Trends in adoption of total neoadjuvant therapy for locally advanced rectal cancer

Does timing of ileostomy closure impact postoperative morbidity?

AIM

Reversal of diverting loop ileostomy (DLI) traditionally occurs at ≥12 weeks after formation. Early closure has been performed in attempts to reduce DLI-associated morbidity. Therefore, the aim of this study was to determine whether time to stoma reversal impacts postoperative morbidity.

METHOD

A retrospective review was conducted using institutional-level American College of Surgeons National Surgical Quality Improvement Program data for adult patients who underwent DLI closure between January 2012 and December 2021 across a multistate health system. Time to DLI closure was stratified into three groups: ≤12, 12-24 or 24-36 weeks. Additional data were obtained from the electronic medical record. The primary outcome was major morbidity after DLI closure.

RESULTS

A total of 482 patients underwent DLI closure. Eighty four patients underwent closure at ≤12 weeks (17.4%), 300 at 12-24 weeks (62.2%) and 98 at 24-36 weeks (20.3%). The most common diagnosis at DLI formation was cancer (n = 211, 43.8%). Patients in the ≤12 weeks closure group more commonly had ulcerative colitis or diverticular disease and a lower American Society of Anesthesiologists class than patients with closure at 24-36 weeks (p < 0.05). There were no significant differences in complication severity, overall major morbidity or its individual components amongst the time to DLI closure groups. There were no differences in anastomotic leaks or need for laparotomy. On multivariable analysis, immunosuppressive therapy and preoperative haematocrit <30% were significant risk factors for major morbidity after DLI closure.

CONCLUSION

Major morbidity did not differ by time to DLI closure group, indicating that closure at ≤12 weeks is safe in selected patients.

Comparison of efficacy and safety between robotic-assisted versus laparoscopic surgery for locally advanced mid-low rectal cancer following neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

BACKGROUND

To some extent, the robotic technique does offer certain benefits in rectal cancer surgery than laparoscopic one, while remains a topic of ongoing debate for rectal cancer patients who have undergone neoadjuvant chemoradiotherapy (NCRT).

METHODS

Potential studies published until January 2024 were obtained from Web of Science, Cochrane Library, Embase, and PubMed. Dichotomous and continuous variables were expressed as odds ratios (ORs) or weighted mean differences (WMDs) with 95% CIs, respectively. A random effects model was used if the I2 statistic >50%; otherwise, a fixed effects model was used.

RESULTS

Eleven studies involving 1079 patients were analysed. The robotic-assisted group had an 0.4 cm shorter distance from the anal verge (95% CI: -0.680 to -0.114, P =0.006) and 1.94 times higher complete total mesorectal excision (TME) rate (OR=1.936, 95% CI: 1.061-3.532, P =0.031). However, the operation time in the robotic-assisted group was 54 min longer (95% CI: 20.489-87.037, P =0.002) than the laparoscopic group. In addition, the robotic-assisted group had a lower open conversion rate (OR=0.324, 95% CI: 0.129-0.816, P =0.017) and a shorter length of hospital stay (WMD=-1.127, 95% CI: -2.071 to -0.184, P =0.019).

CONCLUSION

Robot-assisted surgery offered several advantages over laparoscopic surgery for locally advanced mid-low rectal cancer following NCRT in terms of resection of lower tumours with improved TME completeness, lower open conversion rate, and shorter hospital stay, despite the longer operative time.

Outcome of Patients with Locally Advanced Rectal Cancer Pursuing Non-Surgical Strategy in National Cancer Database

BACKGROUND

Survival data on patients with locally advanced rectal cancer (LARC) undergoing non-operative management (NOM) in a real-world setting are lacking.

METHODS

We analyzed LARC patients from the National Cancer Database with the following features: treated between 2010 and 2020, age 18-65 years, Charlson comorbidity index (CCI) ≤ 1, received neoadjuvant multiagent chemotherapy plus radiation ≥ 45 Gray, and underwent surgery or NOM. Patients were stratified into two groups: (A) clinical T1-3 tumors with positive nodes (cT1-3N+) and (B) clinical T4 tumors, N+/- (cT4N+/-). We performed a comparative analysis of overall survival (OS) with NOM versus surgery by the Kaplan-Meier method and propensity score matching. Additionally, a multivariable analysis explored the association between NOM and OS.

RESULTS

NOM exhibited significantly lower OS than surgery in both groups. In cT1-3N+ patients, NOM resulted in a 5-year OS of 73.9% (95% confidence interval [CI] = 69.7-77.6%) versus 84.5% (95% CI = 83.6-85.3%) with surgery (p < 0.001). In the cT4N+/- group, NOM yielded a 5-year OS of 44.5% (95% CI = 37.0-51.8%) versus 72.5% (95% CI = 69.9-74.8%) with surgery (p < 0.001). Propensity score matching and multivariable analyses revealed similar conclusions.

CONCLUSION

Patients with LARC undergoing NOM versus surgery in real-world settings appear to have inferior survival.

The conundrum of total neoadjuvant therapy in rectal cancer

Total neoadjuvant therapy (TNT) has fast become the paradigm in the management of rectal cancer. The widespread adoption of this approach across the world, not only for locally advanced cancers but even for cancers that otherwise would not merit chemotherapy, leads both to an increase in treatment-related toxicity for patients and burdens the healthcare services of the country. It is important to tailor treatment to each patient based not only on the tumour but, even more importantly, on the patient's expectations and goals. The intent of treatment while prescribing TNT needs to be clear, understanding that not all patients are suitable for an organ preservation (watch and wait) approach and that the survival benefits of TNT are not as obvious as most proponents believe.

Surgical Outcomes after Radiotherapy in Rectal Cancer

Over the past decade, the treatment of rectal cancer has changed considerably. The implementation of TME surgery has, in addition to decreasing the number of local recurrences, improved surgical morbidity and mortality. At the same time, the optimisation of radiotherapy in the preoperative setting has improved oncological outcomes even further, although higher perineal infection rates have been reported. Radiotherapy regimens have evolved through the adjustment of radiotherapy techniques and fields, increased waiting intervals, and, for more advanced tumours, adding chemotherapy. Concurrently, imaging techniques have significantly improved staging accuracy, facilitating more precise selection of advanced tumours. Although chemoradiotherapy does lead to the downsizing and -staging of these tumours, a very clear effect on sphincter-preserving surgery and the negative resection margin has not been proven. Aiming to decrease distant metastasis and improve overall survival for locally advanced rectal cancer, systemic chemotherapy can be added to radiotherapy, known as total neoadjuvant treatment (TNT). High complete response rates, both pathological (pCR) and clinical (cCR), are reported after TNT. Patients who follow a Watch & Wait program after a cCR can potentially avoid surgical morbidity and colostomy. For both early and more advanced tumours, trials are now investigating optimal regimens in an attempt to offer organ preservation as much as possible. Multidisciplinary deliberation should include patient preference, treatment toxicity, and likelihood of end colostomy, but also the burden of intensive surveillance in a W&W program.