Clinical Complete Response in Rectal Cancer Alex Fishberg

Clinical Complete Response in Rectal Cancer Alex Fishberg, MD November 3, 2019

With the realization that a selected subset of rectal cancers can completely regress after neoadjuvant therapy (NAT), the concept of organ preservation in the context of an apparent clinical complete response has emerged, coupled with the advent of a watch and wait paradigm as well as the concepts of total neoadjuvant therapy (TNT) or treatment intensification programs. Comprehensive Rectal Cancer Care pp 195 -211

History • 46 year old AA male with one month of painless rectal bleeding • “My hemorrhoid popped out and I have to push them back in. ” • H/o PE s/p MVA 3/2009 likely related to prolonged immobilization, hypercoagulable work-up negative • MEDICATIONS: Apixaban, metformin, atorvastatin, Lisinopril, Hydrocodone/acetaminophen, cyclobenzaprine.

Initial Colonoscopy Findings Rectal - palpable mass Olympus PCF 180 Boston Bowel Prep • 3 - Left • 3 - Transverse • 3 – Right • Biopsies, CT Chest, Abd/Pelvis w and w/o, CEA

Workup • CT Chest/abdomen/pelvis w and w/o contrast – no metastasis • CEA normal 3. 3 • Biopsy adenocarcinoma Refer to Colorectal Surgeon • • MRI rectum Subclavian port placement Oncology for Chemoradiation vs PROSPECT Plan • Flexible sigmoidoscopy 6 weeks after Chemoradiation complete • TRANSANAL TOTAL MESORECTAL EXCISION WITH ILEOSTOMY

Clinical Colorectal Cancer, Vol. 17, No. 1, 1 -12 ª 2017

Flexible Sigmoidoscopy 6 wks after Chemoradiation Low ulcers noted 4 cm from the anal verge

Watch & Wait vs Surgery • p. CR seen in 20% of Locally Advanced Rectal Cancer (LARC) • 90 day surgical mortality is mortality 3 -6% • High Morbidity – Bowel, Sexual, Urinary dysfunction, and permanent stoma formation • • c. CR seen in 20 -30% LARC 5 year disease free survival 92% Overall survival 100% Which c. CR candidates were chosen for watch and wait is based on retrospective studies • TRIGGER is a randomized prospective trial using MRI to pick LARC candidates for W&W vs Surgery Current Colorectal Cancer Reports (2018) 14: 37– 55 https: //doi. org/10. 1007/s 11888 -018 -0398 -5

TRIGGER - Protocol Battersby et al. Trials (2017) 18: 394 DOI 10. 1186/s 13063 -017 -2085 -2 Current Colorectal Cancer Reports (2018) 14: 37– 55 https: //doi. org/10. 1007/s 11888 -018 -0398 -5

Rectal Cancer Surveillance: • Assessment: every 6 months for 2 years. • CEA every 6 months for 3 years • A completion colonoscopy within the first year if not done at the time of diagnostic work-up (e. g. if obstruction was present). • History and colonoscopy with resection of colonic polyps every 5 years up to the age of 75 years. • A minimum of two CTs of the chest, abdomen and pelvis in the first 3 years. Annals of Oncology 28 (Supplement 4): iv 22–iv 40, 2017 doi: 10. 1093/annonc/mdx 224

Plan for this patient: • Survivorship plan • PCP q 6 months • Specialist team • CR surgeon • MRI q 6 months x 2 years • Clinical exam DRE and CEA q 3 months • Based on São Paulo experience not guideline • Oncology