Recrecimiento tumoral en pacientes bajo esquema de watch-and-wait en cáncer de recto. Ensayo pictórico / Regrowth during watch-and-wait scheme in rectal cancer. Pictorial essay

Resumen En las últimas décadas, la resonancia magnética (RM) ha cobrado un rol fundamental en el diagnóstico, la estadificación y el seguimiento de los pacientes con cáncer de recto. En la estadificación inicial, que sean o no tumores localmente avanzados es lo que determina el tratamiento neoadyuvante o quirúrgico, respectivamente. Posterior a la neoadyuvancia, los pacientes que logren una respuesta clínica completa pueden ser considerados para la inclusión dentro de un esquema de vigilancia activa, comúnmente conocido como watch and wait (WW). La estrategia WW se basa en tres pilares, que son el examen digital rectal, la endoscopía y la RM, buscando detectar la presencia temprana de recrecimiento tumoral. En relación a la RM, la secuencia potenciada en T2 de alta resolución, junto con la de difusión (DWI) y el mapa de ADC, son las piezas clave para la detección temprana de recrecimiento. La estrategia de WW lleva a evitar cirugías resectivas con una alta morbilidad y deterioro de la calidad de vida. El examen digital rectal y la endoscopía son métodos de vigilancia complementarios a la RM, con su principal limitación en lesiones sin compromiso mucoso. Esta razón posiciona a la RM como un pilar indispensable para su implementación, detectando no solo áreas de recrecimiento parietal, sino también aquellas extramurales no accesibles por los otros métodos de vigilancia. En nuestro conocimiento, este es el primer ensayo iconográfico que se centra en el análisis estricto del recrecimiento tumoral en pacientes bajo esquema de WW por RM. El objetivo es enfatizar el protocolo de estudio en estos pacientes y mostrar las distintas formas de recrecimiento tumoral con el fin de lograr su detección temprana.

Abstract During the last decades, the magnetic resonance imaging (MRI) has become an strategic tool for diagnosis, staging and surveillance in patients with rectal cancer. To differentiate patients with locally advanced rectal tumors from those who do not, determinate neoadjuvant therapy or total mesorectal excision, respectively. After neoadjuvant chemoradiotherapy, those who achieve complete clinical response may be considered for inclusion in an active surveillance scheme known as “watch and wait” (WW). WW strategy consists of three pillars, rectal digital exam, endoscopy and the MRI, and the main purpose is to reach the early detection of tumoral regrowth. Regarding MRI, the high-resolution T2-weighted images in conjunction with DWI, and the ADC map plays a key role in this instance. WW leads to avoid resective surgeries with high morbidity rates. The rectal digital exam and endoscopy are complementaries to MRI, whose main limitation is the detection of lesions with no mucosal involvement. This reason places the MRI as a cornerstone in tumoral regrowth, detecting not only luminal regrowth, but those in which the rectal wall is not involved, and thus, not accessible for the other surveillance methods. To our knowledge, this is the first pictorial essay in which imaging regrowth patterns are described. The purpose of this is to emphasize the MRI protocol study and to describe the different forms of tumoral regrowth in order to reach the early tumoral regrowth detection.

Watch and wait, worth It?

Background: The surgery with total mesorectal excision recommended by R. J. Heald in 1982 is the gold standard. Rectal cancer (RC) surgery has a morbidity rate ranging from 6 to 35%, and it can cause functional issues such as sexual, urinary, and bowel dysfunction in the long term. Neoadjuvant chemoradiotherapy (CRT) has been gaining ground in patients with lesions in the middle and lower rectum. The aim of the present study is to present the experience of a reference service in the treatment of RC. Patients and Methods: A retrospective study involving 53 patients diagnosed with RC between January 2017 and December 2019 with follow-up until December 2020. We examined tumor location, disease stage, digital rectal exam findings, carcinoembryonic antigen (CEA), therapeutic modality offered, and follow-up time. Results: A total of 32% of the patients were men and 68% were women, with a mean age of 60 years old. Location: upper rectum in 6 cases, middle rectum in 21 cases, and lower rectum in 26 cases with evolution from 9.8 to 13.5 months. The most frequent complaints were hematochezia and constipation. A total of 36 patients underwent neoadjuvant therapy: 11 complete clinical response (CCR) (30.5%), 20 (55.5%) partial clinical response (PCR), and no response in 5 patients (14%). The follow-up ranged from 12 to 48 months, with a mean of 30.5 months. A total of 25% of the patients had RC that went beyond the mesorectal fascia, and 22.64% had metastases in other parts of the body when they were diagnosed. Conclusion: Neoadjuvant radio and chemotherapy present themselves as an alternative in the treatment of rectal cancer. In 36 patients, 30.5% had a complete clinical response, 55.5% had a partial clinical response, and 14% had no response. It was worth doing the "Watch and Wait" (W&W) to sample. A definitive colostomy was avoided. However, it is necessary to expand the study to a larger follow-up and more patients. Additionally, it is necessary to implement a multicenter study. (AU)

Long-term outcomes of watch&wait (W&W) after neoadjuvant treatment in patients with rectal cancer / 中华放射肿瘤学杂志

