Published online Aug 28, 2014. doi: 10.3748/wjg.v20.i32.11249
Revised: May 8, 2014
Accepted: May 25, 2014
Published online: August 28, 2014
In the present review we discuss the recent developments and future directions in the multimodal treatment of locally advanced rectal cancer, with respect to staging and re-staging modalities, to the current role of neoadjuvant chemo-radiation and to the conservative and more limited surgical approaches based on tumour response after neoadjuvant combined therapy. When initial tumor staging is considered a high accuracy has been reported for T pre-treatment staging, while preoperative lymph node mapping is still suboptimal. With respect to tumour re-staging, all the current available modalities still present a limited accuracy, in particular in defining a complete response. The role of short vs long-course radiotherapy regimens as well as the optimal time of surgery are still unclear and under investigation by means of ongoing randomized trials. Observational management or local excision following tumour complete response are promising alternatives to total mesorectal excision, but need further evaluation, and their use outside of a clinical trial is not recommended. The preoperative selection of patients who will benefit from neoadjuvant radiotherapy or not, as well as the proper identification of a clinical complete tumour response after combined treatment modalities,will influence the future directions in the treatment of locally advanced rectal cancer.
Core tip: There is a growing interest in the possibility of the preoperative identification of locally advanced rectal cancer patients who will or will not benefit from a preoperative chemoradiotherapy. This review evaluates the role of current available imaging techniques in this decision process and critically analyzes the results and future scenarios of the more limited surgical or observational approaches. In particular, the new trends following a pathologic complete response (i.e., local excision, wait and see approach) are discussed on the basis of randomized trials and meta-analyses which form the basis for present treatment recommendations.