For rectal adenocarcinoma initially staged as T2N0 and treated with upfront surgical resection, but pathologically upstaged to pT3N0 without high risk features, how do you approach adjuvant therapy?

It is not uncommon for a rectal cancer which was initially felt to be T1-2 and node negative to be revealed to be more advanced stage after surgery. To know what to do in these settings, we have to go “old school” and revisit trials reported in the 1990s, combined with lessons learned in the 2000s.

Several trials reported in the 1990s demonstrated a benefit to postoperative 5-FU based therapy and radiotherapy for stage 2/3 rectal cancer (Krook NEJM 1991; O’Connell NEJM 1994).

When and where to add oxaliplatin has never been completely addressed to rectal cancer, although considering its addition for stage 2/3 rectal cancer in the adjuvant setting is reasonable.

Note that our current “TNT” approach for rectal cancer treats stage 2/3 patients wi...