Objective:To compare the outcomes of watch&wait (W&W) strategy in patients with locally advanced rectal cancer who achieved complete clinical response (cCR) after neoadjuvant therapy, with those who obtained pathological complete response (pCR) after total mesorectal excision (TME).Methods:This is a retrospective cohort analysis study. Patients histologically proven with locally advanced rectal adenocarcinoma (stage Ⅱ-Ⅲ) who had received neoadjuvant chemotherapy were eligible between January 2014 and December 2019. In whom we included patients who had cCR offered management with W&W strategy after completing neoadjuvant therapy and follow-up ≥1 year (W&W group), and patients who did not have cCR but pCR after TME (pCR group). The primary endpoints were 3-year and 5-year overall survival (OS), colostomy-free survival (CFS), disease-free survival (DFS), non-local regrowth disease-free survival (NR-DFS), and organ preservation rate. Kaplan-Meier analysis was used for survival analysis and log-rank test was performed. For comparative analysis, we also derived one-to-one paired cohorts of W&W versus pCR using propensity-score matching (PSM).Results:A total of 118 patients were enrolled, 49 of whom had cCR and managed by W&W, 69 had pCR, with a median follow-up period of 49.5 months (12.1-79.9 months). No difference was observed in the 3-year OS (97.1% vs. 96.7%) and 5-year OS (93.8% vs. 90.9%, P=0.696) between the W&W and pCR groups. Patients managed by W&W had significantly better 3-year and 5-year CFS (89.1% vs. 43.5%, P<0.001), better 3-year DFS (83.6% vs. 97.0%) and 5-year DFS (83.6% vs. 91.2%, P=0.047) compared with those achieving pCR. The 3-year NR-DFS (95.9% vs. 97.0%) and 5-year NR-DFS (92.8% vs. 97.0%, P=0.407) did not significantly differ between the W&W and pCR groups. Local regeneration occurred in six cases, and 87.7% of patients had successful rectum preservation in the W&W group. In the PSM analysis (34 patients in each group), absolutely better CFS (90.1% vs. 26.5%, P<0.001) was noted in the W&W group. A median interval of 17.5 weeks was observed for achieving cCR, while only 23.9% of patients achieved cCR within 5 to 12 weeks from radiation completion. Patients with short-course sequential chemoradiotherapy achieved cCR significantly later when compared with those with long-course concurrent chemoradiotherapy (19.0 vs. 9.8 weeks, P<0.001). Conclusions:The oncological outcomes of W&W strategy in patients with locally advanced rectal cancer are safe and effective, significantly improving the quality of life. Longer interval for cCR evaluation may improve rectal organ preservation rate.

Advances in organ preservation for locally advanced rectal cancer after neoadjuvant chemoradiotherapy / 中华放射肿瘤学杂志

Neoadjuvant chemoradiotherapy combined with total mesorectal excision is the standard treatment for stage T 3-T 4/N+ locally advanced rectal cancer (LARC). However, proctectomy is burdened with consistent postoperative morbidity, severely affecting the quality of life. "Organ preserving" methods could achieve similar oncological outcomes in highly selected patients whose tumors demonstrate (almost) clinical complete response to neoadjuvant treatment, while maintaining the quality of life and anorectal function by keeping the anus. This article aims to summarize the strategies of organ preservation after neoadjuvant treatment of LARC, salvage treatment for regrowth or recurrence, and anorectal function after organ preservation strategies.

Manejo quirúrgico de la hidatidosis hepática en esta última década: ¿qué hemos aprendido? / Surgical management of liver hydatidosis in the last decade: what have we learned?

Resumen El manejo clínico de la hidatidosis hepática es complejo y se basa fundamentalmente en tres pilares: quirúrgico, percutáneo y farmacológico; los cuales en ocasiones pueden ser complementarios. La terapia debe definirse en función de las características, ubicación y tipo de quiste; a lo cual debe sumarse la experiencia del equipo médico, recursos disponibles y la adherencia de los pacientes al monitoreo a largo plazo. La cirugía es el tratamiento más utilizado, las técnicas percutáneas posiblemente puedan reemplazar a la cirugía en casos específicos. Sin embargo, a pesar de los avances en las técnicas quirúrgicas, en el uso de la quimioterapia y otros tratamientos, el manejo de hidatidosis hepática sigue siendo un problema importante, debido principalmente a la falta de consenso sobre qué procedimiento a utilizar es mejor. El objetivo de esta presentación es dar a conocer el amplio abanico de terapias existentes en el actual manejo de la hidatidosis hepática, así como indicar algunas sugerencias en la utilización de cada una de ellas.

The clinical management of hepatic hydatidosis is complex and is fundamentally based on three pillars: surgical, percutaneous and pharmacological; which can sometimes be complementary. Therapy should be defined based on the characteristics, location and type of cyst; to which must be added the experience of the medical team, available resources and the adherence of patients to long-term monitoring. Surgery is the most used treatment, percutaneous techniques can possibly replace surgery in specific cases. However, despite advances in surgical techniques, in the use of chemotherapy and other treatments, the management of liver hydatidosis continues to be a major problem; mainly due to the lack of consensus on which procedure to use is better. The objective of this presentation is to present the wide range of existing therapies in the current management of hepatic hydatidosis and some suggestions in the use of each one of them.

