Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate

Identifying baseline rectal MRI features as predictive indicators for local recurrence and metastatic disease in rectal cancer treated with surgical resection and neoadjuvant therapy or surgical resection alone

BACKGROUND

To identify baseline rectal MRI characteristics that may serve as predictive factors for recurrence in patients with rectal adenocarcinoma after surgical resection.

METHODS

This retrospective, single-center study included 269 consecutive patients (median age, 55 years [interquartile range, 47-65]; 144 men and 125 women) diagnosed with rectal cancer from January 2015-December 2017 who underwent baseline rectal MRI followed by surgical resection. MRI characteristics were collected from rectal MRI synoptic reports. Recurrence-free survival was defined as the time between surgical resection and recurrence (local recurrence and/or metastatic disease) or death. Statistical analysis included Cox proportional hazards to determine associations between baseline rectal MRI/clinical characteristics and recurrence.

RESULTS

The median recurrence-free survival in the study sample was 6.4 years. Baseline rectal MRI characteristics associated with recurrence at univariable analysis were: age > 55 years (P = 0.044), low rectal tumor location (P = 0.04), craniocaudal length ≥ 5.0 cm (P = 0.007), anal canal involvement (P = 0.011), presence of suspicious total mesorectal excision (TME) lymph nodes > 0.5 cm (P = 0.03), mesorectal fascia involvement (P = 0.04), T3 stage (P = 0.024), T4 stage (P = 0.008), and M1 stage (P = 0.024). At multivariable analysis, only age > 55 years (P = 0.012) and the presence of suspicious TME lymph nodes > 0.5 cm (P = 0.049) remained associated with recurrence.

CONCLUSION

Advanced age and the presence of suspicious TME adenopathy > 0.5 cm on baseline rectal MRI are associated with higher risk of recurrent disease in patients with resected rectal cancer.

Transition to lateral lymph node dissection in rectal cancer: Forty-five years of outcomes data

PURPOSE

To determine how outcomes of lateral lymph node dissection for rectal cancer have changed over time.

METHODS

This retrospective study included patients with rectal cancer without distant metastasis who underwent total mesorectal excision and lateral lymph node dissection at our institution between 1975 and 2020. We examined the association of surgical time period with relapse-free and overall survival. Multivariable analyses were performed using Cox proportional hazards regression models.

RESULTS

Among a total of 992 patients, 386 underwent surgery in 1975-2000, 296 in 2001-2010, and 310 in 2011-2020. Overall, 924 patients (93%) underwent surgery without preoperative therapy. The respective 5-year relapse-free survival rates were 64.2%, 64.2%, and 68.2% (P = .314), and the 5-year overall survival rates were 72.3%, 84.0%, and 89.3% (P < .001). Overall survival could be stratified by surgical time period, especially stage III (P < .001). In patients with lateral lymph node metastasis, the 5-year overall survival rate was 43.5% in 1975-2000, 61.1% in 2001-2010, and 71.1% in 2011-2020 (P = .003). Multivariable analysis revealed significant differences in overall survival between 2011-2020 and 1975-2000 (hazard ratio, 2.81; P < .001) and between 2011-2020 and 2001-2010 (hazard ratio, 1.59; P = .040), but not in relapse-free survival.

CONCLUSION

The impact of lateral lymph node dissection on rectal cancer treatment may not have changed in 45 years, given the lack of difference in relapse-free survival. Treatment outcomes after recurrence may have improved. The prognosis remains poor for lateral lymph node metastasis, highlighting the need for further development of multimodality treatments.

Volumetric histogram analysis of amide proton transfer-weighted imaging for predicting complete tumor response to neoadjuvant chemoradiotherapy in locally advanced rectal adenocarcinoma

OBJECTIVES

To investigate the potential of histogram analysis applied to pre-treatment amide proton transfer-weighted (APTw) imaging in predicting complete pathological regression (pCR) in patients with locally advanced rectal cancer (LARC) undergoing neoadjuvant chemoradiotherapy (nCRT).

