A 62-year-old man has a T3N1M0 rectal adenocarcinoma at 6 cm from the anal verge. MRI shows threatened CRM. Which is the current standard neoadjuvant strategy before TME?

• A Short-course radiotherapy (5×5 Gy) with immediate surgery
• B Long-course chemoradiotherapy (50.4 Gy + 5-FU/capecitabine) followed by surgery 6–8 weeks later
• C FOLFOX chemotherapy alone for 4 cycles, then surgery
• D Total neoadjuvant therapy: FOLFOX then long-course CRT, then surgery ✓

Explanation

For high-risk locally advanced rectal cancer (threatened CRM, T4, N2, EMVI), the RAPIDO and PRODIGE 23 trials established total neoadjuvant therapy (TNT) as superior to standard long-course CRT alone. TNT delivers full systemic chemotherapy (FOLFOX or CAPOX) in addition to radiation pre-operatively, achieving higher pathological complete response rates and reducing distant metastases. Long-course CRT alone is appropriate for lower-risk T3N1; short-course RT with immediate surgery is for technically resectable disease where CRM is not threatened. Chemotherapy alone does not address local disease sufficiently.

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.