Current situation and think of watch and wait strategy after neoadjuvant treatment of rectal cancer / 国际外科学杂志

Some patients with rectal cancer can achieve clinical complete response (cCR) after neoadjuvant chemoradiotherapy. The watch and wait strategy for cCR patients can achieve similar curative effects as radical surgery, avoid surgical complications, and significantly improve the quality of life of patients, which is attracting increasing attention. Although the existing research results support that the watch and wait strategy is safe and feasible, there is still a lack of high-level evidence-based medicine evidence. There are still many issues in the implementation of the watch and wait strategy that need to be further clarified, including long-term oncology efficacy, cCR diagnosis and evaluation criteria, appropriate patient selection, follow-up strategies during the observation period, and treatment methods for local tumor regeneration. This article will explain the above problems based on the results of the existing literature and the clinical experience of our center.

Consensus on the Watch and Wait policy in rectal cancer patients after neoadjuvant treatment (2020 version) / 中华胃肠外科杂志

Patients with clinical complete response(cCR) after neoadjuvant treatment receiving the Watch and Wait('W&W’) policy can achieve similar survival of those with yeild pathological complete response (ypCR), and have significantly improved quality of life compared to those undergoing radical operation. Based on thoroughly reviewing the literatures and guidelines at home and abroad, and referring associated clinical experiences from a lot of domestic medical centers, the present version of Chinese Consensus on W&W was established by a panel of many experts of gastrointestinal surgery, medical oncology, radiation oncology, pathology, endoscopy, radiology. This consensus mainly elucidates important conceptions of the W&W policy, current key evidences, risks and benefits for patients, conditions to carry out W&W, criteria of cCR diagnosis, timing of evaluation, follow - up plan, salvage treatment for local relapse and distant metastasis, associated problems of local resection, and is expected to facilitate the clinical practice and research of W&W policy in China.

Assessment of the non-surgical treatment of patients with rectal cancer who underwent neoadjuvant treatment with chemotherapy and radiotherapy at the oncology department / Avaliação do tratamento não cirúrgico de pacientes com câncer de reto submetido ao tratamento neoadjuvante com quimioterapia e radioterapia no serviço de oncologia

ABSTRACT Objective: To describe the partial results of a study in patients with rectal cancer who underwent neoadjuvant treatment with chemotherapy and radiotherapy regarding the rate of complete clinical response, disease-free survival, anorectal function, and quality of life. Material and methods: This was a prospective study from June 2015 to June 2018, in patients with low- or mid-rectum adenocarcinoma and clinical stage II or III, treated with radiotherapy and chemotherapy (IMRT 54 Gy for six weeks) concomitant with 5-fluorouracil (5-FU) 380 mg/m2 and folinic acid (LV) 20 mg/m2 for five days in the first and fifth weeks and two cycles after radiotherapy (5-FU 400 mg/m2 and LV 20 mg/m2) every 28 days. After the treatment, clinical examination, rectosigmoidoscopy, pelvic magnetic resonance imaging, chest and upper abdomen computed tomography, and CEA testing were performed. Resection surgery was performed in those with incomplete clinical response (iCR). Those with complete clinical response (cCR) are under observation (wait-and-see policy). Manometry and scintigraphic function and quality of life scales were collected before treatment and at 30 and 90 days after the end of treatment. Results: As of June 2018, 11 patients were recruited. One was excluded from the analysis for presenting severe toxicity, suggestive of dihydropyrimidine dehydrogenase (DPD) deficiency, after the first chemotherapy cycle. All others completed the treatment. Two patients presented toxicity grade 3/4 related to chemotherapy and had their doses reduced. Seven patients (70%) presented iRC; three underwent rectosigmoidectomy, and the anatomopathological evaluation indicated complete pathological response in two cases (28.5%). Three (30%) presented cCR and did not present evidence of disease after a mean follow-up of 19 months. Patients presented improvement of anorectal function and quality of life. Conclusions: Advances in the neoadjuvant treatment of rectal tumors contributed to better rates of complete pathological responses. New paradigms promote an increase in the complete clinical response rates, which would allow organ preservation and consequent reduction of surgical morbidity.

RESUMO Objetivo: Descrever os resultados parciais de estudo em pacientes com câncer de reto submetidos a tratamento neoadjuvante com quimioterapia e radioterapia quanto à taxa resposta clínica completa, sobrevida livre de doença, função anorretal e qualidade de vida. Material e métodos: Estudo prospectivo desde junho 2015 até junho de 2018, em paciente com adenocarcinoma de reto baixo ou médio e estadio clínico II ou III tratados com RT/QT (IMRT 54 Gy em 6 semanas) concomitante a 5-Fuorouracil (5-FU) 380 mg/m2 e ácido folínico (LV) 20 mg/m2 por 5 dias nas primeira e quinta semanas e dois ciclos após RT (5-FU 400 mg/m2 e LV 20 mg/m2) a cada 28 dias. Após o tratamento, realizou-se exame clínico, retossigmoidoscopia, RNM de pelve, TC de tórax e abdômen superior e dosagem de CEA. Naqueles com Resposta Clínica Incompleta (iRC) procedeu-se à cirurgia de ressecção. Aqueles com Resposta Completa (cRC) estão em observação (wait and see policy). Manometria e escalas de função esfincteriana e qualidade de vida foram obtidas antes e após 30 e 90 dias do término do tratamento. Resultados: Até junho de 2018, recrutaram-se 11 pacientes. Um foi excluído da análise, pois apresentou toxicidade severa sugestiva de deficiência de DPD após o primeiro ciclo de QT. Todos os demais concluíram o tratamento. Toxicidades graus 3/4 relacionadas à QT ocorreram dois pacientes, reduzindo-se sua dose. Sete (70%) apresentaram iRC, submetendo três à retossigmoidectomia cuja avaliação anatomopatológica evidenciou Resposta Completa (pRC) em dois casos (28,5%). Três (30%) apresentaram cRC e estão sem evidência de doença com seguimento médio de 19 meses. Houve melhora da função anorretal e da qualidade de vida. Conclusões: Avanços no tratamento neoadjuvante dos tumores de reto contribuíram para melhores taxas de pRC. Novos paradigmas promovem crescentes índices de cRC, o que possibilitaria a preservação do órgão e consequente redução da morbidade cirúrgica.