MATERIALS AND METHODS

This retrospective study enrolled LARC patients who underwent preoperative rectal magnetic resonance imaging (MRI). Based on histologic assessment, the patients were divided into a pathological complete response (pCR) group or a non-pCR group. APTw histogram features, apparent diffusion coefficient (ADC), and clinical parameters were analyzed. Mann-Whitney U-test, Spearman rank correlation, and univariate and multivariate logistic regression were used for statistical analysis. The predictive performances of different models were evaluated by the receiver operating characteristic curve (ROC).

RESULTS

One-hundred forty-five patients were included (mean age, 61.6 years ± 11.8 [SD]; 87 men). pCR patients exhibited lower pre-treatment ADC value, higher pre-treatment APTw-10%, APTw-90%, minimum, maximum, median, mean, range, and root mean square (RMS) of the primary tumor compared to non-pCR patients (all p < 0.05). APTw-10%, APTw-90%, maximum, mean, median, minimum, range, and RMS showed negative correlations with the tumor regression grade (TRG) category (r ranged between -0.457 and -0.173; all p < 0.005). Skewness, kurtosis, and entropy exhibited positive correlations with the TRG category (r = 0.278, 0.319, and 0.324, respectively; all p < 0.05). The combined model had a higher AUC of 0.930, with 93.9% sensitivity and 83.9% specificity.

CONCLUSION

Histogram analysis of pre-treatment APTw may hold promise as a novel approach for predicting the response of LARC patients to nCRT.

KEY POINTS

Question Predicting response to nCRT is crucial for early stratified management of LARC patients; however, current radiological studies remain inconclusive. Finding LARC patients with pCR is correlated with higher pre-treatment APTw intensity-related and lower shape-related histogram features. Clinical relevance The APTw-histogram model and the APTw-clinical combined model demonstrated strong diagnostic efficacy and clinical practicality in predicting LARC patients' responsiveness to nCRT, offering new insights for early clinical decision-making.

Contouring atlas and essential points for radiotherapy in rectal cancer

In the last decade, the role of radiotherapy in rectal cancer has changed significantly with the introduction of total neoadjuvant therapy (TNT) and nonoperative management (NOM). For the setting of irradiation field in rectal cancer, the pararectal, lateral lymph nodes, and those along the inferior mesenteric artery (IMA) are most important. In total mesorectal excision (TME), the root of the IMA is dissected. In the atlas of pelvic irradiation for rectal cancer, the setting of the upper margin of the mesorectum varies from atlas to atlas, and no atlas sets the upper margin of the mesorectum to the root of the IMA. In particular, there is no consensus on the definition of anatomical boundaries regarding the lymph nodes along the superior rectal artery (SRA). The upper margin of the irradiation field in clinical trials of preoperative radiotherapy and TNT is generally set at the level of the internal and external iliac artery branches, L5/S1, or S2/S3. However, it is not necessary to include the entire mesorectum to the root of the IMA in patients undergoing preoperative radiotherapy plus TME. Conversely, for patients receiving NOM, the irradiation field may have to include the mesorectum to the IMA root, though the incidence of lymph node metastasis and gastrointestinal adverse events merits consideration. It is increasingly important to determine the extent of clinical target volume around the SRA region and the setting of the upper margin of the irradiation field after formulating the treatment policy together with the surgeons and medical oncologists.

Short-course versus long-course neoadjuvant chemoradiotherapy in patients with rectal cancer: long-term results of a randomized controlled trial

BACKGROUND AND PURPOSE

Short-course radiotherapy (SCRT) and long-course radiotherapy (LCRT) are the primary neoadjuvant radiotherapy schedules for locally advanced rectal cancer. Recent research has questioned the efficacy of SCRT. This study presents an updated analysis of our previous research, extending the follow-up to evaluate 5-year outcomes by comparing the long-term results of these two strategies.

MATERIALS AND METHODS

This randomized controlled trial compared SCRT and LCRT in locally advanced middle or high rectal adenocarcinoma. The SCRT group received 25 Gy/5 fractions over 1 week plus CAPOX, while the LCRT group received 50-50.4 Gy/25-28 fractions over 5-5.5 weeks plus capecitabine. All patients received consolidation chemotherapy and then underwent delayed surgery after 8 weeks or more post-radiotherapy. The endpoints of this updated analysis include overall survival (OS),disease-free survival (DFS), locoregional recurrence (LR) and distant metastasis (DM).

