Salvage surgery for local regrowths in Watch & Wait - Are we harming our patients by deferring the surgery?

BACKGROUND: Rectal cancer surgery conveys significant morbidity/mortality, long-term functional impairment and urinary & sexual dysfunction, especially if associated with neoadjuvant chemoradiotherapy (ChRT). Watch & Wait (W&W) is gaining momentum as an option for patients with clinical complete response (cCR) after ChRT. Approximately 30% will develop a local regrowth (RG) and need deferred surgery. Our study aimed to assess the short-term clinical outcomes after surgery for regrowths. PATIENTS AND METHODS: Consecutive rectal cancer patients from a tertiary institution who underwent neoadjuvant ChRT, between January 2013 and October 2018, were identified from a prospectively maintained database. Patients with RG under W&W surveillance were operated - regrowth deferred surgery (RDS) group - and compared to those with persistent disease after ChRT who did undergo surgery - non-deferred surgery (NDS) group. RESULTS: Total of 124 patients received neoadjuvant treatment: 46 (37%) underwent surgery for persistent disease; 78 (63%) with cCR entered W&W. Twenty three developed RG and underwent surgery, while 55 remain under surveillance. RDS group had lower tumors than NDS group (2.3 cm ±â€¯2 vs 4.5 cm ±â€¯3, p = 0.002). All RG underwent minimally invasive surgery (MIS). Anastomotic leaks, 30-day morbidity, reintervention and readmission rates were similar. Pathology features and 3-year oncological outcomes were identical between groups. CONCLUSION: Patients with initial cCR and local regrowth may be safely managed by deferred surgery. Short-term outcomes suggest equivalent results to patients with incomplete clinical response and immediate radical surgery. Delayed MIS appears to have no negative impact on oncological outcomes.

Delaying surgery after neoadjuvant chemoradiotherapy in rectal cancer has no influence in surgical approach or short-term clinical outcomes.

AIMS: In rectal cancer, increasing the interval between the end of neoadjuvant chemoradiotherapy (CRT) and surgery could improve the pathological complete response (pCR) rates, allow full-dose neoadjuvant chemotherapy, and select patients with a clinical complete response (cCR) for inclusion in a "watch & wait" program (W&W). However, controversy arises from waiting more than 8-12 weeks after CRT, as it might increase fibrosis around the total mesorectal excision (TME) plane potentially leading to technical difficulties and higher surgical morbidity. This study evaluates the type of surgical approach and short term post-operative outcomes in patients with rectal cancer that were operated before and after 12 weeks post CRT. METHODS: Patients from three centres (two in the UK, one in Portugal) who received rectal cancer surgery following neoadjuvant CRT between 2007 and 2016 were identified from prospectively maintained databases. Preoperative CRT was given to patients with high risk for local recurrence (threatened CRM ≤2 mm or T4 in staging MRI). The baseline characteristics and surgical outcomes of patients that were operated <12 weeks and ≥12 weeks after finishing CRT were analysed. RESULTS: A total of 470 patients received rectal cancer surgery, of those 124 (26%) received neoadjuvant CRT. Seventy-six patients (61%) were operated ≥12 weeks after end of neoadjuvant-CRT and 48 < 12 weeks. Patients in the ≥12 weeks cohort had a higher BMI (27 vs 25, p = 0.030) and lower lymph node yield (11 vs 14, p = 0.001). The remaining of the baseline characteristics were similar between the two groups (age, operating surgeon, gender, ASA grade, T stage, surgical approach, operation). Operation time, blood loss, conversion rate, length of stay, 30-day readmission rate, 30-day reoperation rate, anastomotic leak rate, 30-day mortality, CRM clearance, and ypT0 rates were similar between the two groups. Univariate and multivariate analysis showed that delaying surgery ≥12 weeks did not affect morbidity and mortality. CONCLUSION: In our cohort, there was no difference in short term surgical outcomes between patients operated before or after 12 weeks following CRT. The type of surgical procedures and the proposed approach did not differ due to waiting after CRT. Delaying surgery by ≥ 12 weeks is safe, feasible and does not result in higher surgical morbidity.