A 65-year-old man with rectal adenocarcinoma 5 cm from the anal verge undergoes pre-treatment MRI. MRI shows the tumor invades through the muscularis propria but is 4 mm from the mesorectal fascia (circumferential resection margin). What is the most appropriate neoadjuvant strategy per current ESMO guidelines?
- A Long-course chemoradiotherapy (50.4 Gy with capecitabine) followed by total mesorectal excision after 8–12 weeks ✓
- B Short-course radiation (5×5 Gy) followed by immediate surgery
- C Surgery first with adjuvant FOLFOX chemotherapy
- D Total neoadjuvant therapy (TNT): FOLFOX followed by short-course radiation then surgery
Explanation
For locally advanced rectal cancer (cT3/T4 or N+) with threatened circumferential resection margin (<1 mm), current ESMO guidelines recommend long-course chemoradiotherapy (45–50.4 Gy with concurrent fluoropyrimidine) followed by TME after 8–12 weeks to allow tumor downsizing. A CRM of 4 mm is considered 'involved' (< 1 mm per some protocols or 'threatened' at 1–5 mm depending on protocol), requiring neoadjuvant treatment. Short-course 5×5 Gy is appropriate for resectable T3 tumors without threatened CRM; TNT is emerging but not yet standard for all threatened-CRM cases.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.