RESULTS

Ninety-nine cases (45 LCRT, 54 SCRT) were followed for a median of 4.7 years. Five-year OS rates were 77.3% for LCRT vs. 65.6% for SCRT group (P = 0.4). The 5-year DFS rates were 69.6% for LCRT vs. 54.9% for SCRT (P = 0.07). Cox regression indicated no prominent difference between the two groups regarding OS, LR, or DM. Subgroup analysis demonstrated a significantly better DFS with LCRT compared to SCRT in male patients ([HR] = 2.48, 95%CI: 1.04-5.93, P = 0.03), patients under the age of 60 (HR = 3.19, 95%CI: 1.03-9.92, P = 0.04), and cT4 patients (HR not calculated: no events in LCRT group, P = 0.004).

CONCLUSION

DFS showed a trend in favor of the LCRT group, with LCRT being significantly superior among men, patients under 60, and cT4 stage. Despite being intensified, SCRT failed to achieve long-term outcomes comparable to LCRT. Further research is needed to compare these two approaches in the context of total neoadjuvant treatment.

TRIAL REGISTRATION DATA

IRCT2017110424266N3 (Registration date: 2017-11-12).  https://irct.behdasht.gov.ir/trial/20526 .

[Intraoperative frozen section diagnostics for low rectal cancer-Primary surgery vs. neoadjuvant pretreatment]

Depending on the extent of the tumor, the treatment strategies for rectal cancer include primary surgical resection or, in the case of locally advanced carcinoma, neoadjuvant chemo(radio)therapy (C[R]Tx) or total neoadjuvant therapy (TNT), usually followed by surgical treatment. During resection, it is important to find a balance between radicality and preservation of function. Current data show that shorter safety margins are possible for patients who received neoadjuvant treatment without compromising the oncological outcome. This enables continence-preserving surgery in many patients with low rectal cancer. In these cases in particular, intraoperative frozen section diagnostics play a central role in confirming tumor-free margins. However, frozen section diagnostics also play an important role in the transanal resection of early carcinomas or in the therapy of recurrent rectal cancer. It should not be performed routinely, but rather in a targeted maner for specific questions and the corresponding therapeutic consequences. The informative value of frozen section diagnostics in neoadjuvant treated rectal cancer may be limited, so that the final assessment of the resection status and thus the determination of further therapy must be based on paraffin-embedded sections.

Efficacies of radiotherapy in rectal cancer patients treated with total mesorectal excision or other types of surgery: an updated meta-analysis

Background

An updated meta-analysis was conducted to evaluate the efficacy of radiotherapy in rectal cancer patients treated with total mesorectal excision (TME) or other types of surgery (non-TME-only).

Methods

The PubMed, Cochrane Library, and CNKI databases were searched. Data on overall survival (OS) were extracted.

Results

Hazard ratios (HRs) for OS associated with preoperative radiotherapy, preoperative long-course concurrent chemoradiotherapy (LCCRT), preoperative radiotherapy alone, and postoperative radiotherapy in patients treated with TME were 1.02 [95% CI: 0.92-1.14, P = 0.65], 1.04 [95% CI: 0.93-1.16, P = 0.47], 0.87 [95% CI: 0.61-1.25, P = 0.46], and 1.18 [95% CI: 0.91-1.52, P = 0.20], respectively. HRs for OS associated with preoperative radiotherapy, preoperative LCCRT, preoperative radiotherapy alone, preoperative long-course RT (LCRT), and preoperative short-course radiotherapy (SCRT) in patients treated with non-TME-only surgery were 0.85 [95% CI: 0.79-0.90, P < 0.00001], 0.77 [95% CI: 0.63-0.94, P = 0.009], 0.86 [95% CI: 0.80-0.92, P < 0.0001], 0.83 [95% CI: 0.73-0.95, P = 0.005], and 0.84 [95% CI: 0.77-0.91, P= <0.0001], respectively. The HR for postoperative radiotherapy in patients treated with non-TME-only surgery was 1.08 [95% CI: 0.84-1.39, P = 0.57].

