Near-complete clinical response after neoadjuvant therapy in rectal cancer: Decision-making between organ preservation and surgery

Figure 1 Proposed management algorithm for near-complete clinical response after neoadjuvant therapy in rectal cancer. Proposed management algorithm for patients with near-complete clinical response (nCR) after neoadjuvant therapy. Initial assessment is recommended at 8-12 weeks. Management is guided by patient preference and by clinical, endoscopic, and magnetic resonance imaging features distinguishing favorable from unfavorable nCR. Selected patients may undergo interval reassessment (6-12 weeks) to allow conversion to complete clinical response and subsequent watch-and-wait approach. Persistent nCR, local regrowth, or unfavorable features warrant oncologic resection (e.g., total mesorectal excision). Local excision may be considered in selected cases. ¹Endoscopic features adapted from Williams et al[18]. ²Magnetic resonance imaging-based predictors adapted from Yilmaz et al[22]. ³High-risk features include lymphovascular invasion, perineural invasion, extramural venous invasion, positive resection margin, tumor budding, and poor differentiation[42]. nCR: Near-complete clinical response; cCMT: Consolidation chemotherapy; EMVI: Extramural venous invasion; TME: Total mesorectal excision; cCR: Complete clinical response; LN: Lymph node.