Oncologic Outcomes of Organ Preserving Approaches in Patients With Rectal Cancer Treated With Preoperative Chemoradiotherapy

PURPOSE: We evaluated the oncologic outcomes of organ-preserving strategies in patients with rectal cancer treated with preoperative chemoradiotherapy (PCRT). METHODS: Between January 2008 and January 2013, 74 patients who underwent wait-and-watch (WW) (n = 42) and local excision (LE) (n = 32) were enrolled. Organ-preserving strategies were determined based on a combination of magnetic resonance imaging, sigmoidoscopy, and physical examination 4–6 weeks after completion of PCRT. The rectum sparing rate, 5-year recurrence-free survival (RFS), and overall survival (OS) were evaluated. RESULTS: The rectum was more frequently spared in the LE (100% vs. 87.5%, P = 0.018) at last follow-up. Recurrence occurred in 9 (28.1%) WW and 7 (16.7%) LE (P = 0.169). In the WW, 7 patients had only luminal regrowth and 2 had combined lung metastasis. In the LE, 2 (4.8%) had local recurrence only, 4 patients had distant metastasis, and 1 patient had local and distant metastasis. Among 13 patients who indicated salvage surgery (WW, n = 7; LE, n = 11), all in the WW received but all of LE refused salvage surgery (P = 0.048). The 5-year OS and 5-year RFS in overall patients was 92.7% and 76.9%, respectively, and were not different between WW and LE (P = 0.725, P = 0.129). CONCLUSION: WW and LE were comparable in terms of 5-year OS and RFS. In the LE group, salvage treatment was performed much less among indicated patients. Therefore, methods to improve the oncologic outcomes of patients indicated for salvage treatment should be considered before local excision.

Application value of colonoscopic assessment in "watch and wait" strategy for mid-lower rectal cancer after neoadjuvant chemoradiotherapy / 中华胃肠外科杂志

Objective@#To investigate the value of colonoscopic assessment in "watch and wait" strategy for mid-lower rectal cancer after neoadjuvant chemoradiotherapy (nCRT).@*Methods@#A single-center retrospective case series study was performed. Database of mid-lower rectal cancer patients at Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute from March 2011 to June 2017 was retrieved. Inclusion criteria: (1) nCRT was completed (50.6 Gy/22 f, plus oral capecitabine); (2) radical surgery was performed within 12 weeks after nCRT treatment; (3) clinical response to nCRT was determined as clinical complete response (cCR) or near-cCR. Patients who did not undergo colonoscopy and MRI in our center during initial assessment and follow-up, or whose colonoscopy data were unable to re-evaluated, were excluded. Initial evaluation of nCRT response was carried out between 6 and 16 weeks after nCRT. The results of endoscopy (eCR, near-eCR and non-eCR) and MRI (mCR, near-mCR and non-mCR) were compared to local lesion relapse during follow-up. The consistency of the results of colonoscopy and MRI was evaluated by Kappa test (Kappa value of 0.21 to 0.40 indicates general consistency, 0.41 to 0.60 moderate consistency, and 0.61 to 0.80 high consistency). The non-regrowth disease-free survival (NR-DFS) curves of the eCR group and the near-eCR group were plotted by Kaplan-Meier method and compared by log-rank test. Clinical significance of colonoscopy examination in the following "watch and wait" strategy during follow-up period was analyzed.@*Results@#A total of 32 patients were enrolled in the study, including 21 (65.6%) males and 11 (34.4%) females with a median age of 57 years old. The differentiated type of rectal cancer included 1 (3.1%) case of well-differentiated, 26 (81.2%) of moderately differentiated and 5 (15.6%) of poorly differentiated. Clinical stage of the patients included 9 (28.1%) cases of T2-3N0 and 23 (71.9%) of T2-3N+. Median follow-up period was 48 (18 to 80) months. The local regrowth rate was 34.4% (11/32) and median interval of local regrowth was 10.0 (4 to 37) months. Initial colonoscopy evaluation was carried out at a median time of 9 (5 to 19) weeks after nCRT was completed. According to endoscopic findings, patients were divided into 3 groups, including 15 cases in eCR group, 15 cases in near-eCR group and 2 cases in non-eCR group. According to the appearance of MRI, patients were divided into 3 groups, including 8 cases in mCR group, 21 cases in near-mCR group and 3 cases in non-mCR group. The regrowth rate of eCR group was lower than that of mCR group (1/15 vs. 1/8) without significant difference (P=1.000). The regrowth rate of near-eCR group was higher than that of near-mCR group [9/15 vs. 42.9% (9/21)] without significant difference as well (P=0.500). The consistency between colonoscopy and MRI in response evaluation of cCR or near-cCR after nCRT was unsatisfactory (Kappa=0.341, P=0.011). After initial evaluation, 31 patients underwent watch and wait strategy, and 1 underwent local resection. The 1- and 3-year NR-DFS in the eCR group was both 100%, which was higher than that in the near-eCR group (53.3% and 38.9%, respectively), and the difference was statistically significant (P=0.001). During watch and wait period, 11 cases developed local regrowth by colonoscopy examination and the biopsy result included 4 case of high-grade intraepithelial neoplasia (HIN), 6 cases of adenocarcinoma and 1 case of chronic mucosal inflammation. Meanwhile lateral developmental tumor of ascending colon in 1 case and of sigmoid in a case was found by colonoscopy and confirmed as HIN by postoperative pathology. Besides, 4 cases developed colonic multiple adenoma and all underwent endoscopic resection.@*Conclusion@#Colonoscopy examination plays an important role in both initial assessment and regrowth monitoring during watch and wait strategy after nCRT treatment.

