局部进展期直肠癌全程新辅助治疗的临床应用进展

Clinical Application Progress of Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer

摘要: 局部进展期直肠癌的治疗方案选择，对于患者的预后有重要的影响。全程新辅助治疗是指将所有系统治疗提前到手术之前完成的治疗方法，分为诱导化疗模式和巩固化疗模式两种。经过对关键临床试验的详细分析得知，诱导化疗模式是唯一可以取得总生存获益的方案，巩固化疗模式在器官保留方面可能会有优势，两种模式在病理完全缓解率上效果相当。全程新辅助治疗可以明显提高病理完全缓解率和化疗依从性，给观察等待策略的实施创造了条件，使部分患者可以避免根治性手术。患者的确定主要依据高分辨磁共振所做风险分层作为选择的基础。免疫治疗给错配修复缺陷的肿瘤患者带来了手术豁免的可能性，错配修复正常的患者的免疫增敏策略正在积极的探索之中，循环肿瘤DNA检测可以精准地判定疗效。全程新辅助治疗的顺利完成要依靠多学科团队合作、规范化诊疗流程。本文分析可以给局部进展期直肠癌的个体化治疗决策提供参考，也可以推动器官保留策略的规范化应用。

Abstract: The choice of treatment approach for locally advanced rectal cancer plays a crucial role in influencing patient outcomes. Total neoadjuvant therapy involves administering all systemic treatments prior to surgery and consists of two primary types: induction chemotherapy and consolidation chemotherapy. By conducting an in-depth analysis of key clinical trials, it has been found that the induction chemotherapy regimen is currently the only approach proven to provide an overall survival benefit. On the other hand, consolidation chemotherapy may have advantages in terms of organ preservation. Notably, both treatment modalities exhibit similar rates of pathological complete response. Total neoadjuvant therapy markedly enhances pathological complete response rates and chemotherapy adherence, paving the way for the implementation of a watch-and-wait strategy and allowing some patients to circumvent radical surgery. In selecting patients, risk stratification utilizing high-resolution magnetic resonance imaging forms the crucial foundation for making treatment decisions. Immunotherapy has introduced the potential for surgery exemption in mismatch repair-deficient patients. Meanwhile, immune sensitization strategies for mismatch repair-proficient patients are being actively investigated. Additionally, circulating tumor DNA detection holds promise for enabling precise evaluation of treatment efficacy. The successful execution of total neoadjuvant therapy hinges on the collaboration of multidisciplinary teams and the establishment of standardized clinical pathways. This analysis offers valuable reference for guiding personalized treatment decisions and facilitating the standardized implementation of organ preservation strategies in locally advanced rectal cancer.