A 60-year-old man with rectal carcinoma at 8 cm from the anal verge undergoes staging MRI pelvis. The tumor is mrT3 N2 M0 with threatened circumferential resection margin (CRM). According to current ESMO/NCCN guidelines, what is the optimal neoadjuvant treatment?
- A Short-course radiotherapy (5 × 5 Gy) followed by immediate TME
- B Long-course chemoradiation (45–50.4 Gy + concurrent capecitabine) followed by TME at 8–12 weeks
- C Total neoadjuvant therapy: FOLFOX induction → long-course chemoradiation → TME ✓
- D Upfront TME without neoadjuvant therapy
Explanation
For locally advanced rectal cancer with threatened CRM or high-risk features (mrT4, N2), total neoadjuvant therapy (TNT) — comprising induction chemotherapy (FOLFOX or CAPOX) followed by long-course chemoradiation, then surgery — is the current preferred strategy based on RAPIDO and PRODIGE-23 trials, which showed improved pCR rates and distant metastasis-free survival compared to standard chemoradiation alone. Simple short-course RT followed by immediate TME is appropriate for resectable non-threatened-CRM tumors. TNT also increases the probability of organ preservation (watch-and-wait) in complete responders.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.