"Watch and wait" strategy after neoadjuvant therapy for rectal cancer: status survey of perceptions, attitudes and treatment selection in Chinese surgeons / 中华胃肠外科杂志

Objective@#To understand the perceptions, attitudes and treatment selection of Chinese surgeons on the "watch and wait" strategy for rectal cancer patients after achieving a clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT).@*Methods@#A cross-sectional survey was used in this study. Selection of subjects: (1) Domestic public grade III A (provincial and prefecture-level) oncology hospitals or general hospitals possessing the radiotherapy department and the diagnosis and treatment qualifications for colorectal cancer. (2) Surgeons of deputy chief physician or above. Using the "Questionnaire Star" online survey platform to create a questionnaire about cognition, attitude and treatment choice of the "watch and wait" strategy after cCR following nCRT for rectal cancer. The questionnaire contained 32 questions, such as the basic information of doctor, the current status of rectal cancer surgery, the management of pathological complete remission (ypCR) after nCRT for rectal cancer, the selection of examination items for diagnosis of cCR, the selection of suitable people undergoing "watch and wait" approach, the nCRT mode for promotion of cCR, the choice of evaluation time point, the willingness to perform "watch and wait" approach and the treatment choice, and the risk and monitoring of "watch and wait" approach. A total of 116 questionnaires were sent to the respondents via WeChat between January 31 and February 19, 2019. Statistical analysis was performed using Fisher′s exact test for categorical variables.@*Results@#Forty-eight hospitals including 116 surgeons meeting criteria were enrolled, of whom 77 surgeons filled the questionnaire with a response rate of 66.4%. "Watch and wait" strategy was carried out in 76.6% (59/77) of surgeons. Seventy surgeons (90.9%) were aware of the ypCR rate of rectal cancer after preoperative nCRT and 49 surgeons (63.6%) knew the 3-year disease-free survival of patients with ypCR in their own hospitals. Fifty-five surgeons (71.4%) believed that patients with ypCR undergoing radical surgery met the treatment criteria and were not over-treated. Three most necessary examinations in diagnosing cCR were colonoscopy (96.1%, 74/77), digital rectal examination (DRE) (90.9%,70/77) and DWI-MRI (83.1%, 64/77). Responders preferred to consider a "watch and wait" strategy for patients with baseline characteristics as mrN0 (77.9%, 60/77), mrT2 (68.8%, 53/77) and well-differentiated adenocarcinoma (68.8%, 53/77). Sixty-six surgeons (85.7%) believed that long-term chemoradiotherapy (LCRT) with combination or without combination of induction and/or consolidation of the CapeOX regimen (capecitabine + oxaliplatin) should be the first choice as a neoadjuvant therapy to achieve cCR. Forty-one surgeons (53.2%) believed that a reasonable interval of judging cCR after nCRT should be ≥ 8 weeks. Forty-four surgeons (57.1%) routinely, or in most cases, informed patient the possibility of cCR and proposed to "watch and wait" strategy in the initial diagnosis of patients with non-metastatic rectal cancer. Thirteen surgeons (16.9%) would take the "watch and wait" strategy as the first choice after the patient having cCR. Fifty-two surgeons (67.5%) would be affected by the surgical method, that was to say, "watch and wait" approach would only be recommended to those patients who would achieve cCR and could not preserve the anus or underwent difficult anus-preservation surgery. Sixteen surgeons (20.8%) demonstrated that "watch and wait" strategy would not be recommended to patients with cCR regardless of whether the surgical procedure involved anal sphincter. Eleven surgeons (14.3%) believed that the main risk of "watch and wait" approach came from distant metastasis rather than local recurrence or regrowth. Twenty-nine of surgeons (37.7%) did not understand the difference between "local recurrence" and "local regrowth" during the period of "watch and wait". Twenty-six surgeons (33.8%) thought that the monitoring interval for the first 3 years of "watch and wait" strategy was 3 months, and the follow-up monitoring interval could be 6 months to 5 years. Surgeons from cancer specialist hospitals had higher approval rate, notification rate, and referral rate of "watch and wait" strategy than those from general hospitals. Thirty-one surgeons (42.5%) considered that the difficulty and concern of carrying out "watch and wait" approach in the future was the disease progress leading to medical disputes. Twenty-six surgeons (35.6%) demonstrated that their concern was lack of uniform evaluation standard for cCR.@*Conclusions@#Chinese surgeons seem to have inadequate knowledge of non-operative management for rectal cancer patients achieving cCR after nCRT and show relatively conservative attitudes toward the strategy. Chinese consensus needs to be formed to guide the non-operative management in selected patients. Chinese Watch & Wait Database (CWWD) is also needed to establish and provide more evidence for the use of alternative procedure after a cCR following nCRT.

