Department of Colorectal Surgery, Fudan University Shanghai Cancer Center.
Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
Int J Surg. 2023 Jul 1;109(7):1993-2000. doi: 10.1097/JS9.0000000000000438.
The optimal interval from completion of neoadjuvant chemoradiotherapy (CRT) to surgery in locally advanced rectal cancer remains controversial. It seems that delayed surgery is associated with an increase in pathological complete response rates. However, the prognostic effect of delayed surgery in poor responders is unclear.
Patients with locally advanced mid or distal rectal cancer undergoing neoadjuvant CRT followed by total mesorectal excision at a university teaching cancer center between June 2010 and December 2018 were retrospectively reviewed in this study. According to the tumor regression grade, poor responders (tumor regression grade 2-3) to neoadjuvant CRT were selected for analyses. Patients were divided into the longer interval group (greater than 8 weeks) and the shorter interval group (8 weeks or less) based on the wait time from completion of neoadjuvant CRT therapy to surgery. Results: among 916 eligible patients, 522 patients had a poor tumor response. There were 217 patients in the shorter interval group and 305 patients in the longer interval group. At the baseline, patients in the longer interval group were more likely to have a T3 stage and positive vascular invasion. Compared with patients in the shorter interval group, patients in the longer interval group had significantly worse overall survival and disease-free survival (DFS) (log-rank test, overall survival: P =0.004, DFS: P <0.001). The 3-year DFS rates were 75.6 and 63.1% in the shorter interval group and the longer interval group, respectively. In the multivariate analysis, delayed surgery was associated with an increased risk of mortality (hazard ratio: 2.003, 95% CI: 1.233-3.253, P =0.005) and recurrence (hazard ratio: 1.555, 95% CI: 1.121-2.156, P =0.008).
Patients who had a poor tumor response should be identified by restaging MRI and receive radical surgery in time, without a prolonged interval.
新辅助放化疗（CRT）后至手术的最佳时间间隔在局部晚期直肠癌中仍存在争议。似乎延迟手术与病理完全缓解率的增加有关。然而，在反应不佳的患者中，延迟手术的预后效果尚不清楚。
本研究回顾性分析了 2010 年 6 月至 2018 年 12 月在一所大学教学癌症中心接受新辅助 CRT 联合全直肠系膜切除术治疗的局部晚期中或低位直肠腺癌患者。根据肿瘤消退分级，选择新辅助 CRT 反应不良（肿瘤消退分级 2-3 级）的患者进行分析。根据新辅助 CRT 治疗完成至手术的等待时间，将患者分为较长间隔组（大于 8 周）和较短间隔组（8 周或更短）。
在 916 例符合条件的患者中，522 例患者肿瘤反应不良。较短间隔组有 217 例患者，较长间隔组有 305 例患者。在基线时，较长间隔组患者更有可能处于 T3 期和血管侵犯阳性。与较短间隔组患者相比，较长间隔组患者的总生存和无病生存（DFS）明显较差（对数秩检验，总生存：P =0.004，DFS：P <0.001）。较短间隔组和较长间隔组的 3 年 DFS 率分别为 75.6%和 63.1%。多变量分析显示，延迟手术与死亡风险增加相关（风险比：2.003，95%CI：1.233-3.253，P =0.005）和复发（风险比：1.555，95%CI：1.121-2.156，P =0.008）。
对于肿瘤反应不良的患者，应通过再分期 MRI 识别，并及时进行根治性手术，而无需延长间隔。
