A 62-year-old man with a cT3N1M0 mid-rectal adenocarcinoma (5 cm from anal verge, circumferential resection margin threatened on MRI) receives long-course chemoradiotherapy. He achieves clinical complete response at 12 weeks post-CRT reassessment. Which management strategy is supported by current evidence (based on the OPRA trial)?
- A Immediate total mesorectal excision regardless of clinical response
- B Local excision (TEMS/TAMIS) is the only acceptable organ-preserving option
- C Watch-and-wait (organ preservation) with intensive surveillance protocol ✓
- D Restaging MRI must show pCR before watch-and-wait can be offered
Explanation
The OPRA trial (Organ Preservation of Rectal Adenocarcinoma) demonstrated that in patients achieving clinical complete response (cCR) after total neoadjuvant therapy, a watch-and-wait strategy achieves 3-year organ preservation rates of approximately 58–63% without compromise of overall survival compared to TME. The study established that roughly 25% of patients who regrow can still be salvaged by surgery. Clinical cCR is defined by MRI, digital rectal examination, and endoscopy; pathological confirmation is not required for entry into watch-and-wait. Local excision alone is not standard for T3 disease post-CRT.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
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