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Organ preservation in rectal cancer following clinical complete response after short-course radiotherapy-based total
Carlos G Morales1, Erik Manriquez-Alegria1, Valentina Duran2
1Colorectal Surgery Unit, Complejo Asistencial Dr. Sótero del Río, Santiago, Chile.
Background And Purpose:
Organ preservation after total neoadjuvant therapy (TNT) is feasible in patients with locally advanced rectal cancer (LARC) who achieve a clinical complete response (cCR). However, most watch-and-wait (WW) evidence derives from long-course chemoradiotherapy (LCCRT), with limited data regarding short-course radiotherapy (SCRT)-based TNT. We evaluated response-adapted organ preservation following SCRT-based TNT in a public, resource-limited healthcare setting.
Materials And Methods:
This retrospective cohort included consecutive patients with stage II-III LARC (cT3-T4 and/or N+) with palpable tumors ≤8 cm from the anal verge treated between 2020 and 2023. All patients received SCRT (25 Gy in five fractions) followed by consolidation chemotherapy (FOLFOX or CAPOX). Tumor response was assessed 8-12 weeks after TNT using digital rectal examination, pelvic MRI, flexible sigmoidoscopy and CEA levels. Patients achieving a cCR were managed with a structured WW protocol; others underwent total mesorectal excision (TME). Time-to-event outcomes were estimated descriptively.
Results:
Among 51 evaluable patients, 19 (37.3%) achieved cCR and 18 (35.3%) were managed with WW. After a median follow-up of 43.2 months (IQR 34.1-51.5), 3 WW patients (16.7%) developed local regrowth, all successfully salvaged with R0 resection. The estimated 24-month local regrowth-free survival was 82.2% (95% CI 65.8-100%). One WW patient died from systemic progression after salvage surgery. In the surgical group, 4 patients (12.1%) achieved a pathological complete response (pCR). Overall, 13 of 18 WW patients (72.2%) maintained sustained cCR without any oncologic event during follow-up.
Conclusions:
Hypofractionated SCRT integrated into a TNT strategy enabled response-adapted organ preservation with acceptable local regrowth-free survival in selected patients with LARC. This strategy was deliverable within a public healthcare system and achieved acceptable mid-term oncologic control. Prospective validation with longer follow-up is warranted.
