Rethinking Local Therapy for Rectal Cancer in the Era of Precision Oncology—When Less Is More
Mené en Espagne sur 173 patients atteints d'un adénocarcinome rectal de stade T2-T3ab, N0, M0 (durée de suivi : 2 ans ; âge médian : 67 ans ; 67,1 % d'hommes), cet essai randomisé multicentrique de phase III évalue la non-infériorité, du point de vue du taux de récidive locorégionale, d'un traitement combinant une chimioradiothérapie préopératoire et une microchirurgie endoscopique transanale par rapport à une exérèse mésorectale totale
Serra-Aracil and colleagues should be commended for advancing the evidence base supporting surgical deintensification in rectal cancer. Their demonstration of noninferiority between chemoradiation therapy (CRT) followed by transanal endoscopic microsurgery (TEM) and upfront total mesorectal excision (TME) for stage T2-T3ab, N0, M0 disease broadens the population potentially eligible for organ preservation. However, these findings must be interpreted in the context of an evolving treatment landscape—particularly the rise of total neoadjuvant therapy and nonoperative management strategies.The authors report an impressive pathologic complete response (pCR) rate of 44.3% after CRT, with no local failures in this subgroup. Similarly, the Neoadjuvant Chemotherapy, Excision, and Observation for Early Rectal Cancer (NEO) trial demonstrated robust ypT0/1 rates (56.9%) using chemotherapy alone followed by transanal excision in a comparable cohort, with 90% 2-year locoregional relapse-free survival. These data underscore that tumor response to neoadjuvant therapy—rather than the extent of surgical management—is the primary determinant of local control.
JAMA Surgery , éditorial, 2025