Lower GI: Indications for neoadjuvant radiotherapy by stage
Free question published 23 July 2026
A 67-year-old woman is referred with a biopsy-proven rectal adenocarcinoma 9 cm from the anal verge. Staging MRI of the pelvis reports a cT2 tumour confined to the muscularis propria with no suspicious mesorectal nodes, a clear mesorectal fascia, and no extramural venous invasion (cT2 cN0 M0). CT chest, abdomen and pelvis shows no metastatic disease. The case is discussed at the colorectal multidisciplinary team meeting. What is the most appropriate management?
- ADefinitive chemoradiotherapy with a watch-and-wait approach
- BProceed directly to total mesorectal excision without neoadjuvant radiotherapy
- CTotal neoadjuvant therapy with FOLFIRINOX followed by chemoradiotherapy and surgery
- DLong-course preoperative chemoradiotherapy followed by surgery
- EShort-course preoperative radiotherapy (25 Gy in 5 fractions) followed by surgery
Why B is correct
NICE NG151 recommendation 1.3.4 states that preoperative radiotherapy should not be offered for early rectal cancer (cT1-T2 cN0, M0) outside a clinical trial. This good-prognosis tumour with a clear mesorectal fascia and node-negative status is best treated by upfront total mesorectal excision, sparing the patient radiotherapy toxicity.
And why the others are not
- AIncorrect. Watch-and-wait follows neoadjuvant therapy in patients achieving a complete clinical response; it is not a primary strategy for resectable early rectal cancer.
- CIncorrect. Total neoadjuvant therapy is for high-risk locally advanced rectal cancer, not an early node-negative cT2 tumour.
- DIncorrect. Long-course chemoradiotherapy is reserved for higher-risk tumours (cT1-T2 N1-N2 M0 or cT3-T4); it overtreats this early lesion.
- EIncorrect. Short-course radiotherapy adds toxicity without benefit in early node-negative disease, which NICE explicitly excludes from preoperative radiotherapy.
Source NICE NG151 — Colorectal cancer — National Institute for Health and Care Excellence. Colorectal cancer. NICE guideline NG151. Published 29 January 2020.
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