Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
Ups J Med Sci. 2024 Feb 21;129. doi: 10.48101/ujms.v129.10537. eCollection 2024.
Staging and treatment of rectal cancer have evolved over several decades with considerably fewer locoregional recurrences but no marked improved survival since systemic recurrence risks remain virtually unchanged. This development will briefly be summarised followed by a thorough discussion of two recent developments.
A systematic approach towards the literature is aimed at focusing on organ preservation and the delivery of all non-surgical treatments prior to surgery or total neoadjuvant treatment (TNT).
Organ preservation, that is to defer surgery if the tumour happens to disappear completely after any pre-treatment given to locally advanced tumours to decrease recurrence risks has increased in popularity and is, if not universally, widely accepted. To give neo-adjuvant treatment to intentionally obtain a clinically complete remission to avoid surgery is practised in some environments but is mostly still experimental. TNT, that is to provide both radiotherapy and chemotherapy aimed at killing microscopic disease in the pelvis or elsewhere has been subject to several trials. Collectively, they show that the chance of achieving a complete response, pathologically or clinically, has approximately doubled, increasing the chance for organ preservation, and the risk of distant metastasis has decreased at least in some trials. The best schedule remains to be established.
To obtain substantial progress and also improve survival, the systemic treatments need to be improved even if preoperative delivery is more effective and better tolerated than postoperative. The locoregional treatment may be further optimised through better risk prediction.
几十年来，直肠癌的分期和治疗方法不断发展，局部区域复发率明显降低，但由于系统复发风险几乎没有变化，生存率并未显著提高。本文将简要概述这一发展，然后深入讨论最近的两项进展。
旨在通过系统的方法关注器官保留和所有非手术治疗的提供，然后再进行手术或完全新辅助治疗（TNT）。
器官保留，即如果局部晚期肿瘤在任何治疗后完全消失，可以推迟手术以降低复发风险，这种方法越来越受欢迎，如果不是普遍的话，也得到了广泛的认可。在某些环境中，为了获得临床完全缓解而故意进行新辅助治疗以避免手术，但这种方法大多仍处于试验阶段。TNT 即提供旨在杀伤骨盆或其他部位微转移病灶的放疗和化疗，已经进行了多项试验。总的来说，这些试验表明完全缓解的机会（病理或临床）增加了约一倍，增加了器官保留的机会，并且在至少一些试验中，远处转移的风险降低了。最佳方案仍有待确定。
即使术前治疗比术后治疗更有效且更耐受，也需要改善全身治疗以取得实质性进展并提高生存率。通过更好的风险预测，可以进一步优化局部区域治疗。
