Erken ve Lokal İleri Rektum Kanseri
Özet
Rektal kanserli bir hasta için optimum tedavi stratejisini belirlemek zorlu bir iştir. Rektum kanserinde cerrahi müdahale (küratif veya palyatif) yapılıp yapılmayacağına karar vermenin yanı sıra, normal bağırsak fonksiyonunun/anal kontinansın sürdürülmesi veya geri kazanılması ve genital fonksiyonun korunması olasılığı da dahil olmak üzere olası fonksiyonel tedavi sonuçları da dikkate alınmalıdır. Distal rektal kanserli hastalar için, küratif amaçlı tedavi ile yaşam kalitesi üzerindeki etkiyi en aza indirme arasında bir denge kurmak zor olabilir. Ayrıca rektum kanserli hastalarda kolon kanseri hastalarına göre pelvik nüks görülme olasılığı daha yüksektir ve lokal olarak tekrarlayan rektum kanserinin prognozu kötüdür. Hastaların dikkatli bir şekilde belirlenmesi ve multidisipliner yaklaşımla birlikte sıralı multimodal tedavinin kullanılması önerilmektedir. Erken evre rektal kanser için bir tedavi seçeneği de, endoskopik submukozal rezeksiyondur. Rektum kanserinin tedavisi son yıllarda çeşitli faktörlere bağlı olarak giderek zorlaşmaktadır. Özel manyetik rezonans(MR) görüntüleme ile doğru görüntüleme, total mezorektal eksizyonun(TME) standardizasyonu ve neoadjuvan tedavi rejimlerinin uygulamaya konulması, lokal nüks oranlarında anlamlı azalmaya katkıda bulunmuştur. Tümörün radyasyona veya kemoradyoterapiye tam yanıt vermesinin gözlenmesi, seçilmiş hastalarda organ koruyucu tekniklerin önerilmesine fırsat sağladı; bunlar arasında hızlı cerrahiden kaçınmak ve yakın izlem (bekle ve izle) stratejisi yer almaktadır. Rektal kanserlerin, kolon kanserinin eşdeğer evrelerine kıyasla tekrarlama olasılığı daha yüksektir. Rektumun anatomik yerleşimi, cerrahlar için temiz cerrahi rezeksiyon sınırları elde etmede sorun teşkil eder ve rektal kanserde lokal nükse neden olur. Kolon kanserinin aksine, evre II ve III'teki rektal maligniteler genellikle kemoterapi, radyasyon tedavisi ve cerrahinin bir kombinasyonunu gerektirir.
It is difficult to determine the best treatment strategy for a patient with rectal cancer. In addition to deciding whether to perform surgical intervention (curative or palliative) for rectal cancer, the potential functional treatment outcomes, such as maintaining or restoring normal bowel function/anal continence and preserving genital function, should be taken into account. It can be challenging for patients with distal rectal cancer to strike a balance between curative treatment and reducing the impact on quality of life. Furthermore, patients with rectal cancer are more likely to experience pelvic recurrence than those with colon cancer, and the prognosis for locally recurring rectal cancer is poor. Careful patient selection and the use of sequential multimodal treatment with a multidisciplinary approach are advised. Endoscopic submucosal excision is another option for treating rectal cancer in its early stages. The treatment of rectal cancer has gotten more complex in recent years due to a variety of causes. Accurate imaging using special magnetic resonance (MR) imaging, standardization of total mesorectal excision (TME), and the use of neoadjuvant treatment regimens have all contributed to considerable decreases in local recurrence rates. The observation of complete tumor response after radiation or chemoradiotherapy has led to the suggestion of organ-sparing approaches in selected patients, such as skipping immediate surgery and close monitoring (wait-and-see strategy). Rectal tumors are more likely to recur than comparable stages of colon cancer. The rectum's anatomic placement makes it difficult for surgeons to achieve negative surgical resection margins, which leads to local recurrence in rectal cancer. In contrast to colon cancer, stage II and III rectal cancers typically necessitate a combination of chemotherapy, radiation therapy, and surgery.
Referanslar
Siegel RL, Giaquinto AN, Jemal A. Cancer statistics, 2024. CA Cancer J Clin. 2024 Jan 17;74(1):12–49.
Cheng L, Eng C, Nieman LZ, Kapadia AS, Du XL. Trends in Colorectal Cancer Incidence by Anatomic Site and Disease Stage in the United States From 1976 to 2005. Am J Clin Oncol. 2011 Dec;34(6):573–80.
Bailey CE, Hu CY, You YN, Bednarski BK, Rodriguez-Bigas MA, Skibber JM, et al. Increasing Disparities in the Age-Related Incidences of Colon and Rectal Cancers in the United States, 1975-2010. JAMA Surg. 2015 Jan 1;150(1):17.
Weinberg BA, Marshall JL, Salem ME. The Growing Challenge of Young Adults With Colorectal Cancer. Oncology (Williston Park). 2017 May 15;31(5):381–9.
Jhaveri KS, Hosseini-Nik H. MRI of Rectal Cancer: An Overview and Update on Recent Advances. American Journal of Roentgenology. 2015 Jul;205(1):W42–55.
