A 60-year-old man undergoes laparoscopic anterior resection for rectal carcinoma 8 cm from the anal verge. Pre-operative staging MRI shows the tumour involving the mesorectal fascia (CRM <1 mm). The most appropriate neoadjuvant strategy according to current guidelines is:

• A Short-course radiotherapy (SCRT) 5 × 5 Gy followed by immediate surgery
• B FOLFIRINOX-based induction chemotherapy alone without radiotherapy
• C Surgery first followed by adjuvant LCRT
• D Long-course chemoradiotherapy (LCRT) with capecitabine or 5-FU followed by total mesorectal excision (TME) ✓

Explanation

For locally advanced rectal cancer with a threatened or involved circumferential resection margin (CRM ≤1 mm on MRI), long-course concurrent chemoradiotherapy (LCRT; 45–50.4 Gy over 5 weeks with radiosensitising 5-FU or capecitabine) is the standard neoadjuvant treatment prior to TME. This allows tumour downstaging and down-sizing, potentially converting an R1 resection to R0. Short-course RT (SCRT, 5 × 5 Gy) is appropriate for resectable rectal cancer without CRM involvement. Total neoadjuvant therapy (TNT) incorporating SCRT + FOLFIRINOX is emerging but not yet universally standard.

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

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