Неоадъювантная терапия колоректального рака: эволюция подходов, современное состояние и будущие перспективы

Подходы к лечению местнораспространенного колоректального рака претерпевают фундаментальную эволюцию, смещая фокус с универсальных послеоперационных протоколов на персонализированные неоадъювантные стратегии, причем траектории и уровень доказательности существенно различаются для рака прямой и ободочной кишки. Цель настоящего обзора – систематизировать и обобщить современную доказательную базу по неоадъювантной терапии колоректального рака, оценить роль ключевых клинических исследований и определить место молекулярных биомаркеров в персонализации лечебных подходов. Поиск литературы проводился в базах данных PubMed/MEDLINE, eLIBRARY.ru и Cochrane Library по ключевым словам

«колоректальный рак», «рак прямой кишки», «рак ободочной кишки», «неоадъювантная терапия», «тотальная неоадъювантная терапия» за период 2000–2025 гг. В обзор включены 116 публикаций, приоритет отдавался результатам рандомизированных контролируемых и крупных когортных исследований. При раке прямой кишки тотальная неоадъювантная терапия стала новым стандартом лечения, превзойдя классическую химиолучевую терапию с последующей адъювантной химиотерапией. Данные исследований PRODIGE 23, RAPIDO и OPRA показывают, что выбор между индукционным и консолидирующим подходами позволяет индивидуализировать тактику в зависимости от цели – максимальный системный контроль или достижение полного ответа для органосохраняющего лечения. При раке ободочной кишки роль неоадъювантной химиотерапии остается спорной: несмотря на способность к уменьшению стадии опухоли и увеличению частоты R0-резекций, позитивные результаты исследования FOxTROT не были подтверждены в исследованиях OPTICAL и NeoCol. Ключевым фактором персонализации становится статус системы репарации неспаренных оснований ДНК (MMR): для pMMR-опухолей обсуждается неоадъювантная химиотерапия, тогда как для dMMR-опухолей стандартом становится неоадъювантная иммунотерапия (исследование NICHE-2). Будущее лечение местнораспространенного колоректального рака лежит в плоскости глубокой молекулярной персонализации с использованием таких биомаркеров, как статус MMR, циркулирующая опухолевая ДНК и состав кишечного микробиома.

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