Initial treatment of pMMR/MSS, non-metastatic rectal adenocarcinoma

The initial management of pMMR/MSS non-metastatic rectal adenocarcinoma is presented here. The diagnosis must be pathologically confirmed on biopsy, and imaging and clinical studies should show no evidence of distant metastatic disease. Multidisciplinary treatment input is necessary from surgical oncology, radiation oncology, and medical oncology. For further details and evidence, refer to UpToDate content on the management of rectal adenocarcinoma.

AJCC: American Joint Committee on Cancer; CT: computed tomography; CRT: chemoradiation; EUS: endoscopic ultrasound; M: metastasis; MRI: magnetic resonance imaging; MSS: microsatellite stable; N: node; pMMR: proficient mismatch repair; RT: radiation therapy; T: tumor.

* Clinical T1N0 and clinical T2N0 tumors are primarily managed with surgical resection (ie, transanal local excision, transabdominal resection).

Neoadjuvant CRT is an alternative for patients with a primary distal tumor who decline resection or are poor surgical candidates.

¶ Adjuvant therapy is indicated for clinical T1-2, N0 tumors treated with transabdominal resection that subsequently demonstrate pathologic T3-4 or pathologic N1-2 disease on postoperative pathology.

Δ Patients with a complete clinical response to total neoadjuvant therapy may be offered surveillance without further surgery.

◊ Neoadjuvant chemotherapy plus response-guided use of RT allows most patients to omit RT and avoid its late toxicities. Patients treated with neoadjuvant chemotherapy who have a clinical response of 20% or greater for the primary tumor can omit RT and proceed directly to surgical resection, whereas those with a clinical response of less than 20% receive neoadjuvant CRT or RT prior to surgery.

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Initial treatment of pMMR/MSS, non-metastatic rectal adenocarcinoma