Current status and perspectives on "watch and wait" strategy for rectal cancer patients after clinical complete response following neoadjuvant chemoradiation / 中华胃肠外科杂志

Neoadjuvant chemoradiation has been accepted as a standard of care for local advanced middle to low rectal cancer. Patients with clinical complete response (cCR) or near cCR following neoadjuvant chemoradiation may benefit from watch and wait strategy or organ-preserving surgery with good short- and long-term outcome and quality of life (QOL). Yet the criteria of cCR varies and cCR is not consistent with pCR. Therefore, the obstacle to the strategy lies on whether its failure can be salvaged and the complexity of follow-up. Available studies demonstrated that local recurrence or regrowth can be salvaged by surgery without compromising the survival. So, the key is appropriate follow-up schedule and timely salvage. The strategy has not drawn much attention until recently, and relevant studies go slowly because of low data availability, patient awareness, and peer acceptance. We still believe that more and more patients might benefit from this strategy, along with the increasing attention of QOL from the patients. That may be obtained through screening of the right patients and optimizing treatment modality, evaluation methods, and protocol of follow-up.

Transition of treatment strategy for locally advanced rectal cancer towards "watch and wait" / 中华胃肠外科杂志

Therapeutic goal for locally advance rectal cancer (LARC) patients includes long-term survival and function preservation of pelvic organs. During the recent two decades, treatment strategy for LARC is gradually shifing to minimally invasive surgery, even avoiding a major surgery. "Watch and wait (W&W)" strategy is effective in dramatically decreasing surgical trauma and significantly improving preservation of defecation, urination and sexual function. Total neoadjuvant therapy (TNT) shifts all or part of adjuvant chemotherapy to the neoadjuvant phase and has showed obvious advantage in tumor shrinkage and complete clinical response (cCR) achievement. This article will summarize the transition of treatment strategy of LARC towards W&W from standard treatment. After more than ten years of development, both NCCN and ESMO guidelines recommend stratified neoadjuvant treatment considerations based on distinct risk classifications and especially suggest TNT for LARC patients with advanced diseases, which affirms the value of TNT in tumor shrinkage. Although accumulating data show that pelvic control and organ preservation using W&W strategy after cCR is equal or non-inferior to standard surgery, impact on long-term survival still needs prospective randomized controlled study; no consensus has been achieved for the detail of the W&W strategy. Thus W&W strategy is suggested to applied in hospitals specialized in the treatment of rectal cancer within the framework of multiple disciplinary treatment. In view of special medical conditions of our country, we still need to accumulate more experience and data of W&W strategy for rectal cancer patients with appeals for sphincter preservation and actively participate in international researches.

Rational evaluation of the complete response after neoadjuvant therapy in locally advanced mid-low rectal cancer: the pros and cons of "watch and wait" strategy / 中华胃肠外科杂志

Neoadjuvant chemoradiotherapy plus total mesorectal excision (TME) is the standard care for locally advanced middle-low rectal cancer. Some patients could benefit from neoadjuvant chemoradiotherapy to achieve clinical complete response (cCR). Therefore, in recent years, for patients with cCR after neoadjuvant therapy, the "watch and wait" strategy has been widely recommended by their doctors to let them enter "waiting period" without surgery, so that the quality of life is improved. However, the "watch and wait" strategy also has many practical problems that have not been resolved. Firstly, the diagnostic criteria for cCR and pathologic complete response (pCR) are not uniform and different significantly. Secondly, some cCR patients have found tumor regrowth and subsequently underwent salvage surgery during the "watch and wait" period. Thirdly, there is no clinical consensus on the adjuvant therapy for patients during the "watch and wait" period. Fourthly, the role of surgery in patients with cCR is controversial. Finally, we need to accumulate more clinical evidence to confirm whether the "watch and wait" strategy can be selected immediately after achieving cCR for rectal cancer. At the same time, we should find novel molecular markers that can predict the efficacy of chemoradiotherapy. Only rational choice of "watch and wait" strategy will allow more patients with rectal cancer to benefit from chemoradiotherapy.

