Circumferential Rectal Cancer Is a Risk Factor for Stricture Formation and Restaging Uncertainties Following Neoadjuvant Therapy.
Academic Article
Overview
abstract
BACKGROUND: Circumferential rectal tumors treated with total neoadjuvant therapy have the potential to develop into a stricture. These strictures can make assessment of clinical response challenging and are considered a contraindication to non-operative management according to the National Comprehensive Cancer Network guidelines. However, the incidence of stricture formation and its likelihood of harboring occult residual disease remains poorly understood. OBJECTIVE: To investigate which patients with locally advanced rectal cancer are at risk for stricture formation after total neoadjuvant therapy and assess residual tumor at the time of surgery. DESIGN: Retrospective study. SETTING: Single tertiary care center. PATIENTS: Stage II or III rectal cancer patients who underwent total neoadjuvant therapy with curative intent surgery. MAIN OUTCOME MEASURES: The rate of stricture formation after total neoadjuvant therapy and pathologic complete response rate after proctectomy at the primary tumor site. INTERVENTION: Total neoadjuvant therapy. RESULTS: Of the 69 patients included in the analysis, 18 patients (26%) had a circumferential rectal tumor. Four (22%) of these 18 patients developed a stricture at the primary tumor site. No other patients in the study developed a stricture. All four patients with a post-treatment rectal stricture underwent proctectomy due to the concern for residual disease within the stricture despite complete response on endoscopy and magnetic resonance imaging. Three (75%) of the four stricture patients had residual primary disease on final surgical pathology. Fourteen patients with circumferential tumors did not develop a stricture but underwent a proctectomy for incomplete response. Eleven out of 14 (79%) had a pathologic incomplete response. LIMITATIONS: Limited sample size. CONCLUSIONS: Seventy-five percent of these patients with a stricture were found to have residual disease on surgical pathology despite classic findings of complete clinical response. This highlights the inherent difficulty in pursuing non-operative management in this patient population. See Video Abstract.
