A 55-year-old man with a 3 cm rectal carcinoma 6 cm from the anal verge has a staging MRI showing mrT3b (5 mm beyond muscularis propria), mrN1, mrMRF-negative. Per European guidelines (ESMO 2023), the preferred initial treatment is:
- A Long-course chemoradiotherapy (45–50.4 Gy with concurrent capecitabine) followed by TME at 8–12 weeks ✓
- B Upfront total mesorectal excision without neoadjuvant therapy
- C Short-course preoperative radiotherapy (5 × 5 Gy) followed immediately by TME within 1 week
- D Total neoadjuvant therapy with induction FOLFOX followed by chemoradiotherapy then TME
Correct answer: A. Long-course chemoradiotherapy (45–50.4 Gy with concurrent capecitabine) followed by TME at 8–12 weeks
Explanation
For MRI-defined locally advanced rectal cancer (mrT3b with ≥5 mm extramural invasion, or N1 disease) with the tumour below the peritoneal reflection, European guidelines (ESMO/ESSO) recommend long-course chemoradiotherapy as the standard neoadjuvant strategy to downstage before TME. Short-course RT is appropriate for good-risk T3a/b N0 tumours, especially when interval surgery is planned. Total neoadjuvant therapy is increasingly favoured for high-risk features (mrMRF+, N2, EMVI+) but is not standard for this intermediate-risk case.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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