Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL.
Department of Surgery, University of Florida, Gainesville, FL.
Clin Colorectal Cancer. 2018 Mar;17(1):1-12. doi: 10.1016/j.clcc.2017.06.008. Epub 2017 Jun 27.
Colorectal carcinoma is the second leading cause of cancer-related deaths in the United States, with rectal cancer accounting for approximately one-third of newly diagnosed cases, thus representing a major socioeconomic health burden. Although minimally invasive procedures (ie, transanal excision) may be appropriate for a subset of patients with small, superficially invasive tumors, a more comprehensive trimodality approach with neoadjuvant chemoradiotherapy, total mesorectal excision, and systemic chemotherapy is recommended for medically operable patients with nonmetastatic, locally advanced rectal cancer (LARC). Although such multimodality therapy has markedly reduced local recurrence rates, there remains an estimated 5-year distant relapse rate of 35%, representing the leading cause of death in this population. This review critically assesses the literature regarding neoadjuvant therapy for LARC, as well as the available evidence to support selective exclusion of individual modalities from the contemporary therapeutic paradigm, including controversies of nonoperative management, selective radiation sparing, and neoadjuvant systemic therapy. Through the review of existing data and the anticipated results of ongoing clinical trials, we outline the pragmatic opportunities for future investigation into questions of efficacy, safety, and ultimate improvements to the current status quo.
结直肠癌是美国癌症相关死亡的第二大主要原因，其中直肠癌约占新诊断病例的三分之一，因此代表了主要的社会经济健康负担。尽管对于一小部分肿瘤小且侵袭性浅表的患者，经肛门切除等微创程序可能是合适的，但对于有非转移性、局部晚期直肠癌（LARC）的可手术患者，更全面的三联疗法（新辅助放化疗、全直肠系膜切除术和全身化疗）是推荐的。尽管这种多模式治疗显著降低了局部复发率，但估计仍有 5 年远处复发率为 35%，这是该人群死亡的主要原因。本文批判性地评估了 LARC 新辅助治疗的文献，以及支持从当代治疗模式中选择性排除个别治疗方式的现有证据，包括非手术管理、选择性放疗保留和新辅助全身治疗的争议。通过对现有数据的回顾和正在进行的临床试验的预期结果，我们概述了未来在疗效、安全性和对当前现状的最终改进方面进行研究的实际机会。