Wang AY, Hwang JH, Bhatt A, Draganov P V. AGA Clinical Practice Update on Surveillance After Pathologically Curative Endoscopic Submucosal Dissection of Early Gastrointestinal Neoplasia in the United States: Commentary. Gastroenterology. 2021 Dec;161(6):2030-2040.e1.
Draganov P V, Wang AY, Othman MO, Fukami N. AGA Institute Clinical Practice Update: Endoscopic Submucosal Dissection in the United States. Clin Gastroenterol Hepatol. 2019 Jan;17(1):16-25.e1.
Draganov P V, Coman RM, Gotoda T. Training for complex endoscopic procedures: how to incorporate endoscopic submucosal dissection skills in the West? Expert Rev Gastroenterol Hepatol. 2014 Feb 3;8(2):119–21.
Benson AB, Venook AP, Adam M, Chang G, Chen YJ, Ciombor KK, et al. NCCN Guidelines® Insights: Rectal Cancer, Version 3.2024. Journal of the National Comprehensive Cancer Network. 2024 Aug;22(6):366–75.
Conroy T, Bosset JF, Etienne PL, Rio E, François É, Mesgouez-Nebout N, et al. Neoadjuvant chemotherapy with FOLFIRINOX and preoperative chemoradiotherapy for patients with locally advanced rectal cancer (UNICANCER-PRODIGE 23): a multicentre, randomised, open-label, phase 3 trial. Lancet Oncol. 2021 May;22(5):702–15.
Okamura R, Itatani Y, Fujita Y, Hoshino N, Okumura S, Nishiyama K, et al. Postoperative recurrence in locally advanced rectal cancer: how does neoadjuvant treatment affect recurrence pattern? World J Surg Oncol. 2023 Aug 16;21(1):247.
Petrelli F, Trevisan F, Cabiddu M, Sgroi G, Bruschieri L, Rausa E, et al. Total Neoadjuvant Therapy in Rectal Cancer. Ann Surg. 2020 Mar;271(3):440–8.
Sclafani F, Corrò C, Koessler T. Debating Pros and Cons of Total Neoadjuvant Therapy in Rectal Cancer. Cancers (Basel). 2021 Dec 18;13(24):6361.
Aghili M, Khalili N, Khalili N, Babaei M, Farhan F, Haddad P, et al. Short-course versus long-course neoadjuvant chemoradiotherapy in patients with rectal cancer: preliminary results of a randomized controlled trial. Radiat Oncol J. 2020 Jun 30;38(2):119–28.
Bhatti ABH, Waheed A, Hafeez A, Akbar A, Syed AA, Khattak S, et al. Can Induction Chemotherapy before Concurrent Chemoradiation Impact Circumferential Resection Margin Positivity and Survival in Low Rectal Cancers? Asian Pacific Journal of Cancer Prevention. 2015 Apr 14;16(7):2993–8.
Ghalehtaki R, Nourbakhsh F, Abyaneh R, Sharifian A, Pashapour‐Khoyi S, Aghili M, et al. Optimal Sequence for Total Neoadjuvant Therapy in Locally Advanced Rectal Cancer: An Evidence‐Based Review. Cancer Med. 2024 Oct 10;13(19).
Feng S, Yan P, Zhang Q, Li Z, Li C, Geng Y, et al. Induction chemotherapy followed by neoadjuvant chemoradiotherapy and surgery for patients with locally advanced rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis. 2020 Aug 1;35(8):1355–69.
Ng SY, Colborn KL, Cambridge L, Cercek A, Reidy-Lagunes DL, Segal N, et al. Induction Chemotherapy Reduces Patient-reported Toxicities During Neoadjuvant Chemoradiation with Intensity Modulated Radiotherapy for Rectal Cancer. Clin Colorectal Cancer. 2019 Sep;18(3):167–74.
Schrag D, Shi Q, Weiser MR, Gollub MJ, Saltz LB, Musher BL, et al. PROSPECT: A randomized phase III trial of neoadjuvant chemoradiation versus neoadjuvant FOLFOX chemotherapy with selective use of chemoradiation, followed by total mesorectal excision (TME) for treatment of locally advanced rectal cancer (LARC) (Alliance N1048). Journal of Clinical Oncology. 2023 Jun 10;41(17_suppl):LBA2–LBA2.
Pettersson D, Lörinc E, Holm T, Iversen H, Cedermark B, Glimelius B, et al. Tumour regression in the randomized Stockholm III Trial of radiotherapy regimens for rectal cancer. British Journal of Surgery. 2015 Jun 10;102(8):972–8.
Myint AS, Gérard JP. Role of radiotherapy in the treatment of rectal cancer in older patients. European Journal of Surgical Oncology. 2020 Mar;46(3):349–57.
Zhang H, Li G, Cao K, Zhai Z, Wei G, Qu H, et al. Impact of total neoadjuvant therapy consisting of consolidation chemotherapy on locally advanced rectal cancer survival. Int J Colorectal Dis. 2022 Jul 18;37(7):1657–68.
