT Poor surgical risk Refusal to have colostomy	ypT0 (n=23); residual tumour- microscopic (n=17); gross (n=7)	LR=5; DM=5	FU = 63M 10-year OS= 74%
Nair et al. (2008) [13] N=44	T2-3; N0 (n=32); N1 (n=11) CR after LCPRT Poor surgical risk Refusal to have colostomy	ypT0 (n=19); residual tumour (n=25)	LR=4; DM=5	FU=64M 5-yr OS=84%
Kundel et al. (2010) [7] N=14 from cohort of 320 patients treated with LCPRT	T2-3/ NX or N0	All patients included in analysis had pCR following LE	LR=0; DM=0	FU=48M OS=100%rr
Guerrieri et al. (2008) [15] N=145	T2-T3; N0	ypT0 (17%); ypT1 (37%); >ypT2 (46%)	LR=8 (4%)	FU=81M OS=100% (pT0-1); 90% (pT2); 77% (pT3)

DM, distant metastasis; FU, follow-up; LR, local recurrence; OS, overall survival; pCR, pathological complete response; PR, partial response.

Figure 3. Schematic illustration of probable futuristic clinical algorithm for patients considered for conservative management after long-course pre-operative radiotherapy (LCPRT). The paradigm illustrates various molecular, radiological and histological parameters that may be employed at different time-intervals during patient's treatment pathway for the reliable pre-operative identification of pathological complete response (pCR).

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