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Patterns of Local Failure and Survival for Non-operative Treatment of Stage c0 Distal Rectal Cancer Following Neoadjuvant Chemoradiation Therapy
Angelita Habr-Gama1, Rodrigo O. Perez1, Afonso H. Sousa1, Fabio G. Campos1, Igor E. Proscurshim1, Wladimir Nadalin2, Desiderio R. Kiss1, Joaquim Gama-Rodrigues1; 1Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil; 2Radiology, Univeristy of Sao Paulo School of Medicine, Sao Paulo, Brazil

Background: Neoadjuvant chemoradiation therapy (CRT) is considered the preferred treatment option for distal rectal cancer. Complete pathological response after CRT has led to the proposal for the non-operative as an alternative treatment for highly selected patients with complete clinical response. However, the risk of tumor recurrence and local failure following this strategy remains undetermined. Patients and Methods: 361 patients with distal rectal cancer were managed by neoadjuvant CRT including 5FU, Leucovorin and 5040 cGy. Tumor response assessment was performed at 8 weeks following CRT. Patients with complete clinical response were not immediately operated on and were closely followed. Patients with sustained complete clinical response at 12 months of follow-up were considered clinical stage 0. Patients with incomplete clinical response detected before 12 months of follow-up were managed by immediate radical surgery. Results: 99 patients were considered stage c0 (27.4%) and were managed by non-operative close follow-up. 262 patients (72.6%) were considered to have incomplete clinical response and were managed by radical surgery. Mean follow-up interval for patients with stage c0 was 60 months (12-172). Overall, there were 12 recurrences (12.1%) being 5 exclusively endorectal recurrences (5.1%), 6 systemic recurrences (6%) and 1 combined endorectal and systemic recurrence (1%). All 5 isolated endorectal recurrences were amenable to salvage treatment. There were 5 deaths associated with disease progression. Overall and Disease Free 5-year cancer-related survival was 94% and 86%. Conclusions: Non-operative treatment for sustained complete clinical response following neoadjuvant CRT is safe and associated with high overall and disease-free survival rates. Moreover, local failure is associated with high rates of possibility of salvage therapy and local disease control.

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