Survival outcome of adjuvant radiotherapy after local excision for T2 early rectal cancer: An analysis based on the surveillance, epidemiology, and end result registry database

Long-Term Outcomes of Patients with Poor Prognostic Factors Following Transanal Endoscopic Microsurgery (TEMS) for Early Rectal Cancer

Background: Transanal endoscopic microsurgery (TEMS) is an organ-preserving approach for treatment of early rectal cancer (ERC). However, adverse histopathological features identified post-TEMS often necessitate adjuvant therapy. This study aims to compare the long-term oncological outcomes of patients who underwent TEMS and were offered adjuvant treatments with total mesorectal excision (TME), chemoradiotherapy (CRT), radiotherapy (RT), active surveillance, or dose escalation with contact X-ray brachytherapy (CXB). Methods: This study included patients treated with TEMS for ERC between September 2012 and December 2022, with follow-up until December 2023. Patients with adverse histopathological features (extra-mural venous invasion, lympho-vascular invasion, R1 margins, tumour budding) were assigned to adjuvant treatments. Inverse probability of treatment weighting (IPTW) was applied to mitigate selection bias. Results: Of the 117 patients, 24 underwent TME, 17 received CRT, 25 received RT, 14 underwent active surveillance, and 37 patients received CXB boost along with CRT. The median follow-up was 60 months (IQR 52-73). During this time, 29 patients developed recurrence, and 15 died. The 5-year overall survival (OS) was 78.6%, and disease-free survival (DFS) was 70.9%. Compared to CXB, the mortality risk for CRT (HR = 0.81; 95% CI: 0.20-3.28; p = 0.77) and TME (HR = 3.68; 95% CI: 0.46-29.79; p = 0.22) was not significantly different. However, TME was associated with a significantly higher recurrence risk compared to CXB (HR = 7.57; 95% CI: 1.23-46.84; p = 0.029). Conclusions: An organ-preserving strategy with CRT or CRT combined with a CXB boost may offer comparable long-term outcomes and reduced recurrence risks for patients undergoing TEMS for ERC with poor prognostic features. Further research with larger cohorts is needed to validate these results.

Treatment Options for Distal Rectal Cancer in the Era of Organ Preservation

OPINION STATEMENT

The introduction of total mesorectal excision into the radical surgery of rectal cancer has significantly improved the oncological outcome with longer survival and lower local recurrence. Traditional treatment modalities of distal rectal cancer, relying on radical surgery, while effective, take their own set of risks, including surgical complications, potential damage to the anus, and surrounding structure owing to the pursuit of thorough resection. The progress of operating methods as well as the integration of systemic therapies and radiotherapy into the peri-operative period, particularly the exciting clinical complete response of patients after neoadjuvant treatment, have paved the way for organ preservation strategy. The non-inferiority oncological outcome of "watch and wait" compared with radical surgery underscores the potential of organ preservation not only to control local recurrence but also to reduce the need for treatments followed by structure destruction, hopefully improving the long-term quality of life. Radical radiotherapy provides another treatment option for patients unwilling or unable to undergo surgery. Organ preservation points out the direction of treatment for distal rectal cancer, while additional researches are needed to answer remaining questions about its optimal use.

Local versus radical surgery for early rectal cancer with or without neoadjuvant or adjuvant therapy

BACKGROUND

Total mesorectal excision is the standard of care for stage I rectal cancer. Despite major advances and increasing enthusiasm for modern endoscopic local excision (LE), uncertainty remains regarding its oncologic equivalence and safety relative to radical resection (RR).

OBJECTIVES

To assess the oncologic, operative, and functional outcomes of modern endoscopic LE compared to RR surgery in adults with stage I rectal cancer.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, Ovid Embase, Web of Science - Science Citation Index Expanded (1900 to present), four trial registers (ClinicalTrials.gov, ISRCTN registry, the WHO International Clinical Trials Registry Platform, and the National Cancer Institute Clinical Trials database), two thesis and proceedings databases, and relevant scientific societies' publications in February 2022. We performed handsearching and reference checking and contacted study authors of ongoing trials to identify additional studies.

