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Page 6 of 8 Myint et al. Mini-invasive Surg 2018;2:34 I http://dx.doi.org/10.20517/2574-1225.2018.52

cT1 tumour

Surface dose 100% = 30 Gy
MM

MP Depth dose at 5 mm = 50% (15 Gy)

M
Depth dose at 10 mm = 30% (10 Gy)

Figure 3. Treatment diagram and depth dose. MM: muscularis mucosa; MP: muscularis propria; M: mesorectum

tumors, trans-anal endoscopic microscopic surgery (TEMS) can be offered, because a proportion of
residual mucosal abnormalities turn out to be benign adenomas that are difficult to differentiate from
[10]
residual adenocarcinomas . For gross residual tumors, salvage total mesorectal excision (TME) surgery
[11]
should be offered . However, the patient may not be medically fit for TME surgery or may refuse it.
However, in our experience, at this stage most patients will agree for surgery, as they have tried the
alternative non-surgical route and accept that this has failed. It is important to stress to the patient during
the informed consent process that not all rectal cancers respond to CXB boosts after their EBRT, and that
they may need to undergo salvage surgery if there is persistent residual tumor or a local growth at a later
[4,7]
date .
Surgical salvage for local regrowth after cCR following EBCRT or EBRT and CXB
Local regrowth of a rectal cancer after achieving cCR following EBCRT or EBRT and CXB boost can be
successfully treated if the patient is fit and agrees to surgery. Unfortunately, not all patients with local
[8]
regrowth are fit and willing to undergo surgery . Local regrowth following EBCRT or EBRT and CXB
reportedly occurs in 11%-12% of cases [4,6,12,13] , a rate that is much lower than the 25%-38% local regrowth
[3,5]
that has been reported following EBCRT or EBRT alone .

DISCUSSION
Most colorectal cancer treatment protocols and guidelines do not include radiotherapy for early rectal
[1,2]
neoplasms . Most colorectal MDT recommendations do not advocate non- surgical treatment even
for early rectal cancers detected by screening. The dilemmas arise when a patient refuse the MDT
recommendations. The UK National Institute for Health and Clinical Excellence (NICE) guidelines state
[14]
that patients can refuse medical interventions to the extent of electing to undergo no treatment . Most
clinicians will only consider alternative treatment options if there is no evidence from a randomized
trial. It is not always possible to do a randomized trial when two treatment strategies are not in equipoise