Multidisciplinary Approach to Rectal Cancer: Are we Ready for Selective Treatment Strategies?
With optimized local treatment, achieved in the last years by TME surgery and the shift from a postoperative to a preoperative
treatment approach, distant metastases have become the predominant mode of failure in rectal cancer. Therefore, the intensification of
chemotherapy seems essential to improve distant control and survival in rectal cancer. The integration of newer generation
chemotherapeutics and target agents into fluoropyrimidines-based chemoradiotherapy (CRT) has been the more actively pursued
intensification strategy. However, early results from randomized phase III trials, evaluating the addition of oxaliplatin to preoperative
fluoropyrimidines-based CRT, did not show a significant impact on early pathological response with the addition of oxaliplatin, with the
exception of the German CAO/ARO/AIO-04 study. Moreover, the integration of target agents into preoperative CRT, although attractive
in principle, has yielded low rates of pathologic complete responses when combined with cetuximab and some concerns on surgical
morbidity following preoperative treatment with bevacizumab have been raised. Several novel strategies with different sequence of
multimodal treatment components have been developed. However, the evidence that rectal cancers are a widely heterogeneous group of
tumors with different prognostic implications, has indicated that the careful assessment of the risk of recurrence is a critical issue. In the
era of the preoperative approach, staging with MRI, for its ability to predict the involvement of the mesorectal fascia, should be
mandatory for all patients with rectal cancer, to refine the selection of patients for different treatment strategies. Moreover, considering
that response to preoperative treatment is not uniformly obtained in all patients and post-operative chemotherapy is generally met with
poor adherence, a risk-adapted strategy should be pursued in the postoperative setting as well. The selection of patients for different
multidisciplinary treatment strategies based on clinico-pathological features, rather than the current “one size fits all” approach, will
allow minimizing therapy and maximizing outcome for rectal cancer patients.
Keywords: Rectal cancer, magnetic resonance imaging, chemo-radiotherapy, target therapy, organ preservation.
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