The 7th Joint Session between JDDW-KDDW-TDDW1(JDDW)
Thu. November 2nd   9:00 - 12:00   Room 9: Portopia Hotel Main Building Kairaku 3
Evolution of lower rectal cancer treatment with multidisciplinary approach
Yuji Toiyama1, Mikio Kawamura1, Yoshinaga Okugawa2
1Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2Department of Genomic Medicine, Mie University Hospital
In Japan, historically, surgery is the primary treatment for lower rectal cancer. Total mesorectal excision (TME) has established the standard surgical approach for rectal cancer since 1980 and has significantly improved local control and survival rates. In addition, from evidence achieved by JCOG0212, the JSCCR Guidelines recommend performing TME with lateral lymph node dissection (LLND) for cT3 or deeper lower rectal cancer.
In the West, the therapeutic effects of extended lymph node dissection including with LLND were reported in the 1950s. However, due to a high incidence of distant recurrence and postoperative sexual and urinary dysfunction, several clinical trials demonstrated the usefulness of radiation therapy with concurrent chemotherapy before surgery for the suppression of local recurrence. Since then, preoperative chemoradiotherapy (CRT) + TME has become the standard treatment.
Thus, while both preoperative CRT and LLND aim to control pelvic local recurrence, they face challenges in controlling distant metastasis and improving survival. In this context, a powerful preoperative treatment known as Total Neoadjuvant Therapy (TNT), which sequentially introduce radiation therapy and systemic chemotherapy before surgery, has been introduced in Western countries, and demonstrated further shrinking the primary tumor and reducing distant metastasis.
The development of preoperative CRT for rectal cancer has resulted in an increase in cases achieving pathological complete response (CR). In 2004, Habr-Gama proposed the Watch & Wait approach, which involves avoiding immediate surgery and observing patients who achieve clinical CR after preoperative treatment. This approach has been validated as a safe and high-quality treatment primarily in Europe and the United States. It represents a significant shift from the conventional concept of surgery and is expected to increase the proportion of rectal cancer patients who can undergo organ preservation by introducing TNT in the preoperative treatment.
Advances in molecular profiling and genetic testing have enabled the identification of specific genetic mutations or biomarkers in rectal cancer. In particular, the patients with microsatellite satellite instability have merit to use immune checkpoint inhibitors, since high clinical CR rate in extremely high rate and non-operative management can be achieved.
Overall, the evolution of lower rectal cancer treatment with a multidisciplinary approach has led to improved outcomes, reduced morbidity, and enhanced quality of life for patients. Collaboration among surgeons, medical oncologists, radiation oncologists, pathologists, radiologists, and other healthcare professionals is crucial in delivering optimal care and tailoring treatments to individual patients.
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