Conclusion

Preoperative radiotherapy, regardless of the regimen, improves the OS in patients treated with non-TME-only surgery, but not in those treated with TME. Postoperative radiotherapy does not improve OS.

Advances in knowledge

This meta-analysis will serve as a reference for decision-making in multidisciplinary approaches for rectal cancer patients.

Neoadjuvant Radiotherapy vs Up-Front Surgery for Resectable Locally Advanced Rectal Cancer

Importance

Guidelines for resectable locally advanced rectal cancer (LARC) advocate for neoadjuvant radiotherapy (NRT) followed by surgery as the standard approach. However, recent trials have reported no oncological benefits of NRT-based therapy for middle or lower rectal cancer, raising the question of whether NRT followed by surgery remains the optimal treatment approach for resectable LARC overall.

Objective

To compare the outcomes of NRT followed by surgery vs up-front surgery for resectable LARC.

Design, Setting, and Participants

This cohort study, using a target trial emulation framework with nationwide registries in Taiwan, included patients undergoing curative resection for resectable LARC (cT1-2N1-2, cT3Nany) between January 1, 2014, and December 31, 2017, with follow-up until December 31, 2020. Data were analyzed from January 1, 2024, to February 15, 2025.

Exposure

NRT.

Main Outcomes and Measures

The primary outcomes were overall survival (OS) and local recurrence (LR). The secondary outcome was intraoperative diverting stoma outcomes.

Results

A total of 4099 patients were analyzed, including 1436 patients undergoing NRT followed by surgery (median [IQR] age, 62.0 [53.0-71.0] years; 1036 [72.1%] male) and 2663 patients undergoing up-front surgery (median [IQR] age, 65.0 [56.0-74.0] years; 1626 [61.1%] male). NRT followed by surgery, compared with up-front surgery, was associated with higher 3-year OS rates (88.5% vs 85.2%; hazard ratio [HR], 0.74; 95% CI, 0.59-0.92) but higher permanent diverting stoma rates (20.6% vs 11.1%; relative risk [RR], 1.91; 95% CI, 1.62-2.25); LR rates were not significantly different (5.7% vs 6.6%; HR, 0.78; 95% CI, 0.55-1.11). Subgroup analysis revealed that compared with up-front surgery, NRT followed by surgery was associated with improved outcomes in middle or lower rectal cancer but not upper rectal cancer (OS: HR, 1.54; 95% CI, 0.82-2.90; LR: HR, 1.08; 95% CI, 0.23-5.00). NRT followed by surgery was associated with significantly increased risks of permanent diverting stomas across different tumor heights, particularly in upper rectal cancer (RR, 3.54; 95% CI, 1.44-8.69).

Conclusions and Relevance

In this cohort study of nationwide registries in Taiwan, NRT followed by surgery was associated with improved oncological outcomes for overall resectable LARC, with excessive diverting stoma nonreversal as the trade-off. However, the benefits of NRT were not observed for upper rectal cancer. These findings raise concerns about potential harm from NRT and advise caution when performing NRT for upper rectal cancer.

The Landmark Series: Neoadjuvant Therapy for Locally Advanced Rectal Cancer

The management of locally advanced rectal cancer (LARC) has seen much development over recent decades. Neoadjuvant radiotherapy combined with high-quality total mesorectal excision saw improvements in locoregional control. With the advent of several key trials, neoadjuvant therapy for LARC has seen a shift toward total neoadjuvant therapy, with corresponding improvements in tumor response and survival outcomes. The collective pool of evidence has allowed for increasingly personalized treatment of LARC, with organ-preservation now an option for many. The aims of the review are to summarize the evolution of neoadjuvant therapy for LARC, highlight key studies informing contemporary best practices, navigate the complexity of options available, and present areas of ongoing development.

Short- and long-term outcomes of minimally invasive vs. open pelvic exenteration in rectal tumours: a focused meta-analysis

PURPOSE

Pelvic exenteration (PE) is a complex surgical procedure used to treat patients with recurrent or locally advanced rectal cancer (LARC) as a final recourse. Thus, minimally invasive surgery (MIS) has emerged as an alternative to the traditional open PE as it may reduce surgical trauma and improve recovery. This meta-analysis compared the clinical outcomes between MIS and open PE in patients with LARC.