SELECTION CRITERIA

We searched for randomized controlled trials (RCTs) in people with stage I rectal cancer comparing any modern LE techniques to any RR techniques with or without the use of neo/adjuvant chemoradiotherapy (CRT).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. We calculated hazard ratios (HR) and standard errors for time-to-event data and risk ratios for dichotomous outcomes, using generic inverse variance and random-effects methods. We regrouped surgical complications from the included studies into major and minor according to the standard Clavien-Dindo classification. We assessed the certainty of evidence using the GRADE framework.

MAIN RESULTS

Four RCTs were included in data synthesis with a combined total of 266 participants with stage I rectal cancer (T1-2N0M0), if not stated otherwise. Surgery was performed in university hospital settings. The mean age of participants was above 60, and median follow-up ranged from 17.5 months to 9.6 years. Regarding the use of co-interventions, one study used neoadjuvant CRT in all participants (T2 cancers); one study used short-course radiotherapy in the LE group (T1-T2 cancers); one study used adjuvant CRT selectively in high-risk patients undergoing RR (T1-T2 cancers); and the fourth study did not use any CRT (T1 cancers). We assessed the overall risk of bias as high for oncologic and morbidity outcomes across studies. All studies had at least one key domain with a high risk of bias. None of the studies reported separate outcomes for T1 versus T2 or for high-risk features. Low-certainty evidence suggests that RR may result in an improvement in disease-free survival compared to LE (3 trials, 212 participants; HR 1.96, 95% confidence interval (CI) 0.91 to 4.24). This would translate into a three-year disease-recurrence risk of 27% (95% CI 14 to 50%) versus 15% after LE and RR, respectively. Regarding sphincter function, only one study provided objective results and reported short-term deterioration in stool frequency, flatulence, incontinence, abdominal pain, and embarrassment about bowel function in the RR group. At three years, the LE group had superiority in overall stool frequency, embarrassment about bowel function, and diarrhea. Local excision may have little to no effect on cancer-related survival compared to RR (3 trials, 207 participants; HR 1.42, 95% CI 0.60 to 3.33; very low-certainty evidence). We did not pool studies for local recurrence, but the included studies individually reported comparable local recurrence rates for LE and RR (low-certainty evidence). It is unclear if the risk of major postoperative complications may be lower with LE compared with RR (risk ratio 0.53, 95% CI 0.22 to 1.28; low-certainty evidence; corresponding to 5.8% (95% CI 2.4% to 14.1%) risk for LE versus 11% for RR). Moderate-certainty evidence shows that the risk of minor postoperative complications is probably lower after LE (risk ratio 0.48, 95% CI 0.27 to 0.85); corresponding to an absolute risk of 14% (95% CI 8% to 26%) for LE compared to 30.1% for RR. One study reported an 11% rate of temporary stoma after LE versus 82% in the RR group. Another study reported a 46% rate of temporary or permanent stomas after RR and none after LE. The evidence is uncertain about the effect of LE compared with RR on quality of life. Only one study reported standard quality of life function, in favor of LE, with a 90% or greater probability of superiority in overall quality of life, role, social, and emotional functions, body image, and health anxiety. Other studies reported a significantly shorter postoperative period to oral intake, bowel movement, and off-bed activities in the LE group.

AUTHORS' CONCLUSIONS

Based on low-certainty evidence, LE may decrease disease-free survival in early rectal cancer. Very low-certainty evidence suggests that LE may have little to no effect on cancer-related survival compared to RR for the treatment of stage I rectal cancer. Based on low-certainty evidence, it is unclear if LE may have a lower major complication rate, but probably causes a large reduction in minor complication rate. Limited data based on one study suggest better sphincter function, quality of life, or genitourinary function after LE. Limitations exist with respect to the applicability of these findings. We identified only four eligible studies with a low number of total participants, subjecting the results to imprecision. Risk of bias had a serious impact on the quality of evidence. More RCTs are needed to answer our review question with greater certainty and to compare local and distant metastasis rates. Data on important patient outcomes such as sphincter function and quality of life are very limited. Results of currently ongoing trials will likely impact the results of this review. Future trials should accurately report and compare outcomes according to the stage and high-risk features of rectal tumors, and evaluate quality of life, sphincter, and genitourinary outcomes. The role of neoadjuvant or adjuvant therapy as an emerging co-intervention for improving oncologic outcomes after LE needs to be further defined.

