Organ-preserving strategies have gained increasing relevance in the management of rectal cancer, driven by the improved ability of neoadjuvant therapies to induce major and complete tumor regression. The introduction of Total Neoadjuvant Therapy (TNT), delivered through induction and/or consolidation chemotherapy combined with radiotherapy, has substantially increased both pathological and clinical complete response rates. This progress has renewed interest in non-operative management—namely Watch-and-Wait (W&W)—and in local excision (LE) as potential alternatives to total mesorectal excision (TME). However, the W&W strategy raises important oncologic concerns, including a non-negligible rate of local regrowth—consistently reported at approximately 20–30%—which is associated with inferior distant metastasis-free survival and overall survival. These limitations underscore the inherent uncertainty in reliably defining a true clinical complete response. Within this context, LE may serve as a valuable diagnostic and therapeutic modality by confirming the pathological response, improving local control through removal of residual resistant tumor clones, and enabling more accurate stratification of patients suitable for organ preservation versus those requiring completion TME. Overall, while TNT has expanded the therapeutic opportunities for rectal preservation, LE appears to play a critical role in reducing the discordance between clinical and pathological assessment, thereby offering a more oncologically secure pathway toward organ preservation. This narrative review discusses the current role, benefits, and limitations of organ-preserving approaches after TNT in both locally advanced and early rectal cancer.
随着新辅助疗法诱导肿瘤显著和完全消退能力的提升，器官保留策略在直肠癌治疗中的重要性日益凸显。通过诱导和/或巩固化疗联合放疗实施的全新辅助治疗（TNT）显著提高了病理完全缓解率和临床完全缓解率。这一进展重新激发了人们对非手术治疗（即观察等待策略）及局部切除术作为全直肠系膜切除术潜在替代方案的关注。然而，观察等待策略引发了重要的肿瘤学担忧，包括不可忽视的局部再生率（多项研究一致报告约为20%-30%），这与较差的远处无转移生存率和总生存率相关。这些局限性凸显了可靠界定真正临床完全缓解所固有的不确定性。在此背景下，局部切除术通过确认病理反应、通过清除残留耐药肿瘤克隆改善局部控制，以及更准确地区分适合器官保留与需要补充全直肠系膜切除术的患者，可能成为一种有价值的诊断和治疗手段。总体而言，虽然TNT拓展了直肠保留的治疗机会，但局部切除术似乎在减少临床与病理评估差异方面发挥着关键作用，从而为器官保留提供了更具肿瘤学安全性的路径。本文综述将探讨TNT后器官保留策略在局部进展期及早期直肠癌中的当前作用、优势与局限性。
The Role of Organ Sparing Approaches After Total Neoadjuvant Treatment in Rectal Cancer
肿瘤(癌症)患者之家