METHODS

A systematic review and meta-analysis were conducted following PRISMA and AMSTAR guidelines. Six retrospective studies comprising 368 patients (179 MIS patients; 189 open patients) were included. Data on operative parameters along with short-term and long-term outcomes, including the 3-year overall (OS) and disease-free survival (DFS), were extracted. Risk ratios (RRs) and odds ratios (ORs) were calculated for binary outcomes, while standardised mean differences (SMDs) were calculated for continuous outcomes. All measures were reported with 95% confidence intervals (CIs) using random-effects models.

RESULTS

MIS was associated with significantly reduced blood loss (standardised mean difference (SMD), - 1.57; 95% CI, - 2.27 to - 0.88; p < 0.00001), shorter hospital stays (SMD, - 6.46; 95% CI, - 12.21 to - 0.71; p = 0.03), and quicker diet resumption (SMD: - 0.79; 95% CI, - 1.36 to - 0.21; p = 0.008) than open PE. MIS was associated with a borderline reduction in total complications (OR, 0.45; 95% CI, 0.20-1.00; p = 0.05) and lower rates of abdominal wound complications (OR, 0.22; 95% CI, 0.11 to 0.45; p < 0.0001). No significant differences were observed in R0 resection rates, major complications, or mortality. For long-term outcomes, MIS demonstrated significantly improved 3-year OS (RR, 1.19; 95% CI, 1.01 to 1.41; p = 0.04), whereas 3-year DFS showed no significant difference (RR, 1.02; 95% CI, 0.79 to 1.41; p = 0.87).

CONCLUSION

MIS offers significant short-term advantages over open PE, including reduced blood loss, faster recovery, and fewer complications while demonstrating improved 3-year OS. These findings support MIS PE as a safe, effective, and viable option for patients with recurrent or LARC.

Treatment outcomes after pelvic exenteration with IGAM or VRAM flap reconstruction: Review of 130 consecutive cases

BACKGROUND

Pelvic exenteration (PE) is an extensive surgical procedure with high perioperative morbidity. Although the vertical rectus abdominis myocutaneous (VRAM) flap is considered the gold standard for reconstructing complex perineal defects, it is associated with substantial donor (10-20%) and recipient (20-30%) site complications. An alternative form of locoregional flap reconstruction, the inferior gluteal artery myocutaneous (IGAM) flap was introduced. This study evaluated flap-specific complications, donor associated morbidity and compared the treatment outcomes in patients undergoing VRAM or IGAM reconstructions following PE.

METHODS

Data were prospectively collected and retrospectively reviewed for adult patients treated at Peter MacCallum Cancer Centre, Melbourne, Australia between January 2008 and 2020. Statistical analyses assessed the relationships between patient demographics, clinical features, reconstructive characteristics, and treatment outcomes. The primary outcome was the occurrence of partial or total flap failure. Secondary outcomes included early return to theatre (RTT), wound dehiscence, surgical site infection, perioperative transfusion, and chronic pain.

RESULTS

Among the 130 patients (97.7% previously irradiated), 56 (43.1%) received IGAM and 74 (56.9%) received VRAM flap reconstructions. The median overall survival was 74.3 months and the 5-year overall survival was 56.2%. Univariate analysis demonstrated that VRAM flaps were significantly associated with higher rates of flap failure (p = 0.01), early RTT, dehiscence, and infection (p < 0.001) compared with IGAM. Multivariate logistic regression confirmed increased adverse outcomes in the VRAM sub-group.

CONCLUSION

In this study, IGAM flaps showed lower flap-specific complications, reduced donor morbidity, and improved treatment outcomes. These findings support the IGAM as the preferred flap choice over VRAMs for reconstructing complex perineal defects after PE.

Radiation Therapy for Rectal Cancer: An ASTRO Clinical Practice Guideline Focused Update

PURPOSE

With the results of several recently published clinical trials, this guideline focused update provides evidence-based recommendations for the indications and dose-fractionation regimens for neoadjuvant radiation therapy (RT), optimal sequencing of RT and systemic therapy in the context of total neoadjuvant therapy (TNT), and considerations for selective omission of RT and surgery for rectal cancer.

