A 60-year-old patient with a T3N1M0 rectal carcinoma located 6 cm from the anal verge is planned for curative resection. MRI shows threatened circumferential resection margin (CRM ≤ 1 mm). According to current guidelines (ESMO/NCCN), what is the optimal pre-operative treatment?

• A Short-course radiotherapy (5 × 5 Gy) followed by immediate surgery
• B Total neoadjuvant therapy (TNT): FOLFOX then long-course CRT then surgery ✓
• C Long-course chemoradiotherapy (45–54 Gy + concurrent 5-FU) followed by surgery at 8–12 weeks
• D Surgery first followed by adjuvant FOLFOX 6 cycles

Explanation

In locally advanced rectal cancer with threatened CRM (≤ 1 mm on MRI), total neoadjuvant therapy (TNT) is increasingly the preferred approach per current guidelines (RAPIDO and PRODIGE 23 trials). TNT involves full-dose chemotherapy (FOLFOX or CAPOX) combined with radiotherapy (either short-course RT followed by chemotherapy, or long-course CRT followed by chemotherapy) before surgery. TNT improves pCR rates, distant metastasis-free survival, and allows assessment of organ preservation. For threatened CRM, down-staging before surgery is critical, and TNT achieves higher pCR compared to standard long-course CRT alone.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.