Basic surgical principles for locally advanced rectal cancer in complex therapy

Background. Compliance with principles of surgical oncology is necessary to choose effective treatment options for locally advanced rectal cancer (LARC).

Objective: to show the basic surgical principles for LARC using a new option of complex therapy.

Material and Methods. The basic surgical principles for LARC using a new option of complex therapy with polyradiomodifcation (local microwave hyperthermia + intrarectal administration of a polymer composition with Metronidazole) in combination with polychemotherapy (oral administration of Capecitabine + intravenous administration of Oxaliplatin) with concurrent prolonged hypofractionated radiation therapy were presented.

Results. The treatment outcomes of the new option of complex neoadjuvant therapy with the compliance of surgical oncology principles were studied in 46 patients with LARC (T3cd-T4a N1c-2ab M0, CRM+, EMVI+). An analysis of the immediate outcomes showed that postoperative complications were diagnosed in only 4 (8.7 %) of 46 patients and no deaths were recorded. The local control was achieved: cancer recurrence was diagnosed in only 1 (2.2 %) and distant metastases in 4 (8.7 %) of patients. The 5-year recurrence-free survival rate in these patients was signifcantly higher than that observed in patients who received conventionally fractionated radiotherapy in combination with Capecitabine (81.0 vs 56.8 %, p=0.02). The improvement of results was achieved both by adhering to the principles of surgical oncology and increasing the radiosensitivity of the tumor: pathologic complete response was achieved in 35 (76.1 %) patients. This made it possible to perform sphincter-preserving surgeries in 71.7 % (33 out of 46) patients and in 66.7 % (18 out of 27) with lower-ampullary cancer.

Conclusion. The use of a new method of complex therapy for LARC and compliance with the basic principles of surgical oncology allowed the improvement of long-term treatment outcomes by achieving local control of the tumor, contributing to the expansion of indications for performing sphincter-preservingsurgeries.

1. Barsukov Yu.A. Rectal and anal cancer: prospects for combined treatment. Manual for doctors. Moscow, 2019. 856 p. (in Russian).

2. Capirci C., Rubello D., Pasini F., Galeotti F., Bianchini E., Del Favero G., Panzavolta R., Crepaldi G., Rampin L., Facci E., Gava M., Banti E., Marano G. The role of dual-time combined 18-fuorodeoxyglucose positron emission tomography and computed tomography in the staging and restaging workup of locally advanced rectal cancer, treated with preoperative chemoradiation therapy and radical surgery. Int J Radiat Oncol Biol Phys. 2009; 74(5): 1461–9. doi: 10.1016/j.ijrobp.2008.10.064.

3. Horisberger K., Treschl A., Mai S., Barreto-Miranda M., Kienle P., Ströbel P., Erben P., Woernle C., Dinter D., Kähler G., Hochhaus A., Post S., Willeke F., Wenz F., Hofheinz R.D.; MARGIT (Mannheimer Arbeitsgruppe für Gastrointestinale Tumoren). Cetuximab in combination with capecitabine, irinotecan, and radiotherapy for patients with locally advanced rectal cancer: results of a Phase II MARGIT trial. Int J Radiat Oncol Biol Phys. 2009; 74(5): 1487–93. doi: 10.1016/j.ijrobp.2008.10.014.

4. Glynne-Jones R., Wyrwicz L., Tiret E., Brown G., Rödel C., Cervantes A., Arnold D.; ESMO Guidelines Committee. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2017; 28(s4): 22–40. doi: 10.1093/annonc/mdx224. Erratum in: Ann Oncol. 2018; 29(s4). doi: 10.1093/annonc/mdy161.

5. The Beyond TME Collaborative. Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg. 2013; 100(8): 1009–14. doi : 10.1002/bjs.9192.

6. Barsukov Yu.A., Tkachev S.I., Mamedli Z.Z., Aliyev V.A., Vlasov O.A., Vainson A.A., Perevoshchikov A.G., Kulushev V.M., Ivanov S.V., Khailenko V.A., Nikolaev A.V., Oltarzhevskaya N.D., Korovina M.A., Kovaleva Yu.Yu., Dudayev Z.A. Complex treatment of patients with rectal cancer: guidelines. Moscow, 2023. 56 p. (in Russian).

7. Davydov M.I. Etudes in oncosurgery. Moscow, 2009. 46 p. (in Russian).

8. Abel A.L. The modern treatment of cancer the colon and rectum. Milwaukee Proc. 1931; 296–300. Цит. по: Büchler M.W., Heald R.J., Ulrich B., Weits J. (eds). Rectal Cancer Treatment. Springer, Berlin, 2005. 280 p.

9. Kholdin S.A. Rectal cancer. Leningrad, 1955. 360 p. (in Russian).

10. Heald R.J., Husband E.M., Ryall R.D. The mesorectum in rectal cancer surgery – the clue to pelvic recurrence? Br J Surgery. 1982; 69(10): 613–16.

11. Barsukov Yu.A., Mamedli Z.Z., Tkachev S.I., Aliev V.A., Vlasov O.A., Perevoshchikov A.G., Oltarzhevskaya N.D., Korovina M.A., Dudaev Z.A., Goncharov S.V., Ivanov S.M. Methodological aspects of complex therapy of locally advanced rectal cancer. Oncology. P.A. Herzen Journal of Oncology. 2024; 13(3): 20–26. (in Russian). doi: 10.17116/onkolog20241303120.

12. Lavnikova G.A., Gosh T.E., Talalaeva A.V., Kobozeva S.A, Chervonnaya L.V. Histological method of quantitative assessment of the degree of tumor radiation injury. Medical Radiology. 1978; 23(3): 6–9. (in Russian).

13. Dworak O., Keilholz L., Hoffmann A. Pathological features of rectal cancer after preoperative radiochemotherapy. Int J Colorectal Dis. 1997; 12(1): 19–23. doi: 10.1007/s003840050072.