Presentation Information
[ESCP]Stage II and III Rectal Cancers Selected by Precision MRI Can Be Safely Managed with Upfront Total Mesorectal Excision Without Neoadjuvant Therapy
José Moreira Azevedo M.D. PhD(e) 1,2, Laura Fernandez PhD1, Carlos Carvalho M.D.1, Richard J. Heald1, Amjad Parvaiz, M.D., F.R.C.S.1,3 (1. Champalimaud Foundation, Champalimaud Clinical Center, Department of Surgical Oncology, Lisbon, Portugal, 2. Faculty of Medicine, University of Lisbon, Portugal, 3. University of Portsmouth, Portsmouth, United Kingdom)
Introduction
Neoadjuvant chemoradiotherapy is widely accepted as standard treatment for locally
advanced rectal cancer, reducing local recurrence but without clear survival benefit and
with significant toxicity. Advances in high-resolution magnetic resonance imaging (MRI)
allow more precise risk stratification, potentially identifying patients who may safely
undergo upfront surgery without neoadjuvant treatment.
Methods
This was a retrospective analysis of a prospectively maintained database from a single
tertiary center, including patients with clinical stage II/III rectal cancer (mrT3/T4 and/or
mrN+) and clear mesorectal fascia (>1 mm), treated with upfront total mesorectal
excision (TME) between 2013 and 2024. A propensity-score match (PSM) between
patients that met inclusion criteria but received radiotherapy was performed, to compare
outcomes with the upfront surgery group. Primary outcomes included local recurrence-
free survival, distant metastasis-free survival, overall survival, and resection margin
status.
Results
Among 322 patients, 141 underwent upfront surgery and 94 with stage II/III disease met
inclusion criteria. R0 resection was achieved in 99% of cases. Local recurrence-free
survival was 100% at 3 years and 97% at 5 years. Distant metastasis-free survival was
87% and 81% at 3 and 5 years, respectively. Overall survival reached 97% at 3 years
and 95% at 5 years, with a median follow-up of 34.5 months. When PSM was performed,
to compare patients that received radiotherapy and those that underwent upfront
surgery, no signifcant diferences were observed. Patients in both groups had a local
recurrence-free survival of 100% and 96% at 3 years and 5 years (p=0.182),
respectively.
Conclusion
In selected patients with stage II/III rectal cancer and clear mesorectal fascia on high-
resolution MRI, upfront TME achieves excellent oncological outcomes. These findings
support a selective, MRI-based approach that may safely avoid neoadjuvant therapy in
a defined subgroup of patients.
Neoadjuvant chemoradiotherapy is widely accepted as standard treatment for locally
advanced rectal cancer, reducing local recurrence but without clear survival benefit and
with significant toxicity. Advances in high-resolution magnetic resonance imaging (MRI)
allow more precise risk stratification, potentially identifying patients who may safely
undergo upfront surgery without neoadjuvant treatment.
Methods
This was a retrospective analysis of a prospectively maintained database from a single
tertiary center, including patients with clinical stage II/III rectal cancer (mrT3/T4 and/or
mrN+) and clear mesorectal fascia (>1 mm), treated with upfront total mesorectal
excision (TME) between 2013 and 2024. A propensity-score match (PSM) between
patients that met inclusion criteria but received radiotherapy was performed, to compare
outcomes with the upfront surgery group. Primary outcomes included local recurrence-
free survival, distant metastasis-free survival, overall survival, and resection margin
status.
Results
Among 322 patients, 141 underwent upfront surgery and 94 with stage II/III disease met
inclusion criteria. R0 resection was achieved in 99% of cases. Local recurrence-free
survival was 100% at 3 years and 97% at 5 years. Distant metastasis-free survival was
87% and 81% at 3 and 5 years, respectively. Overall survival reached 97% at 3 years
and 95% at 5 years, with a median follow-up of 34.5 months. When PSM was performed,
to compare patients that received radiotherapy and those that underwent upfront
surgery, no signifcant diferences were observed. Patients in both groups had a local
recurrence-free survival of 100% and 96% at 3 years and 5 years (p=0.182),
respectively.
Conclusion
In selected patients with stage II/III rectal cancer and clear mesorectal fascia on high-
resolution MRI, upfront TME achieves excellent oncological outcomes. These findings
support a selective, MRI-based approach that may safely avoid neoadjuvant therapy in
a defined subgroup of patients.