Total Mesorectal Excision vs. Transanal Endoscopic Microsurgery Followed by Radiotherapy for T2N0M0 Distal Rectal Cancer: A Multicenter Randomized Trial

Introduction

Transanal endoscopic microsurgery (TEM) is an organ-preserving treatment alternative for patients with early rectal cancer. However, TEM alone is associated with greater risk of local recurrence and inferior survival in comparison with total meso-rectal excision (TME). As an important adjuvant therapy, radiotherapy can effectively reduce the local recurrence rate of rectal cancer. This study aimed to investigate whether TEM followed by radiotherapy can be a valid alternative to TME in T2N0M0 distal rectal cancer treatment.

Methods

We plan to recruit 168 participants meeting established inclusion criteria. Following informed consent, participants will randomly receive treatment protocols of TEM followed by radiotherapy (a total dose of 45–50.4 Gy given in 25–28 factions) or TME. Depending on post-operative pathology, the participants will receive either long-term follow-up or further treatment. The primary endpoint of this trial is 3-year local recurrence rate. The secondary end points include 3-year disease-free survival rate, 3-year overall survival rate, 3-year mortality rate, post-operative quality of life, post-operative safety index, intraoperative evaluation index and post-operative short-term evaluation index.

Discussion

This trial is the first prospective randomized trial to investigate the rectum preserving treatment by using transanal local excision followed by radiotherapy.

Clinical trial registration

The trial was prospectively registered at ClinicalTrials.gov NCT04098471 on September 20, 2019.

Long-term outcomes of patients with poor prognostic factors following transanal endoscopic microsurgery for early rectal cancer

AIM

Management of early rectal cancer following transanal microscopic anal surgery poses a management dilemma when the histopathology reveals poor prognostic features, due to high risk of local recurrence. The aim of this study is to evaluate the oncological outcomes of such patients who undergo surgery with total mesorectal excision (TME), receive adjuvant chemo/radiotherapy (CRDT/RT) or receive close surveillance only (no further treatment).

METHODS

We identified patients with poor prognostic factors-pT2 adenocarcinoma, poor differentiation, deep submucosal invasion (Kikuchi SM3), lymphovascular invasion, tumour budding or R1 resection margin-between 1 September 2012 and 31 January 2020 and report their oncological outcomes.

RESULTS

Of the 53 patients, 18 had TME, 14 had CRDT and 14 had RT; seven patients did not have any further treatment. The median follow-up was 48 months, 12 developed recurrence and six died. Overall, 5-year survival (OS) was 88.9% and disease-free survival (DFS) was 79.2%. Compared to the surgical group, in which there were eight recurrences and two deaths, there were zero recurrences or deaths in the CRDT group, log-rank test P = 0.206 for OS and P = 0.005 for DFS. The 5-year survival rates in the RT and surveillance only groups were OS 78.6%, DFS 85.7% and OS 71.5%, DFS 71% respectively. TME assessment in the surgical group revealed Grade 3 quality in seven of the 16 available reports.

CONCLUSION

These findings support the strategy of adjuvant CRDT as first line treatment for patients undergoing transanal endoscopic microsurgery for early rectal cancer with poor prognostic factors on initial histological assessment.

A multi-centre analysis of adjuvant contact X-ray brachytherapy (CXB) in rectal cancer patients treated with local excision - Preliminary results of the CONTEM1 study

INTRODUCTION

Early rectal cancers are increasingly diagnosed through screening programmes and are often treated using local excision (LE). In the case of adverse pathological features completion total mesorectal excision surgery (TME) is the standard recommendation. The morbidity and mortality risks of TME have stimulated the use of adjunctive treatments following LE to achieve organ preservation.

