Goal-directed neoadjuvant therapy: What should we offer in each case?

Area of Science:

• Oncology
• Surgical Oncology
• Radiology

Background:

• Rectal cancer management has evolved significantly.
• Total mesorectal excision (TME) and neoadjuvant chemoradiation (nCRT) were traditional standards.
• Advancements in staging and understanding tumor biology have reshaped treatment paradigms.

Purpose of the Study:

• To review the evolution of rectal cancer management.
• To highlight the impact of advanced imaging and novel therapeutic strategies.
• To discuss the shift towards personalized, organ-preserving approaches.

Main Methods:

• Review of advancements in staging techniques, particularly high-resolution magnetic resonance imaging (MRI).
• Analysis of evolving treatment strategies including neoadjuvant chemoradiation (nCRT), total neoadjuvant therapy (TNT), and organ-preserving options.
• Inclusion of recent breakthroughs like immunotherapy for specific tumor subtypes.

Main Results:

• High-resolution MRI has improved locoregional staging and identification of prognostic markers (e.g., extramural venous invasion [EMVI]).
• Complete clinical response (cCR) has enabled organ-preserving strategies (Watch & Wait, transanal local excision).
• Total neoadjuvant therapy (TNT) shows potential for improved systemic outcomes, though optimal use is debated.
• Immunotherapy offers new non-surgical options for microsatellite instability-high rectal tumors.

Conclusions:

• Current rectal cancer management emphasizes personalized treatment based on tumor characteristics and risk factors.
• Organ preservation strategies are increasingly viable, balancing oncologic control with functional outcomes.
• The field is moving towards tailored approaches that optimize efficacy, patient quality of life, and functional results.