Practice patterns for complex situations in the management of rectal cancer: A multidisciplinary inter-group national survey

Management after local excision of small rectal cancers. Indications for completion total mesorectal excision and possible alternatives

The treatment of superficial rectal cancers (local excision, or proctectomy with total mesorectal excision (TME) remains controversial. Endoscopy and endorectal ultrasonography are essential for the precise initial definition of these small cancers. During endoscopy, the depth of the lesion can be estimated using virtual chromoendoscopy with magnification, thereby aiding the assessment of the possibilities of local excision. Current international recommendations indicate completion proctectomy after wide local excision for cases where the pathologic examination reveals poorly-differentiated lesions, lymphovascular invasion, grade 2 or 3 tumor budding, and incomplete resection. But debate persists regarding whether the depth of submucosal invasion can accurately predict the risk of lymph node spread. Recent data from the literature suggest that the depth of submucosal invasion should no longer, by itself, be an indication for additional oncological surgery. Adjuvant radio-chemotherapy could be an alternative to completion proctectomy in patients with pT1 rectal cancer and unfavorable histopathological criteria. A Dutch randomized controlled trial is underway to validate this strategy.

Three perspectives: the approach to neoadjuvant treatment of rectal cancer according to medical oncologists, radiation oncologists, and surgeons

Background: Two treatment options considered for radiotherapy are short-course radiotherapy and immediate surgery, or chemoradiation with 5-Fluorouracil based chemotherapy and delayed surgery. Aim of the study: Evaluate the real-life treatment approaches of medical, radiation, and surgical oncologists, to neoadjuvant treatment of rectal cancers. Material and methods: An online survey was established via Google Forms. The survey was taken voluntarily by medical oncologists, radiation oncologists, surgical oncologists, and general surgeons. Results: Of those who participated, 183 were medical oncologists, 36 were radiotherapists, and 36 were surgeons. Most of the study population preferred long-course radiation therapy and chemotherapy (85%). Meanwhile, two-thirds of the participants preferred chemotherapy prior to operating. The most frequent chemotherapy cycles for the pre-operative setting were ‘three’ and ‘four-or-more’ (27.8% and 25.1%, respectively). Medical oncologists had a significantly higher tendency to offer chemotherapy between radiation therapy and surgery compared to the other groups. Optimal time of surgery was different between groups, but there was no difference among groups between surgery and the ‘watch & wait’ strategy. Neoadjuvant chemotherapy regimens were significantly different between groups. Conclusions: We found that the new pre-operative chemotherapy regimen with short-course radiotherapy was slowly adopted into current practice. Also, medical oncologists tended to prefer pre-operative chemotherapy in comparison to the other groups.

What is the Best Therapeutic Strategy for Metachronous Resectable Colorectal Liver Metastases After Adjuvant Oxaliplatin-Based Chemotherapy? A Multidisciplinary Inter-Group Survey

BACKGROUND

To report the current clinical practice of French physicians for metachronous resectable liver metastasis (LM) occurring after a FOLFOX adjuvant chemotherapy for primary cancer.

METHODS

Twenty four clinical situations were proposed to a panel of experts via 4 learned societies. Clinical situations varied according time of recurrence (early between 6 and 12 month or > 12 month), extension of LM (limited ≤ 2 or extended > 2 lesions), presence of a neuropathy or not, and of a RAS or BRAF mutation.

RESULTS

A total of 157 physicians participated in this study. A consensus was reached in 17 (71%) clinical situations. For an early limited recurrence, whatever presence of neuropathy, the preferred therapeutic approach (45%) was upfront surgery. For an early extended recurrence, whatever presence of neuropathy, there was a consensus (64%) for a preoperative chemotherapy by FOLFIRI + biologic agent. For a late recurrence without neuropathy, there was a consensus (50%) for a preoperative FOLFOX chemotherapy, whatever the extension of LM. For a late recurrence with neuropathy, upfront surgery was chosen (52%) for limited LM, and preoperative chemotherapy by FOLFIRI + biologic agent (73%) for extended LM. No response was influenced by the RAS mutation status. There was a strong consensus for intensified preoperative chemotherapy in all clinical situations for BRAF-mutated LM.

CONCLUSIONS

This national survey provides an overview of the practice patterns in the treatment of LM occurring after adjuvant FOLFOX for primary. It could be a basis to establish expert's recommendations for the clinical practice.