Preoperative treatment for locally advanced rectal cancer: is there enough evidence to define the preferable radiotherapy schedule?

Worldwide earlier diagnosis and improvement in treatment modalities gained a huge amelioration of clinical results for locally advanced rectal cancer (i.e., T3, T4 and/or nodal positive clinical presentations) in the last three decades, but still there is urgency for further improvement; moreover, there are some controversies regarding the preferable clinical management. Radiotherapy currently plays a central role in primary treatment [1,2]. In the 1990s, at the beginning of the use of preoperative radiotherapy, its use gained a survival benefit with respect to the use of surgery alone [3].  After the introduction of a high-level surgical technique, as the total mesorectal excision (i.e., en-bloc resection of the rectum with its mesorectum performed to the levator muscle in the avascular plane outside of the mesorectum) [4] survival improvement was not demonstrated in single randomized trials [5]. Nevertheless, long-term results of the main randomized trials clarified that a preoperative approach should be preferred to the postoperative adjuvant [6].

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