For the last decades, surgery with R0 resection has been the best treatment option for patients with colorectal cancer (CRC), offering good oncologic results. Neoadjuvant treatment (when indicated) has increased cancer survival and allowed surgeons to conduct an R0 resection in locally advanced cancers. Adjuvant treatment has also improved patients’ survival. In sum, the improvement in CRC oncological results is essentially due to advances in oncology, while surgical techniques are kept basically unchanged. Even new local resection techniques for rectal cancer are possible due to the great results seen after neoadjuvant chemoradiation.
From the idea of neoadjuvant treatment to surgery, we may be moving towards a neoadjuvant treatment to a primary organ-sparing strategy for rectal cancer. This idea is discussed in an article published in 2024 by Jacobus Burger et al. from two Surgical Oncology Departments in The Netherlands. According to the authors, 15-20% of patients who undergo neoadjuvant chemoradiation for rectal cancer with the objective of downsizing and facilitating surgery, have a cCR at restaging. These patients can enter a watch-and-wait strategy and do not undergo total mesorectal excision (TME) – opportunistic or secondary organ preservation.
Considering these results and the fact that most patients prefer an organ preservation strategy, a planned or primary organ preservation strategy is now being considered, particularly for smaller tumors (at least for now, I would say). This approach offers the benefit of fewer complications and avoids temporary stomas or end colostomies. In this context, patients with smaller tumors (not locally advanced) may receive neoadjuvant chemoradiation therapy aimed at achieving cCR, followed by a watch-and-wait strategy focused on primary organ preservation. These patients undergo neoadjuvant chemoradiation not due to oncological requirements (to improve survival and facilitate surgery) but because doctors aim to preserve the rectum. Even if a small remnant remains after neoadjuvant treatment, local excision can proceed with organ preservation. As the authors state: “In this strategy, the role of (chemo)radiation has shifted from improving oncological outcomes to preserving function and quality of life.”
Multiple studies have been conducted and reported promising results, supporting this primary organ preservation strategy. In low-risk rectal cancer (without the following high-risk features: positive margins, lymphovascular invasion, poorly differentiated tumors, or sm3 invasion), a preservation rate exceeding 50% has been observed. Patients with locally advanced tumors (≥T3 and/or N+) show a pCR and cCR rate of 27-28%, which explains why primary organ preservation is less common in these situations. Nevertheless, the authors indicate that the possibility of rectum preservation in locally advanced rectal cancer “is certainly not insignificant.”
Despite multiple studies showing high success rates, some patients undergoing neoadjuvant therapy aiming at primary organ preservation will have an insufficient response and require surgery for TME. This is an important drawback of this strategy. These are patients who did not need neoadjuvant therapy from an oncological point of view but were exposed to radiation before surgery. So, they had no benefit from neoadjuvant therapy but will suffer from the potential complications from it. All surgeons know that performing surgery in an irradiated field is a “minefield.” On the other hand, patients do not want a colostomy, and any oncological accepted option is valid if the objective is to avoid a stoma. An important piece of information we get from this paper is that many patients refuse to be operated on if a primary organ strategy is an option.
Since the beginning of my learning as a surgeon, R0 resection has been the gold standard of care for any digestive cancer. I believe that if complete resection is possible, we should go for it. Removing a tumor “must” be the best option from an oncological point of view, and till now, all neoadjuvant treatments aim at downsizing for safe and complete resection. Is this idea old school? Is this idea not true for rectal cancer anymore? The authors end the paper by saying that “although salvage TME will remain the standard technique for patients with an insufficient response or local regrowth, it is inconceivable that the future of rectal cancer care will be dominated by upfront surgery.”
Are game rules changing? …
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Dr. Carlos Eduardo Costa Almeida
General Surgeon
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