METHODS

The American Society for Radiation Oncology convened a multidisciplinary task force to update 3 key questions that focused on the role of RT for patients with operable rectal cancer. The key questions addressed (1) indications for neoadjuvant RT, (2) selection of neoadjuvant regimens, and (3) indications for consideration of a nonoperative management (NOM) or local excision approach after definitive/preoperative chemoradiation. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for quality of evidence grading and strength of recommendation.

RESULTS

For patients with stage II-III rectal cancer, neoadjuvant RT was strongly recommended; however, among patients deemed at lower risk of locoregional recurrence, consideration of omission of neoadjuvant RT was conditionally recommended in favor of neoadjuvant chemotherapy with a favorable treatment response or upfront surgery. For patients with T3-T4 and node-positive rectal cancer undergoing neoadjuvant RT, a TNT approach was strongly recommended. Among patients with higher risk of locoregional recurrence, TNT with chemotherapy before or after long-course chemoradiation was strongly recommended, whereas TNT with short-course RT followed by chemotherapy was conditionally recommended. For patients with rectal cancer for whom NOM is a priority, concurrent chemoradiation followed by consolidation chemotherapy was strongly recommended. Selection of RT dose-fractionation regimen, sequencing of therapies, and consideration of NOM should be determined by multidisciplinary consensus and based on disease extent, disease location, patient preferences, and quality of life considerations.

CONCLUSIONS

The task force proposed recommendations to inform best clinical practices on the use of RT for rectal cancer with strong emphasis on multidisciplinary care. Future studies should focus on further addressing optimal treatment regimens to allow for more personalized recommendations based on individual risk stratification and patient priorities regarding quality of life.

Neoadjuvant Modified Infusional Fluorouracil, Leucovorin, and Oxaliplatin With or Without Radiation Versus Fluorouracil Plus Radiation for Locally Advanced Rectal Cancer: Updated Results of the FOWARC Study After a Median Follow-Up of 10 Years

We present 10-year results of the phase Ⅲ FOWARC trial, which evaluated the efficacy of modified infusional fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) with or without radiation compared with fluorouracil with radiation in patients with locally advanced rectal cancer. A total of 495 patients age 18-75 years with stage Ⅱ-Ⅲ rectal cancer were randomly assigned to three treatment arms: fluorouracil plus radiotherapy, mFOLFOX6 plus radiotherapy, or mFOLFOX6 alone, followed by surgery and adjuvant chemotherapy. With a median follow-up of 10 years, the 10-year disease-free survival (DFS) rates were 52.5%, 62.6%, and 60.5%, respectively (P = .56). The 10-year locoregional recurrence (LR) rates were 10.8%, 8.0%, and 9.6% (P = .57), and the 10-year overall survival (OS) rates were 65.9%, 72.3%, and 73.4% (P = .90). Subgroup analysis identified ypTNM stage as a significant prognostic factor for DFS, LR, and OS (P < .0001, P < .006, P < .0001, respectively). Patients achieving pathologic complete response had 10-year DFS, LR, and OS rates of 84.3%, 3.0%, and 92.4%, respectively. No significant difference was observed in long-term survival outcome between mFOLFOX6 with and without radiation and fluorouracil plus radiation. These results demonstrate that neoadjuvant mFOLFOX6 chemotherapy can be considered as a therapeutic option in LARC.

Adenosquamous carcinoma of the gallbladder: a Bi-institutional experience in managing this rare entity

BACKGROUND

Adenosquamous Gallbladder Cancers (ASGBC) are rare variety of GBCs. Relative paucity of data with regards to the management of ASGBC exists.

METHODS

Patients with diagnosis of ASGBC from January 2012 to March 2022 were categorised into 'Early', 'Locally advanced (LA)' and 'Metastatic (M)' ASGBC as per the predefined 'TMH Criteria'.

