Jehaes Constance, Panis Yves, Fernandez Laura, Lelong Bernard, Julião Guilherme Sao, Vailati Bruna, Lefevre Jeremie H, Tuech Jean-Jacques, Azevedo José, Benoist Stéphane, Parvaiz Amjad, Diane Mege, Gama Angelita Habr-, Perez Rodrigo, Denost Quentin
Bordeaux Colorectal Institute, Clinique Tivoli-Ducos, Bordeaux, France.
Department of Digestive Surgery, Groupe Hospitalier Privé Ambroise Paré - Hartmann, Neuilly-Sur-Seine, France.
Eur J Surg Oncol. 2025 Jul;51(7):109761. doi: 10.1016/j.ejso.2025.109761. Epub 2025 Mar 14.
Watch and Wait (WW) strategy is currently used for mid/low rectal adenocarcinoma after neoadjuvant treatment (NAT). Local regrowth (LR) is a well-known risk, but its impact on distant metastasis (DM) is increasingly debated. This study aimed to assess the rate of DM after local excision (LE) for near-complete clinical response (ncCR) at restaging versus salvage surgery for regrowth following WW.
Retrospective analysis of DM rates from a prospective international registry, comparing patients with ncCR after NAT who underwent LE and patients with initial complete clinical response (cCR) and WW strategy, who underwent salvage surgery for regrowth. The primary endpoint was the 5-year distant metastasis-free survival (5y-DMFS). Univariate/Multivariate analysis were performed to identify risk factors of DM.
Among 138 patients included, 59 had LE for ncCR and 79 had salvage surgery after regrowth including TME (n = 23), APR (n = 30) and LE (n = 26). The 5y-DMFS was lower in patients with surgery at regrowth, 71 % vs. 93 % (p = 0.006). LR was the only independent risk factor associated with DM (OR:3.89; 95 % CI:1.34-11.25; p = 0.012). When only patients managed by salvage LE for LR are considered, 5y-DMFS was equivalent to LE at restaging (87 vs. 93; p = 0.442).
Patients with rectal cancer undergoing LE for ncCR after NAT have a significantly lower rate of DM compared to patients undergoing salvage surgery after LR within WW approach. Patients managed by LE for regrowth may represent a distinct subgroup where the risk of subsequent DM is equivalent to patients managed by LE at restage.
目前，观察等待（WW）策略用于中低位直肠腺癌新辅助治疗（NAT）后。局部复发（LR）是一个众所周知的风险，但它对远处转移（DM）的影响存在越来越多的争议。本研究旨在评估在重新分期时对接近完全临床缓解（ncCR）进行局部切除（LE）后与WW后复发进行挽救性手术相比的远处转移率。
对一个前瞻性国际登记处的远处转移率进行回顾性分析，比较NAT后接受LE的ncCR患者和最初完全临床缓解（cCR）并采用WW策略、因复发接受挽救性手术的患者。主要终点是5年无远处转移生存率（5y-DMFS）。进行单因素/多因素分析以确定远处转移的危险因素。
在纳入的138例患者中，59例因ncCR接受LE，79例在复发后接受挽救性手术，包括全直肠系膜切除术（TME，n = 23）、腹会阴联合切除术（APR，n = 30）和LE（n = 26）。复发时接受手术的患者5y-DMFS较低，分别为71%和93%（p = 0.006）。LR是与远处转移相关的唯一独立危险因素（OR：3.89；95%CI：1.34 - 11.25；p = 0.012）。当仅考虑因LR接受挽救性LE治疗的患者时，5y-DMFS与重新分期时的LE相当（87%对93%；p = 0.442）。
NAT后因ncCR接受LE的直肠癌患者与在WW方法下LR后接受挽救性手术的患者相比，远处转移率显著更低。因复发接受LE治疗的患者可能代表一个独特的亚组，其后续远处转移风险与重新分期时接受LE治疗的患者相当。
