Wo Jennifer Y, Ashman Jonathan B, Bhadkamkar Nishin A, Bradfield Lisa, Chang Daniel T, Hanna Nader, Hawkins Maria, Holtz Michael, Kim Edward, Kelly Patrick, Ling Diane C, Olsen Jeffrey R, Palta Manisha, Raldow Ann C, Ruiz-Garcia Erika, Sheybani Arshin, Stitzenberg Karyn B, Das Prajnan
Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona.
Pract Radiat Oncol. 2025 Mar-Apr;15(2):124-143. doi: 10.1016/j.prro.2024.11.003. Epub 2024 Nov 25.
With the results of several recently published clinical trials, this guideline focused update provides evidence-based recommendations for the indications and dose-fractionation regimens for neoadjuvant radiation therapy (RT), optimal sequencing of RT and systemic therapy in the context of total neoadjuvant therapy (TNT), and considerations for selective omission of RT and surgery for rectal cancer.
The American Society for Radiation Oncology convened a multidisciplinary task force to update 3 key questions that focused on the role of RT for patients with operable rectal cancer. The key questions addressed (1) indications for neoadjuvant RT, (2) selection of neoadjuvant regimens, and (3) indications for consideration of a nonoperative management (NOM) or local excision approach after definitive/preoperative chemoradiation. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for quality of evidence grading and strength of recommendation.
For patients with stage II-III rectal cancer, neoadjuvant RT was strongly recommended; however, among patients deemed at lower risk of locoregional recurrence, consideration of omission of neoadjuvant RT was conditionally recommended in favor of neoadjuvant chemotherapy with a favorable treatment response or upfront surgery. For patients with T3-T4 and node-positive rectal cancer undergoing neoadjuvant RT, a TNT approach was strongly recommended. Among patients with higher risk of locoregional recurrence, TNT with chemotherapy before or after long-course chemoradiation was strongly recommended, whereas TNT with short-course RT followed by chemotherapy was conditionally recommended. For patients with rectal cancer for whom NOM is a priority, concurrent chemoradiation followed by consolidation chemotherapy was strongly recommended. Selection of RT dose-fractionation regimen, sequencing of therapies, and consideration of NOM should be determined by multidisciplinary consensus and based on disease extent, disease location, patient preferences, and quality of life considerations.
The task force proposed recommendations to inform best clinical practices on the use of RT for rectal cancer with strong emphasis on multidisciplinary care. Future studies should focus on further addressing optimal treatment regimens to allow for more personalized recommendations based on individual risk stratification and patient priorities regarding quality of life.
基于近期发表的多项临床试验结果，本指南重点更新内容针对新辅助放疗（RT）的适应证和剂量分割方案、在全新辅助治疗（TNT）背景下RT与全身治疗的最佳序贯安排以及直肠癌选择性省略RT和手术的考量因素，提供了循证推荐。
美国放射肿瘤学会召集了一个多学科特别工作组，以更新聚焦于RT对可切除直肠癌患者作用的3个关键问题。所涉及的关键问题包括：（1）新辅助RT的适应证；（2）新辅助方案的选择；（3）在确定性/术前放化疗后考虑非手术治疗（NOM）或局部切除方法的适应证。推荐基于系统的文献综述，并采用预定义的共识构建方法以及证据质量分级和推荐强度系统制定。
对于II - III期直肠癌患者，强烈推荐新辅助RT；然而，在被认为局部区域复发风险较低的患者中，有条件地推荐考虑省略新辅助RT，转而采用新辅助化疗，前提是治疗反应良好或直接进行手术。对于接受新辅助RT的T3 - T4期且伴有淋巴结转移的直肠癌患者，强烈推荐采用TNT方法。在局部区域复发风险较高的患者中，强烈推荐在长程放化疗之前或之后进行化疗的TNT，而对于短程RT后序贯化疗的TNT则有条件地推荐。对于将NOM作为优先考虑的直肠癌患者，强烈推荐同步放化疗后进行巩固化疗。RT剂量分割方案的选择、治疗的序贯安排以及对NOM的考量应通过多学科共识确定，并基于疾病范围、疾病位置、患者偏好和生活质量考量因素。
特别工作组提出了相关推荐，以指导直肠癌RT使用的最佳临床实践，特别强调多学科护理。未来的研究应专注于进一步探讨最佳治疗方案，以便根据个体风险分层和患者对生活质量的优先考虑做出更个性化的推荐。