Principle of surgical management for rectal cancer patients with complete clinical response after neoadjuvant therapy / 中华胃肠外科杂志

A proportion of patients with locally advanced rectal cancer will achieve clinical complete response (cCR) or pathologic complete response (pCR) after neoadjuvant chemoradiotherapy. With the proposal of the concept of total neoadjuvant therapy (TNT), higher complete response rates will be observed. The management of patients with cCR has long been an issue of controversy and is attractive for clinical trials. A "watch and wait" strategy for patients with cCR has been put forward by some scholars. A non-operative approach can preserve the organfunction and avoid complications after radical surgery. The safety and feasibility of a "watch and wait" strategy have been established in several non-randomized controlled studies. There is no consensus on how to make an optimal decision for patients with cCR. For example, it is only observed in partial patients that cCR is consistent with pCR and the molecular biomarkers for predicting pCR are suboptimal. Besides, cCR is inconsistently defined and surveillance recommendations varies. Furthermore, there are insufficient high-level evidence for the "watch and wait" strategy. For patients with good response after chemoradiotherapy, local excision is an attractive alternative to total mesorectal excision, however with uncertain indications and challenged oncological safety. For patients with cCR, we implement the therapeutic principles of goal-orientation, layered treatment and the whole process management.

Several issues worthy of attention in clinical research of low rectal cancer / 中国实用外科杂志

Total mesorectal excision(TME) regulates the extent of resection of low rectal cancer surgery and is the gold standard for low rectal cancer. Colorectal surgeons need to comprehensively consider the comprehensive treatment strategy for rectal cancer to reduce the risk of local recurrence,how to protect patients' anal,sexual and urinary function,and improve their quality of life,and consider how to reduce surgical trauma. At present,the research hotspots in the fieldof rectal cancer diagnosis and treatment turn to how to betterprotect the function and further reduce the risk of localrecurrence. Among them,the "watch and wait" strategy of "clinical complete response" after neoadjuvant chemoradiotherapy,the lateral lymph node dissection and the procedure of transanal total mesorectal excision,is a hot issue in clinical research.

Manejo no operatorio del cáncer de recto con respuesta clínica completa luego de quimiorradioterapia neoadyuvante: experiencia en 8 casos / Non-operative management of rectal cancer with complete clinical response after neoadjuvant chemoradiotherapy: experience in 8 cases

Introducción: Se diagnostican hasta 13000 nuevos casos de cáncer colorrectal por año, y esto va en aumento. El cáncer de recto debe ser tratado mediante un abordaje multimodal. Luego de la implementación del tratamiento neoadyuvante y de la aparición de la respuesta patológica completa se implementó el manejo no operatorio. Nuestro objetivo es describir nuestra experiencia con el manejo inicial no operatorio de pacientes con cáncer de recto, que recibieron neoadyuvancia y desarrollaron una respuesta clínica completa inicial. Diseño: Estudio observacional, descriptivo, retrospectivo. Pacientes y Métodos: 49 pacientes con diagnóstico de cáncer de recto bajo (< 8 cm), recibieron tratamiento neoadyuvante con radioquimioterapia (RQT). Se realizó radioterapia (RT), a una dosis de 5040 cGy por un total de 5 semanas, y concomitante a esta, quimioterapia (QT) con 5-Fu-leucovorina en las semanas 1 y 5. Aquellos pacientes en los cuales se encontró cCR inicial a la neoadyuvancia, y la cirugía resectiva implicaba alto riesgo quirúrgico debido a sus comorbilidades y/o imposibilidad de la conservación de esfínteres se planteó la posibilidad de tomar una conducta no operatoria. Resultados: Se incluyeron 8 pacientes con cCR. El promedio de edad de los pacientes fue de 70 años (mediana 69,5 años), el promedio de altura del tumor fue de 5,8 cm; todos en estadio IIa. La mediana de seguimiento fue de 72,5 meses. 3 pacientes presentaron recaídas, todas endoluminales, 2 fueron tempranas (9 y 12 meses) y una tardía (18 meses), los cuales fueron operados, 2 de ellos se encuentran actualmente libres de enfermedad y el tercero óbito a los 30 días POP. La sobrevida global de los pacientes fue de un 87,5% y se evitó una cirugía mayor en 5 pacientes (62,5%). Conclusión: La implementación del tratamiento inicial no operatorio del cáncer de recto en aquellos pacientes que desarrollaron cCR luego del tratamiento neoadyuvante puede ser seguro, siempre y cuando estos pacientes estén incluidos en un programa de seguimiento estricto que permita una cirugía de rescate. El tratamiento conservador sin cirugía debe ser reservado para pacientes de alto riesgo quirúrgico o en los que la cirugía implique la necesidad de una cirugía de amputación abdominoperineal. (AU)