Verheij FS, Omer DM, Williams H, Lin ST, Qin LX, Buckley JT, et al. Long-Term Results of Organ Preservation in Patients With Rectal Adenocarcinoma Treated With Total Neoadjuvant Therapy: The Randomized Phase II OPRA Trial. Journal of Clinical Oncology. 2024 Feb 10;42(5):500–6.
Fokas E, Allgäuer M, Polat B, Klautke G, Grabenbauer GG, Fietkau R, et al. Randomized Phase II Trial of Chemoradiotherapy Plus Induction or Consolidation Chemotherapy as Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: CAO/ARO/AIO-12. Journal of Clinical Oncology. 2019 Dec 1;37(34):3212–22.
Fokas E, Schlenska-Lange A, Polat B, Klautke G, Grabenbauer GG, Fietkau R, et al. Chemoradiotherapy Plus Induction or Consolidation Chemotherapy as Total Neoadjuvant Therapy for Patients With Locally Advanced Rectal Cancer. JAMA Oncol. 2022 Jan 20;8(1):e215445.
Garcia-Aguilar J, Patil S, Gollub MJ, Kim JK, Yuval JB, Thompson HM, et al. Organ Preservation in Patients With Rectal Adenocarcinoma Treated With Total Neoadjuvant Therapy. Journal of Clinical Oncology. 2022 Aug 10;40(23):2546–56.
Schrag D, Shi Q, Weiser MR, Gollub MJ, Saltz LB, Musher BL, et al. Preoperative Treatment of Locally Advanced Rectal Cancer. New England Journal of Medicine. 2023 Jul 27;389(4):322–34.
Deng Y, Chi P, Lan P, Wang L, Chen W, Cui L, et al. Neoadjuvant Modified FOLFOX6 With or Without Radiation Versus Fluorouracil Plus Radiation for Locally Advanced Rectal Cancer: Final Results of the Chinese FOWARC Trial. Journal of Clinical Oncology. 2019 Dec 1;37(34):3223–33.
van der Valk MJM, Hilling DE, Bastiaannet E, Meershoek-Klein Kranenbarg E, Beets GL, Figueiredo NL, et al. Long-term outcomes of clinical complete responders after neoadjuvant treatment for rectal cancer in the International Watch & Wait Database (IWWD): an international multicentre registry study. The Lancet. 2018 Jun;391(10139):2537–45.
Cercek A, Lumish M, Sinopoli J, Weiss J, Shia J, Lamendola-Essel M, et al. PD-1 Blockade in Mismatch Repair–Deficient, Locally Advanced Rectal Cancer. New England Journal of Medicine. 2022 Jun 23;386(25):2363–76.
Crane CH, Eng C, Feig BW, Das P, Skibber JM, Chang GJ, et al. Phase II Trial of Neoadjuvant Bevacizumab, Capecitabine, and Radiotherapy for Locally Advanced Rectal Cancer. International Journal of Radiation Oncology*Biology*Physics. 2010 Mar;76(3):824–30.
Landry JC, Feng Y, Prabhu RS, Cohen SJ, Staley CA, Whittington R, et al. Phase II Trial of Preoperative Radiation With Concurrent Capecitabine, Oxaliplatin, and Bevacizumab Followed by Surgery and Postoperative 5-Fluorouracil, Leucovorin, Oxaliplatin (FOLFOX), and Bevacizumab in Patients With Locally Advanced Rectal Cancer: 5-Year Clinical Outcomes ECOG-ACRIN Cancer Research Group E3204. Oncologist. 2015 Jun 1;20(6):615–6.
Habr-Gama A, Perez RO, Proscurshim I, Campos FG, Nadalin W, Kiss D, et al. Patterns of Failure and Survival for Nonoperative Treatment of Stage c0 Distal Rectal Cancer Following Neoadjuvant Chemoradiation Therapy. Journal of Gastrointestinal Surgery. 2006 Dec;10(10):1319–29.
Dossa F, Chesney TR, Acuna SA, Baxter NN. A watch-and-wait approach for locally advanced rectal cancer after a clinical complete response following neoadjuvant chemoradiation: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2017 Jul;2(7):501–13.
SEER. Cancer stat facts: Colorectal cancer. Accessed July 24, 2023https://seer.cancer.gov/statfacts/html/colorect.html.
Dasari A, Morris VK, Allegra CJ, Atreya C, Benson AB, Boland P, et al. ctDNA applications and integration in colorectal cancer: an NCI Colon and Rectal–Anal Task Forces whitepaper. Nat Rev Clin Oncol. 2020 Dec 6;17(12):757–70.
Beets GL, Figueiredo NL, Habr-Gama A, van de Velde CJH. A new paradigm for rectal cancer: Organ preservation. European Journal of Surgical Oncology (EJSO). 2015 Dec;41(12):1562–4.
Smith JJ, Strombom P, Chow OS, Roxburgh CS, Lynn P, Eaton A, et al. Assessment of a Watch-and-Wait Strategy for Rectal Cancer in Patients With a Complete Response After Neoadjuvant Therapy. JAMA Oncol. 2019 Apr 11;5(4):e185896.
