Lauscher Johannes Christian, Schineis Christian H W, Weixler Benjamin, Kreis Martin E
Klinik für Allgemein- und Viszeralchirurgie, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Deutschland.
Charité Universitätsmedizin Berlin, Berlin, Deutschland.
Chirurg. 2021 Jul;92(7):591-598. doi: 10.1007/s00104-021-01414-9. Epub 2021 Apr 23.
Neoadjuvant chemoradiotherapy was implemented in the treatment of rectal cancer for UICC stages II and III in 2004. Recent studies have provided new insights with respect to the indications and sequence of radiotherapy in the concept of multimodal treatment.
The aim of the study was to review the status of radiotherapy in the context of current developments in the treatment of rectal cancer, such as magnetic resonance imaging (MRI)-based surgery, total neoadjuvant therapy and the watch and wait strategy for complete clinical remission.
The indications for neoadjuvant radiotherapy based on the clinical T and N stages are not exact and can lead to overtreatment in 18-27% of cases. Radiotherapy is associated with a worsening of anorectal and urogenital functions. Local recurrence rates of 3% with surgery alone can be achieved in patients with negative circumferential resection margins (low risk cancer) in MRI. For rectal cancer with high-risk features, such as cT4 tumor, positive circumferential resection margins and extramural vascular invasion, an improved disease-free survival and a lower rate of distant metastases could be achieved with total neoadjuvant therapy compared to standard neoadjuvant chemoradiotherapy in recent phase III randomized trials. Pathological complete remission is achieved in 28% of patients after total neoadjuvant therapy.
The high rate of complete remission has fired the debate regarding watch and wait after total neoadjuvant therapy; however, no prospective randomized phase III trials comparing total mesorectal resection vs. watch and wait in complete clinical remission have been published. Hence, resection remains the gold standard in this scenario given the excellent long-term oncological results.
2004年新辅助放化疗被应用于国际抗癌联盟（UICC）II期和III期直肠癌的治疗。近期研究在多模式治疗理念下，就放疗的适应症和顺序提供了新见解。
本研究旨在回顾直肠癌治疗当前进展背景下的放疗现状，如基于磁共振成像（MRI）的手术、全新辅助治疗以及等待观察实现完全临床缓解的策略。
基于临床T和N分期的新辅助放疗适应症并不确切，可能导致18%-27%的病例过度治疗。放疗与肛门直肠和泌尿生殖功能恶化相关。MRI检查环周切缘阴性（低风险癌症）的患者单纯手术局部复发率可达3%。对于具有高风险特征的直肠癌，如cT4肿瘤、环周切缘阳性和壁外血管侵犯，在近期的III期随机试验中，与标准新辅助放化疗相比，全新辅助治疗可实现更好的无病生存期和更低的远处转移率。全新辅助治疗后28%的患者实现了病理完全缓解。
高完全缓解率引发了关于全新辅助治疗后等待观察的争论；然而，尚无比较全直肠系膜切除术与等待观察实现完全临床缓解的前瞻性随机III期试验发表。因此，鉴于出色的长期肿瘤学结果，在这种情况下切除仍然是金标准。
