理性看待局部进展期中低位直肠癌新辅助治疗完全缓解后采取"等待观察"策略的得与失

Rational evaluation of the complete response after neoadjuvant therapy in locally advanced mid-low rectal cancer: the pros and cons of "watch and wait" strategy

新辅助放化疗加全直肠系膜切除手术(TME)已经成为局部进展期中低位直肠癌的标准治疗方法。临床上有一定比例的患者会从新辅助放化疗中获益而达到临床完全缓解(cCR)。近年来,"等待观察"策略已被广泛应用于这部分患者,使其免于外科手术,生活质量得到改善。但是,该策略也存在诸多尚未解决的实际问题:(1)临床cCR和病理完全缓解(pCR)的诊断标准并不统一,而且差异较大。(2)部分达到cCR患者进入"等待观察"期间出现了肿瘤再生,需要进一步采取解救手术。(3)对于实施"等待观察"的患者,是否需要进行后续的辅助治疗,临床上尚未达成共识。(4)出现cCR的患者外科手术的作用存在争议。因此,我们需要积累更多的临床证据去证实,新辅助治疗后的直肠癌患者一旦达到cCR是否即可进入"等待观察"。另外,寻找能够更有效地预测放化疗疗效的分子标志物也刻不容缓。总之,应该理性地选择"等待观察"策略,方可让更多的直肠癌患者从放化疗中获益。

Neoadjuvant chemoradiotherapy plus total mesorectal excision (TME) is the standard care for locally advanced middle-low rectal cancer. Some patients could benefit from neoadjuvant chemoradiotherapy to achieve clinical complete response (cCR). Therefore, in recent years, for patients with cCR after neoadjuvant therapy, the "watch and wait" strategy has been widely recommended by their doctors to let them enter "waiting period" without surgery, so that the quality of life is improved. However, the "watch and wait" strategy also has many practical problems that have not been resolved. Firstly, the diagnostic criteria for cCR and pathologic complete response (pCR) are not uniform and different significantly. Secondly, some cCR patients have found tumor regrowth and subsequently underwent salvage surgery during the "watch and wait" period. Thirdly, there is no clinical consensus on the adjuvant therapy for patients during the "watch and wait" period. Fourthly, the role of surgery in patients with cCR is controversial. Finally, we need to accumulate more clinical evidence to confirm whether the "watch and wait" strategy can be selected immediately after achieving cCR for rectal cancer. At the same time, we should find novel molecular markers that can predict the efficacy of chemoradiotherapy. Only rational choice of "watch and wait" strategy will allow more patients with rectal cancer to benefit from chemoradiotherapy.