Top Line: Modern treatment for locally-advanced rectal cancer can be individualized based on disease characteristics and patient goals.
The Guidelines: Here we have relatively concise ASTRO guidelines on the current indications for radiation for rectal cancer. To put things simply, neoadjuvant radiation in sequence with neoadjuvant chemotherapy (typically 3-4 months of FOLFOX or CAPOX) was strongly recommended for all patients with stage II-III disease. Regarding radiation, long-course radiation concurrent with 5FU or capecitabine is the default radiation with boosts beyond 50 Gy reserved for patients who hope to avoid surgery. Conditionally, radiation can be omitted for lower risk (read: cT2-3 tumor >5 cm from anal verge and ≥0.2 cm from mesorectal fascia with no extramural vascular invasion and no more than three enlarged nodes) that achieves at least 20% reduction with neoadjuvant chemotherapy. When the goal of non-operative management is opted for by a patient motivated to undergo intensive surveillance, neoadjuvant chemoradiation should precede neoadjuvant chemo for cT3-4 or cN+. Alternatively, for patients with low-lying cT2-3N0 disease <4 cm, neoadjuvant chemoradiation followed by local excision approach is an option for patients motivated to avoid a total mesorectal excision that would threaten the sphincter. Patients considering surgery omission should understand upfront that post-treatment surveillance includes “proctoscopy/sigmoidoscopy with digital rectal exam every 3-4 months for the first 2 years then every 6-12 months for 5 years AND pelvic MRI with rectal protocol every 3-6 months for the first 2 years then every 6-12 months AND CT of the chest, abdomen, and pelvis every 6-12 months for the first 2 years then every 12 months.” Finally, IMRT/VMAT with daily image guidance is the preferred radiation approach per expert opinion.
TBL: Notwithstanding quite a bit a nuance, a plethora of modern data support neoadjuvant long-course chemoradiation in sequence with neoadjuvant chemotherapy as the default standard for stage II-III rectal cancer. | Wo, Pract Radiat Oncol 2024
The Guidelines: Here we have relatively concise ASTRO guidelines on the current indications for radiation for rectal cancer. To put things simply, neoadjuvant radiation in sequence with neoadjuvant chemotherapy (typically 3-4 months of FOLFOX or CAPOX) was strongly recommended for all patients with stage II-III disease. Regarding radiation, long-course radiation concurrent with 5FU or capecitabine is the default radiation with boosts beyond 50 Gy reserved for patients who hope to avoid surgery. Conditionally, radiation can be omitted for lower risk (read: cT2-3 tumor >5 cm from anal verge and ≥0.2 cm from mesorectal fascia with no extramural vascular invasion and no more than three enlarged nodes) that achieves at least 20% reduction with neoadjuvant chemotherapy. When the goal of non-operative management is opted for by a patient motivated to undergo intensive surveillance, neoadjuvant chemoradiation should precede neoadjuvant chemo for cT3-4 or cN+. Alternatively, for patients with low-lying cT2-3N0 disease <4 cm, neoadjuvant chemoradiation followed by local excision approach is an option for patients motivated to avoid a total mesorectal excision that would threaten the sphincter. Patients considering surgery omission should understand upfront that post-treatment surveillance includes “proctoscopy/sigmoidoscopy with digital rectal exam every 3-4 months for the first 2 years then every 6-12 months for 5 years AND pelvic MRI with rectal protocol every 3-6 months for the first 2 years then every 6-12 months AND CT of the chest, abdomen, and pelvis every 6-12 months for the first 2 years then every 12 months.” Finally, IMRT/VMAT with daily image guidance is the preferred radiation approach per expert opinion.
TBL: Notwithstanding quite a bit a nuance, a plethora of modern data support neoadjuvant long-course chemoradiation in sequence with neoadjuvant chemotherapy as the default standard for stage II-III rectal cancer. | Wo, Pract Radiat Oncol 2024