MATERIAL AND METHODS

Patients treated with adjuvant CXB following local excision between 2004 and 2017 in three centres were identified (Clatterbridge, Hull, Nice). All patients had adverse pathological features including: lymphovacular invasion, Sm2-3 Kikuchi level, tumour budding, pT2, positive resection margins (R1). CXB was performed with the Papillon50 ^tm machine to a dose of 40-60 Gy in 2 or 3 fractions over 2-4 weeks preceding/following external beam chemo/radiotherapy. Kaplan Meier survival estimates were used for outcomes measures.

RESULTS

194 patients were identified. Median age was 70 years. pT staging was: pT1:143, pT2:45, pT3:6. CXB alone was given in 24 pts and combined with EBRT in 170. Median follow-up time was 77 months (range 7-122 months). Local relapse rate was 8% and distant metastases 9%. Organ preservation was achieved in 95%. 6 year local recurrence free and overall survival was 91% and 81% respectively. Cancer specific survival was 97%. No treatment related mortality was seen.

CONCLUSION

This large multi-centre cohort study using adjuvant CXB following local excision suggests excellent oncological outcomes for these patients without completion TME. This treatment approach can be considered as an alternative for selective patients compliant with long term follow up.

Oncologic Nomogram for Stage I Rectal Cancer to Assist Patient Selection for Adjuvant (Chemo)Radiotherapy Following Local Excision

Background: Because of the low rate of lymph node metastasis in stage I rectal cancer (RC), local resection (LR) can achieve high survival benefits and quality of life. However, the indications for postoperative adjuvant therapy (AT) remain controversial. Methods: A retrospective analysis was performed in 6,486 patients with RC (pT1/T2) using the Surveillance, Epidemiology, and End Results (SEER) database. Patients were initially diagnosed from 2004 to 2016; following LR, 967 received AT and 5,519 did not. Propensity score matching (PSM) was used to balance the confounding factors of the two groups; the Kaplan-Meier method and the log-rank test were used for survival analysis. Cox proportional hazards regression analysis was used to screen independent prognostic factors and build a nomogram on this basis. X-tile software was used to divide the patients into low-, moderate-, and high-risk groups based on the nomogram risk score. Results: Multivariate analysis found that age, sex, race, marital status, tumor size, T stage, and carcinoembryonic antigen (CEA) in the non-AT group were independent prognostic factors for stage I RC and were included in the nomogram prediction model. The C-index of the model was 0.726 (95% CI, 0.689-0.763). We divided the patients into three risk groups according to the nomogram prediction score and found that patients with low and moderate risks did not show an improved prognosis after AT. However, high-risk patients did benefit from AT. Conclusion: The nomogram of this study can effectively predict the prognosis of patients with stage I RC undergoing LR. Our results indicate that high-risk patients should receive AT after LR; AT is not recommended for low-risk patients.

Oncological outcome after local treatment for early stage rectal cancer

BACKGROUND

Treatment of early rectal cancer is evolving towards organ-preserving therapy which includes endoscopic resection and transanal approaches. We aimed to explore the role of local treatments such as endoscopic polypectomy (Endoscopic Mucosal Resection (EMR) or Endoscopic submucosal dissection (ESD)) and transanal endoscopic microsurgery/ transanal minimal invasive surgery (TEM/TAMIS) in patients who had early rectal cancer. We considered these outcomes alongside conventional major surgery using total mesorectal excision (TME) for early stage disease.

METHODS

All patients identified at MDT with early stage rectal cancer at our institution between 2010 and 2019 were included. Long-term outcomes in terms of local recurrence, survival and procedure-specific morbidity were analysed.