RESULTS

A total of 196 patients included were categorised into early ASGBC (n = 19,9.7%), LA - ASGBC (n = 53,27%) and M - ASGBC (n = 124,63.3%) with median overall survival (OS) being worst for M - ASGBC (3.9 months) and best for early ASGBC (not reached). The 1-year and 3-year OS of LA-ASGBC patients who underwent surgery was significantly higher than those with non-surgical treatment (72.6%, 35.6% vs 25.1%, 0%, p <0.001). Although, the median OS of resected ASGBC was less as compared to resected gallbladder adenocarcinomas (GBACs) (40.8 vs. 56.1 months), it did not reach statistical significance (p=0.06). However, at higher stages of resected LA - ASGBC (Stage III), the median OS was significantly lower as compared to stage-matched resected GBACs (14.5 vs. 30.1 months, p= 0.006).

CONCLUSION

Multimodality treatment consisting of margin negative surgical resection with perioperative chemotherapy offers the best chance of long-term survival in ASGBC.

Prospective analysis of 246 fires of da Vinci SureForm SmartFire stapler in colorectal cancer: First Indian study

INTRODUCTION

One of the critical steps involved is the distal transection of the rectum in rectal cancer surgeries. Multiple staple firings have been proven to increase the rate of anastomotic leakage. In this study, we intended to learn the effectiveness of the robotic SureForm SmartFire (SS) stapling system and its application in robotic sigmoid colon and rectal procedures performed at our institution.

PATIENTS AND METHODS

Prospective study of patients who underwent surgeries for sigmoid/rectal cancer at our centre was considered. During the surgery, SS staplers were used, and its internal data log with regard to reload selection by the colour, reloads, clamp attempts and staple fires was considered along with intra- and post-operative outcomes.

RESULTS

246 firings were done in 147 cases with mean body mass index of 26.3 ± 4.3 kg/m2; mean blood loss was 53.6 ± 21.8 ml. None of our patients had stapler-related complications, and the mean length of stay was 7.18 ± 1.5 days. Average reloads used in robotic-low anterior resection (LAR) were 1.73 with the fire attempts beyond lap angle occurring only in robotic-assisted LAR (RA-LAR)/abdominoperineal resection in 87 fires (41%) with 120 instances of controlled and sequential pauses occurred in 246 fires once fire pedal was activated.

CONCLUSION

Apart from oncological nodal and margin clearance in the carcinoma rectum surgery, obtaining adequate distal margin, sphincter preserving approach and distal transection of the rectum forms one of the key steps in the low anterior resection. Robotic SS staplers have 120° angulation in both axes with EndoWrist technology that has better manoeuvrability within the confines of the pelvis.

Therapeutic Management of Locally Advanced Rectal Cancer: Existing and Prospective Approaches

Rectal cancer (RC) presents significant challenges in diagnosis and treatment, with increasing incidence among younger populations. Treatment approaches, particularly for locally advanced rectal cancer (LARC), have evolved, notably with the introduction of total neoadjuvant therapy (TNT). TNT combines neoadjuvant chemotherapy and chemoradiotherapy before surgery, improving overall survival and reducing both metastasis and local recurrence rates compared to traditional methods, while enabling more patients to complete the full oncological treatment. Clinical trials, such as RAPIDO, OPRA, and PRODIGE 23, have demonstrated the effectiveness of TNT in tumor downstaging and complete pathological responses, offering better outcomes for patients; however, debates persist regarding the role of neoadjuvant radiotherapy, with novel strategies exploring its omission in specific cases to reduce toxicity and enhance quality of life. In addition, organ preservation strategies, such as the watch-and-wait (WW) approach, have emerged as viable options for patients with a complete response to neoadjuvant therapy. Future directions point towards personalized treatment plans incorporating radiogenomics and the integration of artificial intelligence into diagnostics to optimize patient outcomes. This review aims to synthesize current treatment strategies and ongoing advancements in rectal cancer management, providing insights into potential future innovations.

Radioresistance in rectal cancer: can nanoparticles turn the tide?

Rectal cancer accounts for over 35% of the worldwide colorectal cancer burden representing a distinctive subset of cancers from those arising in the colon. Colorectal cancers exhibit a continuum of traits that differ with their location in the large intestine. Due to anatomical and molecular differences, rectal cancer is treated differently from colon cancer, with neoadjuvant chemoradiotherapy playing a pivotal role in the control of the locally advanced disease. However, radioresistance remains a major obstacle often correlated with poor prognosis. Multifunctional nanomedicines offer a promising approach to improve radiotherapy response rates, as well as to increase the intratumoral concentration of chemotherapeutic agents, such as 5-Fluorouracil. Here, we revise the main molecular differences between rectal and colon tumors, exploring the complex orchestration beyond rectal cancer radioresistance and the most promising nanomedicines reported in the literature to improve neoadjuvant therapy response rates.

