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Page 2 of 8 Myint et al. Mini-invasive Surg 2018;2:34 I http://dx.doi.org/10.20517/2574-1225.2018.52

surgery even for early rectal cancer as this is regarded as the standard of care. However, non-surgical
management of rectal cancer is increasingly gaining acceptance as it avoids extirpative surgery and a
[3]
stoma . In patients who are not suitable for surgery because of advancing age or medical comorbidities,
and also in a small number of patients who are stoma phobic and refuse surgery, we need to consider an
[4]
alternative treatment option to surgery . In most cases, external beam radiotherapy alone (EBRT) or with
chemotherapy (EBCRT) is offered as an alternative to surgery. It is likely that with EBCRT alone, 10%-30%
[5,6]
of patients can achieve clinical complete response (cCR) . For these patients, a “watch and wait” strategy
can be offered that avoids extirpative surgery with a stoma. The published evidence indicates that in 25%-
[3,5]
38% of cases, local regrowth can develop late after achieving a cCR following EBCRT alone . In patients
who are fit and agree to proceed, these recurrences require salvage surgery. Once the patient develops a
regrowth, if they are not fit for surgery or if the patient refuse surgery, palliative care is the only available
option and the majority will die from symptomatic progressive local regrowth. The burden of care for
these patients can put strain on their health care providers as these patients can survive for months or even
years. The alternative approach is to offer them contact X-ray brachytherapy (CXB, Papillon treatment)
[4]
which can reduce the risk of local regrowth . Case selection is important to achieve the best results.

Case selection for treatment
In patients who are not suitable for surgery, or in younger, medically fit patients who vehemently refuse
surgery because of stoma phobia, an alternative treatment option is radical radiotherapy. There are two
types of radiation: either external beam radiotherapy (EBCRT/EBRT) or CXB (using a Papillon).

The choice of radiation type and which treatment modality to start depends on: (1) stage of the tumor (cT1 );
(2) possible lymph node spread (cT2, cT3); and (3) size of the tumor (< 3 cm or > 3 cm).

Inclusion criteria for CXB alone for early rectal tumors with curative intent
(1) mobile exophytic early rectal cancer (cT1);
(2) well to moderately differentiated adenocarcinoma;
(3) tumor size < 3 cm;
(4) no evidence of suspicious lymph nodes;
(5) no evidence of distant metastases;
(6) tumor within 12 cm of the anal verge;
(7) patient suitable for long-term follow-up.

Exclusion criteria
(1) poorly differentiated adenocarcinoma;
(2) presence of lymphatic or vascular invasion;
(3) bulky rectal cancer involving more than half the circumference (> 3 cm);
(4) fixed rectal adenocarcinoma with deep ulceration (cT3, cT4).

TREATMENT STRATEGIES

Early small rectal cancers (cT1, cN0, < 3 cm)
When an asymptomatic early (cT1) small ( < 3 cm) rectal cancer is diagnosed (which usually occurs
through the national bowel cancer screening program), the standard of care is to offer the patient surgery
that may involve abdominoperineal resection of the rectum (APER) if the tumor is low in the rectum ( < 6 cm
from the anal verge). If the patient is not suitable for surgery or refuses surgery, an alternative option is to
[4]
offer them CXB (Papillon) alone .

More advanced larger rectal cancers (cT2, cT3a/cNo/cN1, > 3 cm)
If the tumor size is > 3 cm or if the tumor is at stage cT2 or cT3a, then the risk of lymph node metastases