Introduction: 13000 new cases of colorectal cases are diagnosed per year. Rectal cancer must be treated with a multimodal approach. After the administration of neoadjuvant treatment and the appearance of a pathologic complete response, nonoperative management was implemented. Our objective is to describe our experience with nonoperative management of patients with rectal cancer that received neoadjuvant therapy and developed an initial complete clinical response. Design: Retrospective descriptive observational study. Patients and Methods: Forty-nine patients with low rectal cancer (< 8 cm) received neoadjuvant radiochemotherapy. Radiotherapy was performed with a total dose of 5040 cGy for 5 weeks, and concomitant 5-FU-leucovorin-based chemotherapy in weeks 1 and 5. Nonoperative management was attempted on patients experiencing initial cCR to neoadjuvant therapy and with a higher surgical risk due to their comorbidity and/or impossibility of conserving the sphincters. Results: Eight patients with cCR were included. The average age of the patients was 70 years; the average height of the tumor was 5.8 cm; all of them at stage IIA. Median follow-up was 72.5 months. Two patients developed an early endoluminal recurrence (after 9 and 12 months) and one had a late recurrence (18 months). All of them had surgery. Two of them are disease-free and one died 30 days after surgery. Conclusion: Implementation of initial nonoperative treatment of rectal cancer in patients that developed cCR after neoadjuvant therapy can be safe, provided that those patients are included in a strict monitoring programme that would allow for a rescue surgery. Conservative treatment without surgery must be reserved for patients with a higher surgical risk or who require an abdominoperineal resection. (AU)

Multidisciplinary decision on a rectal cancer patient with multiple synchronous pulmo-nary metastasis / 中国肿瘤临床

Lungs are the second most common distant metastatic organs of colorectal cancer, following the liver. However, clinical re-searches on lung metastasis are insufficient comparing with that on liver metastasis due to its low occurrence and relatively mild bio-logical behavior. This paper aims to investigate the clinicopathological characteristics and prognostic factors of rectal cancer patients with multiple synchronous lung metastases. The patient was from the Second Affiliated Hospital of Zhejiang University, School of Medi-cine underwent multi-disciplinary diagnosis and treatment. Moreover, this article aims to discuss the related existing consensus and controversies on this issue.

Diagnosis and treatment strategy for clinical complete responders after chemoradiotherapy for rectal cancer: is watch-and-wait policy safe? / 中华外科杂志

Neo-adjuvant chemoradiotherapy (NACRT) combined with total mesorectal excision (TME) surgery is the main treatment for locally advanced middle-low rectal cancer, and NACRT significantly improves the local control rate of rectal cancer. According to the current guidelines, patients who receive clinical complete response (cCR) after NACRT are recommended for treatment with TME surgery. A few studies have shown that the watch-and-wait (WAW) policy is safe and could ensure anorectal function and quality of life in patients with cCR. In addition, such patients must be closely observed and followed up so as to enable salvage surgery for long periods of tumor re-growth. However, there is not enough evidence to provide a clear answer to the oncological effect of the WAW policy. As a result, WAW policy is not widely available in clinical practice, and further prospective studies are needed to assess its risk and benefit for the patients.

Functional outcome and quality of life following treatment for rectal cancer / Resultados funcionais e qualidade de vida após tratamento do câncer retal

Introduction: Over the last decades, treatment for rectal cancer has substantially improved with development of new surgical options and treatment modalities. With the improvement of survival, functional outcome and quality of life are getting more attention. Study objective: To provide an overview of current modalities in rectal cancer treatment, with particular emphasis on functional outcomes and quality of life. Results: Functional outcomes after rectal cancer treatment are influenced by patient and tumor characteristics, surgical technique, the use of preoperative radiotherapy and the method and level of anastomosis. Sphincter preserving surgery for low rectal cancer often results in poor functional outcomes that impair quality of life, referred to as low anterior resection syndrome. Abdominoperineal resection imposes the need for a permanent stoma but avoids the risk of this syndrome. Contrary to general belief, long-term quality of life in patients with a permanent stoma is similar to those after sphincter preserving surgery for low rectal cancer. Conclusion: All patients should be informed about the risks of treatment modalities. Decision on rectal cancer treatment should be individualized since not all patients may benefit from a sphincter preserving surgery "at any price". Non-resection treatment should be the future focus to avoid the need of a permanent stoma and bowel dysfunction.

Introdução: Ao longo das últimas décadas, o tratamento do câncer retal melhorou substancialmente com o desenvolvimento de novas opções terapêuticas. Com a melhoria da sobrevida, os resultados funcionais e a qualidade de vida são cada vez mais tidos em consideração. Objetivos do estudo: Rever as modalidades atuais de tratamento do câncer retal, com enfase nos resultados funcionais e qualidade de vida. Resultados: Os resultados funcionais após tratamento para o câncer retal é influenciado pelas características do doente, do tumor, da técnica cirúrgica, do uso de radioterapia pré-cirúrgica e do método e nível da anastomose. A cirurgia poupadora de esfíncter do câncer retal baixo resulta frequentemente em maus resultados funcionais que prejudicam a qualidade de vida, denominados síndrome da ressecção anterior baixa. A amputação abdominoperitoneal impõe a necessidade de uma colostomia definitiva mas evita os riscos de resultados funcionais deficitários. Contrariamente à crença geral, a qualidade de vida a longo-prazo em doentes com colostomia definitiva é semelhante à qualidade de vida após cirurgia poupadora de esfíncter do câncer retal baixo. Conclusão: Todos os doentes devem ser informados sobre o risco das opções terapêuticas. A decisão do tratamento do câncer retal deve ser individualizada uma vez que nem todos os doentes beneficiarão de uma cirurgia poupadora de esfíncter "a qualquer preço". A possibilidade de tratamento sem ressecção devem ser o foco futuro para evitar a necessidade de uma colostomia definitiva e disfunção gastrointestinal.