The current standard of care of patients with locally advanced rectal cancer includes the use of neoadjuvant chemoradiotherapy. Overall, 10–20% of patients achieve a complete rectal pathological response after chemoradiation. Some investigators have even demonstrated a sustained clinical response in the absence of rectal resection, with a low recurrence rate of 4.6%, and five-year overall and disease-free survival rates of 96 and 72% [14, 15].
Despite these benefits, pelvic radiotherapy is linked to a number of limitations. It induces a peri-rectal inflammation, and the use of chemotherapy-only could make surgery easier, with higher chances of achieving a resection with appropriate margins by a minimally invasive approach. The use of radiotherapy in the management of rectal cancer is making another curative pelvic radiation impossible for potential prostatic, gynecological, bladder or anal cancer. In addition, it has long-term impact on anorectal, urinary and sexual function [16, 17]. Finally, the recent improvements in the management of rectal cancer, including chemoradiotherapy and total mesorectal excision, have no impact on known or microscopic distant metastases.
The present patient with pCR received a chemotherapy combining oxaliplatin, 5-fluorouracil, irinotecan, leucovorin and bevacizumab. Oxaliplatin-based neoadjuvant chemotherapy, currently mainly used in stage IV patients, may represent an attractive alternative to the neoadjuvant radiation therapy for rectal cancer. Induction chemotherapy has the added advantage of earlier administration of systemic therapy and may improve the control or the prevention of distant metastasis.
Prospective randomized studies should be carried out to demonstrate effectiveness of systemic therapy into combined-modality programs and to evaluate the benefit of chemotherapy alone in selected patients with stages II-III rectal adenocarcinoma with or without distant metastasis.