RESULTS

In total, 536 patients with rectal cancer were identified, of which 112 were included based on their pre-operative identification at the MDT on the basis that they had node-negative early rectal cancer. Among these, 30 patients (27%) had the lesion excised by flexible endoscopic polypectomy techniques (EMR/ESD), 67 (60%) underwent TEM/TAMIS and 15 (13%) had major surgery. There were no differences in patient demographics between the three groups except for TEM/TAMIS patients being more likely to be referred from another hospital (p < 0.001) and they were less active (WHO performance status p = 0.04). There were no significant differences in overall survival rates and cancer-specific survival between the three treatment groups. The 5-year overall survival rate for endoscopic polypectomy, TEM/TAMIS or major resection was 96% versus 90% and 88%, respectively (p = 0.89). The 5- year cancer-specific survival rate was 96%, versus 96% and 100%, respectively (p = 0.74).

CONCLUSION

Endoscopic polypectomy by EMR/ESD is an appropriate local treatment for early stage rectal cancer in selected patients. It is possible to achieve good oncological outcomes with a polypectomy similar to TEM/TAMIS and major surgery; however, a multidisciplinary approach is necessary enabling close surveillance and the use of adjuvant radiotherapy.

Adequate Lymph Node Assessments and Investigation of Gut Microorganisms and Microbial Metabolites in Colorectal Cancer

Purpose

To analyze the lymph node metastasis status and prognosis in CRCs and to investigate the gut microorganisms and microbial metabolites at different lymph node stages.

Methods

The Surveillance, Epidemiology, and End Results (SEER) database and STAT software were used to analyze the clinical features and lymph node metastasis. Bacterial 16S V3-V4 and fungal ITS V3-V4 ribosomal RNA genes were sequenced in 53 stool samples and gas chromatography/mass spectrometry (GS/MS) was performed to detect the microbial metabolites in 48 stool samples from CRC patients.

Results

A higher number of lymph node metastases predicted a poor prognosis. Inadequate evaluation of lymph nodes affects the accuracy of prognostic assessments. We constructed a nomogram model for the assessment of prognostic factors. There were multiple characteristic bacteria identified, including Akkermansia, Megamonas, Dialister, etc., and fungi, including Penicillium, Filobasidium, Debaryomyces, etc. A total of 27 characteristic microbial metabolites in different lymph node metastasis status were also identified.

Conclusion

Gut microorganisms and microbial metabolites may provide reference and guidance for the adequate lymph node assessments (ALNA) in CRC.

Analysis of prognosis, genome, microbiome, and microbial metabolome in different sites of colorectal cancer

BACKGROUND

The colorectum includes ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. Different sites of colorectal cancer (CRC) are different in many aspects, including clinical symptoms, biological behaviour, and prognosis.

PURPOSE

This study aimed to analyse prognosis, genes, bacteria, fungi, and microbial metabolome in different sites of CRC.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database and STAT were used to statistically describe and analyse the prognosis in different sites of CRC. RNA sequences of CRC from Broad Institute's GDAC Firehose were re-annotated and reanalysed based on different sites using weighted gene co-expression network analysis (WGCNA). The Kaplan-Meier method was used to analyse the prognosis and Cytoscape was used to construct a drug-target network based on DGIdb databases. Bacterial 16S V3-V4 and fungal ITS V3-V4 ribosomal RNA genes of stool samples were sequenced. Gas chromatography/mass spectrometry (GS/MS) was performed to detect the microbial metabolites in stool samples. Bioinformatics analysis was performed to compare distinct gut microorganisms and microbial metabolites between rectal and sigmoid cancers.

RESULTS

The prognosis in CRC with different sites is significantly different. The closer to the anus predicted longer survival time. The difference between genes and co-expression pairs in CRC with different sites were constructed. The relative abundance of 112 mRNAs and 26 lncRNAs correlated with the sites of CRC were listed. Nine differentially expressed genes at different sites of CRC were correlated with prognosis. A drug-gene interaction network contained 227 drug-gene pairs were built. The relative abundance of gut bacteria and gut fungus, and the content of microbe-related metabolites were statistically different between rectal and sigmoid cancers.

CONCLUSIONS

There are many differences in prognosis, genome, drug targets, gut microbiome, and microbial metabolome in different colorectal cancer sites. These findings may improve our understanding of the role of the CRC sites in personalized and precision medicine.

