¿Es necesaria la quimio-radioterapia preoperatoria en todos los pacientes con cáncer del recto localmente avanzado? Análisis de una serie consecutiva de pacientes estadificados preoperatoriamente como T2N+ o T3

Background: Preoperative chemoradiation is becoming the standard treatment for patients with locally advanced rectal cancer. However, since the introduction of total mesorectal excision (TME), local recurrence rates have been significantly reduced and some patients can be spared from potentially toxic overtreatment. This study was designed to assess factors predicting recurrence in an institutional series of rectal cancer patients with clinical stage cT2N+, cT3N0/+, treated by radical surgery without preoperative chemoradiation. Methods: Between November 1997 and November 2008, our multidisciplinary group preoperatively staged 398 rectal cancer patients by ERUS and/or MRI. This analysis included 152 consecutive patients with cT2N+, cT3N0, or cT3N+ rectal cancer, who underwent TME without preoperative chemoradiation. Macroscopical assessment of mesorectal excision and circumferential resection margin (CRM) were determined. Factors potentially related with local recurrence (LR), disease free survival (DFS) and cancer-specific survival (CSS) were analyzed. Results: After a median follow-up of 39 months, 5-year actuarial rate for LR, DFS and CSS were respectively 9.5%, 65.4% and 77.8% for the whole group. Threatened mesorectal fascia at preoperative staging was the only independent preoperative factor to predict a higher risk for LR (p=0.007), shorter DFS (p=0.007) and CSS (p=0.05). In particular, 5-year LR rate in patients with or without preoperative threatened CRM was 19.4 % and 5.4% respectively. Conclusion: Our study suggests that rectal cancer patients clinically staged as T3N0/+ or T2N+ with a free margin >2 mm from mesorectal fascia could be treated with TME alone, avoiding overtreatment with preoperative chemoradiation.