Can chemoradiation with local excision result in acceptable survival and recurrence rates?

The authors aimed to review the use of adjuvant chemoradiotherapy with local excision for early stage rectal cancer.

Traditionally the surgical management of early rectal cancer has involved major abdominal surgery including total mesorectal excision (a significant length of bowel tissue around the tumor is removed). Local excision (removal of the tumor with minimal amounts of surrounding tissue) of early rectal cancer is a less severe alternative that is sphincter-sparing (does not damage the ring of muscle surrounding the anus) while facilitating a quicker recovery. However, local lymph nodes are not sampled using this technique, and therefore careful preoperative staging needs to be undertaken in order to reduce the the risk of recurrence (return of the cancer) associated with lymph node involvement.

Pre- and post-operative adjuvant treatments (additional treatments to surgery) are now available with the aim of reducing the risk of recurrence after local excision. This review aimed to determine the rates of disease control associated with local excision with neoadjuvant (given before surgery) or adjuvant (given alongside or after surgery) chemoradiotherapy (chemotherapy and radiation therapy) applied to a carefully defined group of patients.

11 studies evaluating the role of local excision with adjuvant or neoadjuvant chemotherapy including 455 patients were included. The average time of follow-up across all studies was 30.5 – 115.2 months. Patients were staged before surgery based on imaging techniques and physical examination. All patients had been diagnosed with early T1 – T2 rectal cancer (cancer is still confined to the rectum) with no evidence of lymph node metastases (spread of the cancer to the lymph nodes).

 The average overall survival rate was 75%, while the average disease-specific survival rate (percentage of people who have not died from a specific disease in a given time period) was 89%. The average disease-free survival rate (percentage of patients who survived without any signs or symptoms of that cancer) was 74%. The average overall recurrence rate was 13.1%. The average local recurrence (cancer that has recurred at or near the same place as the original tumor) rate was 10%, while the average distant recurrence (cancer that has spread to areas farther away from where the cancer was first located) rate was 4.7%. The average rate of salvage surgery (the number of patients with local recurrence undergoing surgical removal of the cancer) was 100%, indicating that every patient who had local recurrence underwent salvage therapy.

Where reported, mortality (death) was 0% across all studies.

For patients with an accurately staged and small rectal cancer without the presence of lymph node or distant metastases, local excision combined with pre-operative chemoradiotherapy may avoid the need for major surgery.

This review encompassed a small number of reviews with a small number of patients.