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Abstract：
OBJECTIVE: Improvements in neoadjuvant therapy for locally advanced cT4 rectal cancer have led to improved tumour response and thus a variety of suitable management strategies. The aim of this study was to report management and outcomes of patients with cT4 rectal cancer undergoing a spectrum of treatment strategies from organ preservation (OP) to pelvic exenteration (PE).
METHODS: Patients who underwent elective treatment for cT4 rectal cancer between 2016 and 2021 were included. All patients were treated with curative intent. Surgical management was adapted to tumour response. Kaplan-Meier curves were generated to compare 3-year overall survival (3y-OS), local recurrence (3y-LR) and distant metastases (3y-DM) between different strategies.
RESULTS: Among 152 patients included, 13 (8%) underwent OP, 71 (47%) TME and 68 (45%) APR/PE. The median follow-up was 31.3 months. Patients undergoing OP had a lower tumour pretreatment (p < 0.001). Compared to patients with TME, those with APR/PE had a higher rate of ypT4 (p = 0.001) with a lower R0 rate (p = 0.044). The 3y-OS and 3y-DM were 78% and 15.1%, respectively, without significant differences. The 3y-LR was 6.6%, and patients with OP had a significantly worse 3y-local regrowth compared to 3y-LR in patients with TME and APR/PE (30.2% vs. 5.4% vs. 2%, p = 0.008).
CONCLUSIONS: cT4 tumours may be suitable for the full spectrum of rectal cancer management from organ preservation to pelvic exenteration depending on tumour response to neoadjuvant therapy. However, careful attention is required in OP as local regrowth in up to 30% of cases reinforces the need for sustained active surveillance in Watch&Wait programmes.
METHODS: Patients who underwent elective treatment for cT4 rectal cancer between 2016 and 2021 were included. All patients were treated with curative intent. Surgical management was adapted to tumour response. Kaplan-Meier curves were generated to compare 3-year overall survival (3y-OS), local recurrence (3y-LR) and distant metastases (3y-DM) between different strategies.
RESULTS: Among 152 patients included, 13 (8%) underwent OP, 71 (47%) TME and 68 (45%) APR/PE. The median follow-up was 31.3 months. Patients undergoing OP had a lower tumour pretreatment (p < 0.001). Compared to patients with TME, those with APR/PE had a higher rate of ypT4 (p = 0.001) with a lower R0 rate (p = 0.044). The 3y-OS and 3y-DM were 78% and 15.1%, respectively, without significant differences. The 3y-LR was 6.6%, and patients with OP had a significantly worse 3y-local regrowth compared to 3y-LR in patients with TME and APR/PE (30.2% vs. 5.4% vs. 2%, p = 0.008).
CONCLUSIONS: cT4 tumours may be suitable for the full spectrum of rectal cancer management from organ preservation to pelvic exenteration depending on tumour response to neoadjuvant therapy. However, careful attention is required in OP as local regrowth in up to 30% of cases reinforces the need for sustained active surveillance in Watch&Wait programmes.
摘要：
目的：局部晚期cT4直肠癌新辅助治疗的改善导致了肿瘤反应的改善，因此有多种合适的治疗策略。这项研究的目的是报告cT4直肠癌患者接受从器官保存（OP）到盆腔切除术（PE）的一系列治疗策略的管理和结果。
方法：纳入2016年至2021年接受cT4直肠癌择期治疗的患者。所有患者均接受治愈性治疗。手术治疗适应肿瘤反应。生成Kaplan-Meier曲线以比较3年总生存期（3y-OS），不同策略之间的局部复发（3y-LR）和远处转移（3y-DM）。
结果：在152名患者中，13例（8%）接受手术，71（47%）TME和68（45%）APR/PE。中位随访时间为31.3个月。接受OP的患者的肿瘤预处理较低（p<0.001）。与TME患者相比，APR/PE患者的ypT4发生率较高(p=0.001),R0发生率较低(p=0.044).3y-OS和3y-DM分别为78%和15.1%，分别,没有显著差异。3y-LR为6.6%，与TME和APR/PE患者的3y-LR相比，OP患者的3y局部再生长明显更差(30.2%vs.5.4%与2%,p=0.008)。
结论：根据肿瘤对新辅助治疗的反应，cT4肿瘤可能适用于从器官保存到盆腔切除术的全部直肠癌治疗。然而,在OP中需要特别注意，因为多达30％的病例中的本地再增长加强了对“观察与等待”计划中持续积极监视的需求。
方法：纳入2016年至2021年接受cT4直肠癌择期治疗的患者。所有患者均接受治愈性治疗。手术治疗适应肿瘤反应。生成Kaplan-Meier曲线以比较3年总生存期（3y-OS），不同策略之间的局部复发（3y-LR）和远处转移（3y-DM）。
结果：在152名患者中，13例（8%）接受手术，71（47%）TME和68（45%）APR/PE。中位随访时间为31.3个月。接受OP的患者的肿瘤预处理较低（p<0.001）。与TME患者相比，APR/PE患者的ypT4发生率较高(p=0.001),R0发生率较低(p=0.044).3y-OS和3y-DM分别为78%和15.1%，分别,没有显著差异。3y-LR为6.6%，与TME和APR/PE患者的3y-LR相比，OP患者的3y局部再生长明显更差(30.2%vs.5.4%与2%,p=0.008)。
结论：根据肿瘤对新辅助治疗的反应，cT4肿瘤可能适用于从器官保存到盆腔切除术的全部直肠癌治疗。然而,在OP中需要特别注意，因为多达30％的病例中的本地再增长加强了对“观察与等待”计划中持续积极监视的需求。