Survival Analysis of Cancer Patients in North Eastern Nigeria from 2004 - 2017 - A Kaplan - Meier Method

BACKGROUND:

Cancer is a deadly malignant disease and is prevalent in Sub Saharan Africa. The North East part of Nigeria in particular and the country, in general, are struggling to cope with the increasing burden of cancer and other communicable and non-communicable diseases. The situation is worsened by the ongoing insurgency and terrorist activities in the area.

AIM:

The aim of this paper is to present the research findings from a cohort study aimed at the analysis of the estimation of the survivorship time of the real data of cancer patients in the North-eastern part of Nigeria and to establish if the insurgency in the region has contributed negatively to the life expectancy of its inhabitants.

MATERIAL AND METHODS:

The record of 1,090 patients from medical records departments of the University of Maiduguri Teaching Hospital (UMTH), located in Maiduguri, the capital city of Borno State in northeast Nigeria was obtained. The record showed patients that were diagnosed and died of one type of cancer or the other from 2004 to 2017. All the cancer cases included in the present study were grouped into sex, age, marital status, occupation, date admitted and date of death/discharge. Descriptive statistics and Kaplan-Meier method were used to analyse the data using SPSS version 23 while Microsoft EXCEL and Minitab 16.0 were used for data cleansing and organisation.

RESULTS:

Of the 1,090 patients analysed, 920 (84.40%) experienced the event, i.e. death, while 170 (15.60%) patients were censored. The data were analysed based on the ages and sex of the patients. 50.20% of the patients were of ages 21-50 years. The proportions of patients in this age bracket surviving past 7 days are 75%, while those between ages 80 years and above is 12 days. Others are of survival time of 5 days (ages 0-20 years) and 7 days (51-79 years). Using sex, 75% of the patients’ survival time is 7 days in the case of male and 6 days for females. It is safe to say that the survival time for cancer patients of the university the Maiduguri is 6 days and the result reflects the Northeastern part of Nigeria. This is because the hospital is one of few tertiary healthcare facilities in that area and consequently, cancer cases are often referred there.

CONCLUSION:

Cancer incidence is high, and the probability of survival reduces as the survival time increases. This is a dire situation in need of urgent intervention from the government, groups and individuals to tackle the scourge of cancer, thereby improving on the life expectancy battered by the ongoing Boko Haram insurgency in that region.

Comparison of Short-Term Clinical and Pathological Outcomes after Transanal versus Laparoscopic Total Mesorectal Excision for Low Anterior Rectal Resection Due to Rectal Cancer: A Systematic Review with Meta-Analysis

Background: Transanal total mesorectal excision (TaTME) is a new technique that is designed to overcome the limits of the open and laparoscopic approach for rectal resections. Objective: This study is designed to compare TaTME with standard laparoscopic TME (LaTME). Methods: We searched Medline, Embase, and Scopus databases covering a up to October 2018. Inclusion criteria for study enrolment: (1) study comparing laparoscopic resection of rectal cancer vs. TaTME for rectal malignancy, (2) reporting of overall morbidity, operative time, or major complications. Results: Eleven non-randomized studies were eligible with a total of 778 patients. We found statistical significant differences in regard to major complications in favour of TaTME (RR = 0.55; 95% CI 0.31–0.97; p = 0.04). We did not found significant differences regarding overall complications intraoperative adverse effects, operative time, anastomotic leakage, intra-abdominal abscess occurrence, Surgical Site Infection, reoperations, Length of stay, completeness of mesorectal excision, R0 resection rate, number of harvested lymph nodes, circumferential resection margin, and distal resection margin. Conclusions: This meta-analysis shows benefits of TaTME technique regarding major postoperative complications. Regarding clinicopathological features transanal approach is not superior to LaTME. Currently, the quality of the evidence on benefits of TaTME is low due to lack of randomized controlled trials, which needs to be taken into consideration in further evaluation of the technique. Further evaluation of TaTME require conducting large randomized control trials.