Upfront chemotherapy and short-course radiotherapy with delayed surgery for locally advanced rectal cancer with synchronous liver metastases

Pelvic Radiotherapy in Rectal Cancer Patients With Synchronous Potentially Treatable Liver Metastases

BACKGROUND

The optimal management strategy for Stage IV rectal cancer with potentially treatable liver metastases remains controversial, particularly regarding the role of pelvic radiotherapy (RT).

AIMS

We intend to investigate the impact of pelvic RT on oncological outcomes of rectal cancer with potentially treatable liver metastasis.

METHODS AND RESULTS

This retrospective study included 83 patients diagnosed with rectal cancer and synchronous liver metastases from June 2012 to January 2022. All patients underwent radical surgery for rectal cancer and treatment of synchronous liver metastases, as determined by a multidisciplinary team (MDT). We divided the 83 patients into two treatment groups: chemoradiotherapy and surgery (CRT + S) and chemotherapy and surgery (C + S). The CRT + S group (n = 40) received pelvic RT, systemic therapy, and liver metastasis treatment. The C + S group (n = 43) received systemic therapy and liver metastasis treatment only. A total of 83 patients were analyzed with a median follow-up of 45 months (range 12-127 months). In the CRT + S group, 48.2% (40/83) of patients underwent chemoradiotherapy, while the C + S group comprised 51.8% (43/83) of patients who received chemotherapy only. The CRT + S group demonstrated significantly longer local recurrence-free survival compared to the C + S group (median 37.5 vs. 34 months; p = 0.011). In addition, patients in the CRT + S group had a longer median overall survival (OS) compared to the C + S group (46.50 vs. 44.0 months; p = 0.0497). Notably, achieving no evidence of disease (NED) status after definitive treatment for both primary and liver metastases was associated with improved OS (p = 0.008).

CONCLUSION

This study suggests that the addition of pelvic RT to multimodality therapy for patients with rectal cancer and potentially treatable liver metastases may improve local control and long-term survival. The findings support the consideration of RT in the clinical management of this patient population.

The role of superior hemorrhoidal vein ectasia in the preoperative staging of rectal cancer

Objective

The prognosis of colorectal cancer has continuously improved in recent years thanks to continuous progress in both the therapeutic and diagnostic fields. The specific objective of this study is to contribute to the diagnostic field through the evaluation of the correlation between superior hemorrhoidal vein (SHV) ectasia detected on computed tomography (CT) and Tumor (T), Node (N), and distant metastasis (M) examination and mesorectal fascia (MRF) invasion in the preoperative staging of rectal cancer.

Methods

Between January 2018 and April 2022, 46 patients with histopathological diagnosis of rectal cancer were retrospectively enrolled, and the diameter of the SHV was evaluated by CT examination. The cutoff value for SHV diameter used is 3.7 mm. The diameter was measured at the level of S2 during portal venous phase after 4× image zoom to reduce the interobserver variability. The parameters evaluated were tumor location, detection of MRF infiltration (defined as the distance < 1 mm between the tumor margins and the fascia), SHV diameter, detection of mesorectal perilesional lymph nodes, and detection of metastasis.

Results

A total of 67.39% (31/46) of patients had SHV ectasia. All patients with MRF infiltration (4/46, 7.14%) presented SHV ectasia (average diameter of 4.4 mm), and SHV was significantly related with the development of liver metastases at the moment of primary staging and during follow-up.

Conclusion

SHV ectasia may be related to metastasis and MRF involvement; therefore, it could become a tool for preoperative staging of rectal cancer.

Locally advanced mid/low rectal cancer with synchronous resectable liver metastases: systematic review of the available strategies and outcome

The management of patients with locally advanced mid/low rectal cancer with resectable liver metastases is complex because of the need to combine the optimal treatment of both tumors. This study aims to review the available treatment strategies and compare their outcome, focusing on radiotherapy (RT) and liver-first approach (LFA). A systematic review was performed in PubMed, Embase, and web sources including articles published between 2000 and 02/2023 and reporting mid-/long-term outcomes. Overall, twenty studies were included (n = 1837 patients). Three- and 5-year overall survival (OS) rates were 51-88% and 36-59%. Although several strategies were reported, most patients received RT (1448/1837, 79%; > 85% neoadjuvant). RT reduced the pelvic recurrence risk (5.8 vs. 13.5%, P = 0.005) but did not impact OS. Six studies analyzed LFA (n = 307 patients). LFA had a completion rate similar to the rectum-first approach (RFA, 81% vs. 79%) but the interval strategy-an LFA variant with liver surgery in the interval between radiotherapy and rectal surgery-had a better completion rate than standard LFA (liver surgery/radiotherapy/rectal surgery, 92% vs. 75%, P = 0.011) and RFA (79%, P = 0.048). Across all series, LFA achieved the best survival rates, and in one paper it led to a survival advantage in patients with multiple metastases. In conclusion, different strategies can be adopted, but RT should be included to decrease the pelvic recurrence risk. LFA should be considered, especially in patients with high hepatic tumor burden, and RT before liver surgery (interval strategy) could maximize its completion rate.