I have a 35 yo female (not desirous of future preg, No FHx)with a locally advanced (mri pending but CT with prob adenopathy, T3 at a minimum) distal rectal cancer (palp tip of finger, moving bowel, no weight loss). MSS. CEA 3. Doesn't need diversion. Picture of health. Question: Neoadjuvant FOLFIRINOX then chemo (xeloda) + RTx or chemo/RT then chemo (FOLFIRINOX or Cape/Ox, etc). I am leaning toward FOLFIRINOX, Colon Surgery wants chemo/RTx then re-eval but this is clearly TNT to me, just how to arrange the chairs. Any thoughts appreciated. No mets on imaging.
We obviously need the MRI, but I would discuss PROSPECT style therapy vs TNT. To me, the nodal disease makes the biggest deciding point and/or if T4. I don’t use FOLFIRINOX unless someone has really advanced disease, but that is variable what people will do (being addressed in the JANUS trial). As she has such a distal tumor, I would think she would want to try and avoid an APR, but it is worth a discussion. Given her young age, even if not desiring kids, you may want to do an oophoropexy before you start to try and keep some endogenous hormones before you start radiation. I agree with you about TNT, but I typically do chemoRT first as it is logistically easier for the schedule of restating before considering NOM, if you are lucky to have a good response
