Is radical surgery needed if chemoradiation destroys the rectal tumor?

This study investigated the long-term outcome of a minimally invasive surgical procedure in patients after chemoradiation.

The main treatment for patients with rectal cancer is chemoradiation followed by radical surgery. Radical surgery involves removal of the tumor and a large portion of the surrounding bowel. However, in 15-30% of patients chemoradiation alone will cause the tumor to disappear. For these patients radical surgery may be unnecessary and may increase the risk of permanent bowel, bladder or sexual problems.

For patients whose tumors completely disappear transanal endoscopic microsurgery (TEM) might be a less risky option. TEM is a minimally invasive procedure that can be used to remove small portions of bowel without any incision into the abdomen. It causes less bleeding, reduces the risk of infections and damage, decreases the duration of hospital stay and improves recovery. However, the long-term survival and relapse rates after this procedure are unknown.

The authors analyzed medical records from 43 patients who elected to undergo TEM after chemoradiation or were unfit for radical surgery. All patients had T2-T3 rectal cancer, indicating that the cancer had invaded the outer muscle layer or the outer layer of the rectum. Before TEM the growth of the cancer was evaluated using imaging technology (such as ultrasound and/or magnetic resonance imaging).

After chemoradiation, 30.2% of patients had no evidence of cancer in their rectal samples. None of these patients died but two patients (15.4%) had complications after TEM, one had bleeding and the wound ruptured for the other. The cancer did not relapse in any of the patients with no evidencue of tumor during the follow-up (on average 81 months) and no patients died as a result of their tumors.

30 patients (69.8%) only had a small response to chemoradiation or no response at all. The cancer relapsed in the rectum for 56.7% of patients in this group. For 23.3% of patients the cancer returned at a distant site.

The authors concluded that TEM could be used to replace radical surgery in patients whose tumors disappeared after chemoradiation. They also suggest that the procedure could be used to determine cancer stage and prognosis after chemoradiation.

This study only included a relatively small number of patients and techniques used to diagnose the rectal cancer stage have improved since some of the data was collected (1993-2013). Therefore, newer research with more patients is needed to ensure the accuracy of the results.