Bordeaux Colorectal Institute, Clinique Tivoli, 220 Rue Mandron, 33000, Bordeaux, France.
Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France.
Int J Colorectal Dis. 2024 Jul 31;39(1):123. doi: 10.1007/s00384-024-04675-y.
Improvements in neoadjuvant therapy for locally advanced cT4 rectal cancer have led to improved tumour response and thus a variety of suitable management strategies. The aim of this study was to report management and outcomes of patients with cT4 rectal cancer undergoing a spectrum of treatment strategies from organ preservation (OP) to pelvic exenteration (PE).
Patients who underwent elective treatment for cT4 rectal cancer between 2016 and 2021 were included. All patients were treated with curative intent. Surgical management was adapted to tumour response. Kaplan-Meier curves were generated to compare 3-year overall survival (3y-OS), local recurrence (3y-LR) and distant metastases (3y-DM) between different strategies.
Among 152 patients included, 13 (8%) underwent OP, 71 (47%) TME and 68 (45%) APR/PE. The median follow-up was 31.3 months. Patients undergoing OP had a lower tumour pretreatment (p < 0.001). Compared to patients with TME, those with APR/PE had a higher rate of ypT4 (p = 0.001) with a lower R0 rate (p = 0.044). The 3y-OS and 3y-DM were 78% and 15.1%, respectively, without significant differences. The 3y-LR was 6.6%, and patients with OP had a significantly worse 3y-local regrowth compared to 3y-LR in patients with TME and APR/PE (30.2% vs. 5.4% vs. 2%, p = 0.008).
cT4 tumours may be suitable for the full spectrum of rectal cancer management from organ preservation to pelvic exenteration depending on tumour response to neoadjuvant therapy. However, careful attention is required in OP as local regrowth in up to 30% of cases reinforces the need for sustained active surveillance in Watch&Wait programmes.
新辅助治疗在局部晚期 cT4 直肠癌中的应用得到了改善，从而提高了肿瘤的反应，因此出现了各种合适的管理策略。本研究的目的是报告接受从器官保留（OP）到盆腔廓清术（PE）的一系列治疗策略的 cT4 直肠癌患者的治疗方法和结局。
纳入 2016 年至 2021 年期间接受选择性 cT4 直肠癌治疗的患者。所有患者均接受根治性治疗。手术管理根据肿瘤反应进行调整。生成 Kaplan-Meier 曲线以比较不同策略之间的 3 年总生存率（3y-OS）、局部复发（3y-LR）和远处转移（3y-DM）。
在 152 名患者中，13 名（8%）接受了 OP，71 名（47%）接受了 TME，68 名（45%）接受了 APR/PE。中位随访时间为 31.3 个月。接受 OP 的患者术前肿瘤大小较低（p<0.001）。与接受 TME 的患者相比，接受 APR/PE 的患者 ypT4 发生率更高（p=0.001），R0 率更低（p=0.044）。3y-OS 和 3y-DM 分别为 78%和 15.1%，无显著差异。3y-LR 为 6.6%，OP 患者的 3y 局部复发率明显高于 TME 和 APR/PE 患者（30.2%比 5.4%比 2%，p=0.008）。
cT4 肿瘤可能适合从器官保留到盆腔廓清术的直肠癌全谱管理，具体取决于新辅助治疗对肿瘤的反应。然而，在 OP 中需要谨慎注意，因为多达 30%的病例存在局部复发，这强化了在 Watch&Wait 方案中持续积极监测的必要性。
