Treatment of locally advanced rectum cancer

SUMMARY – Over the last several decades, local control (LC) for rectal cancer has markedly improved because of advances in surgical technique and the adoption of adjuvant or neoadjuvant chemoradiotherapy (CRT). Total mesorectal excision (TME) during surgical resection of localized rectal cancer, which involves removal of the entire circumferential perirectal tissue envelope, decreases rates of both involved surgical margins and local recurrences. Similarly, for patients with locally advanced rectal cancer (LARC), including T3 and T4 tumors and lymph node-positive disease, adjuvant and more preferably neoadjuvant CRT has exhibited the ability to both improve disease-free survival (DFS) and LC. Some patients undergoing neoadjuvant CRT achieve a complete pathologic response (pCR) to CRT and the oncologic outcomes are particularly favourable in this group. In contrast to improved local control, patients’ overall survival rates are in need of improvement, and the major factor limiting the outcome is the appearance of metachronous distant metastases. The main approach to overcome this issue is the escalation of systemic therapy in the neoadjuvant setting, e.g. by addition of induction or consolidation chemotherapy before or after neoadjuvant chemoradiotherapy (the so-called total neoadjuvant treatment, TNT, approach). The aim was to present a short overview of the role of radiotherapy and radiochemotherapy in the management of rectal cancer with a focus on current treatment stand wasards for locally advanced rectal cancer.