Nonoperative Management of Distal Rectal Cancer After Chemoradiation: Experience with the “Watch & Wait” Protocol

Surgical treatment alone for locally advanced rectal cancer (T3/T4 or N1 tumors) has been associated with considerably high local recurrence rates. Even with appropriate total mesorectal excision (TME), radical surgery leads to excellent local disease control only in highly selected cases.(Simunovic et al. 2003) In this setting, the need for additional or complementary treatment strategies was highly warranted. In the late 80’s and early 90’s it was observed that the addition of adjuvant radiotherapy with or without chemotherapy significantly improved disease control as well as survival rates in this group of patients.(Krook et al. 1991) Later on, results from randomized controlled trials suggested that the neoadjuvant approach was superior for local disease control, even when appropriate surgical technique (total mesorectal excision) was performed when compared to adjuvant treatment. (Sauer et al. 2004) Apart from the theoretical advantage of exposing unscarred tissue with optimal oxygen delivery to chemoradiation (CRT), further benefits including reduced toxicity rates, significant tumor downstaging and downsizing, greater rates of sphincter preservation, and better functional results have been reported after neoadjuvant CRT. (Habr-Gama et al. 2004; Sauer et al. 2004) Tumor downstaging in some patients may be so significant, that no residual cancer was detected during final pathological assessment. Still, radical surgery was associated with considerably immediate postoperative mortality and morbidity rates. In addition to usual postoperative complications, total mesorectal excision may lead to significant sexual and urinary dysfunctions. Also, even when abdominal perineal excision (and a permanent stoma) could be avoided, temporary loop ileostomies are mandatory in order to avoid potential septic consequences of anastomotic leaks in these patients. (Peter Matthiessen et al. 2007)