A 60-year-old man presents with a T3N1M0 rectal tumour at 5 cm from the anal verge on MRI. The MRI also shows threatened circumferential resection margin (CRM). According to the MERCURY study and ESMO guidelines, the preferred primary management is:
- A Immediate surgery (TME) followed by adjuvant chemotherapy
- B Long-course chemoradiotherapy (45–50 Gy with concurrent capecitabine or 5-FU) followed by TME after 8–12 weeks ✓
- C Short-course preoperative radiotherapy (SCPRT) 5 × 5 Gy followed by immediate surgery
- D Palliative diversion colostomy with chemotherapy for unresectable disease
Correct answer: B. Long-course chemoradiotherapy (45–50 Gy with concurrent capecitabine or 5-FU) followed by TME after 8–12 weeks
Explanation
For locally advanced rectal cancer with threatened or involved CRM (within 1 mm on MRI), standard management per ESMO/NICE guidelines is neoadjuvant long-course chemoradiotherapy (45–50.4 Gy in 25–28 fractions with concurrent fluoropyrimidine). This downstages the tumour, converts involved CRM to clear, and reduces local recurrence. Surgery (TME) is performed 8–12 weeks after completion. The MERCURY study validated MRI-based CRM assessment as the key predictor of surgical margin status and oncological outcomes.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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