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Page 4 of 8 Myint et al. Mini-invasive Surg 2018;2:34 I http://dx.doi.org/10.20517/2574-1225.2018.52

Pre treatment Post 1st CXB Post 2nd CXB
Day 0 - 28/12/12 Day 14 - 11/01/13 Day 28 - 25/01/13

Post 3rd CXB Post treatment 5 years
Day 42 - 08/03/13

Figure 1. Treatment response to contact X-ray brachytherapy (CXB). Case 1: 65-year-old male diagnosed with low rectal adenocarcinoma
staged as cT1cN0cM0 on MRI and CT scan. Refused surgery including trans-anal endoscopic microscopic surgery (TEMS) and external
beam radiotherapy. Patient’s choice. Treated only with CXB. Started his treatment in December 2012 after informed consent. Fully
understand and accepted that CXB is non standard treatment for rectal cancer. Significant regression of tumour after only one fraction of
CXB and no palpable or visible tumour after 2nd fraction. Clinical complete response (cCR) maintained after 5 years with good quality of
life and bowel control. No bleeding despite being on clopidrogel

[8]
important during this period. Most of the regrowth is intraluminal and can be detected by endoscopic
examination, which should be carried out every 3 months during the first year, every 3-4 months during
the second year, and every 6 months from the third to the fifth post-treatment year. Full colonoscopy
should be done at 5 years if not performed earlier. Usually a digital rectal examination (DRE) is carried
out just before inserting the endoscope for this procedure to assess any palpable local regrowth and its
mobility. High-resolution whole-pelvis magnetic resonance imaging (MRI) should be done every 3-4
months during the first 2 years and at 6-month intervals in the third year to detect local and/or nodal
regrowth. Computerized tomography (CT) scan of the chest, abdomen and pelvis should be done every 6
months during the first 3 years to detect distant metastases. The risk of both local and distant metastases
is low after 3 years. Therefore, we do not recommended routine radiological examinations unless there is
suspicion of a persistent tumor or development of distant metastases . We advocate regular follow-up of
[7]
the patients in the center where the treatment was delivered initially, by the same observer (if possible) or
by a dedicated clinician following a “watch and wait” program. Patient follow-up also can be performed
at the referring center, alternating with the CXB treatment center, by a limited number of clinicians who
are experienced in the watchful waiting protocol. The radiological examinations should be done under
a strict rectal protocol and reported by a radiologist familiar with the “watch and wait” clinical strategy,