Nonoperative management of rectal cancer

The management of locally advanced rectal cancer has changed drastically in the last few decades due to improved surgical techniques, development of multimodal treatment approaches and the introduction of a watch and wait (WW) strategy. For patients with a complete response to neoadjuvant treatment, WW offers an opportunity to avoid the morbidity associated with total mesorectal excision in favor of organ preservation. Despite growing interest in WW, prospective data on the safety and efficacy of nonoperative management are limited. Challenges remain in optimizing multimodal treatment regimens to maximize tumor regression and in improving the accuracy of patient selection for WW. This review summarizes the history of treatment for rectal cancer and the development of a WW strategy. It also provides an overview of clinical considerations for patients interested in nonoperative management, including restaging strategies, WW selection criteria, surveillance protocols and long-term oncologic outcomes.

Effects of Adjuvant Chemotherapy on Oncologic Outcomes in Patients With Stage ⅡA Rectal Cancer Above the Peritoneal Reflection Who Did Not Undergo Preoperative Chemoradiotherapy

PURPOSE

This study aimed to evaluate the effects of adjuvant chemotherapy (AC) on oncologic outcomes for patients with stage IIA upper rectal cancer and to investigate whether AC is associated with improved survival outcomes.

METHODS

This retrospective study comprised 432 patients with rectal cancer above the peritoneal reflection who had undergone curative resection without preoperative chemoradiotherapy between 2008 and 2016. This study cohort was divided according to whether AC was received (AC group) or not (no-AC group). Risk factors included obstruction, perforation, poorly-differentiated tumor, lympho-vascular invasion, perineural invasion, resection margin involvement, and < 12 lymph nodes harvested.

RESULTS

Among the 432 patients, 279 (64.6%) had received AC. The AC group had significantly higher 5-year overall survival (OS) rates than those of the no-AC group (93.2% vs. 84.6%, P = .001). Among patients with ≥ 1 risk factors, the AC group (n = 123) had significantly higher rates of 5-year recurrence-free survival (RFS) (81.6% vs. 64.1%, P = .01) and 5-year OS (88.8% vs. 69.0%, P = .001) than those of the no-AC group (n = 59). No significant difference in survival outcomes was observed between the 2 groups in patients aged > 65 years.

CONCLUSION

AC was significantly associated with better 5-year RFS and 5-year OS rates in patients with stage IIA rectal cancer above peritoneal reflection who did not receive preoperative chemoradiotherapy, especially in those with ≥ 1 risk factors.

Neoadjuvant chemoradiotherapy is associated with prolonged relapse free survival in patient with MRI-detected extramural vascular invasion (mrEMVI) positive rectal cancer: A multicenter retrospective cohort study in Japan

PURPOSE

Neoadjuvant chemoradiotherapy (nCRT) is employed for the local control of locally advanced rectal cancer; however, its prognostic impact is limited and often impairs pelvic organ function. Therefore, careful patient selection is essential. This study aimed to investigate the impact of nCRT on relapse-free survival (RFS) by stratifying patients according to MRI detected circumferential resection margin (mrCRM) or extramural vascular invasion (mrEMVI), as the ability of MRI findings to identify patients who will have beneficial outcomes from nCRT is uncertain.

METHODS

We retrospectively analyzed patients with clinical stage II-III lower rectal cancer who underwent surgical resection with or without nCRT between 2010 and 2011 at 69 hospitals in Japan. The impact of nCRT on RFS was evaluated using multivariable Cox regression models in the entire cohort and in subgroups stratified by mrCRM or mrEMVI status.

RESULTS

In the entire cohort (nCRT, n = 172; surgery alone, n = 503), nCRT showed a trend toward improved RFS, although the difference was not statistically significant (HR, 0.74; 95 % CI, 0.54-1.03; P = 0.074). Among mrCRM-negative and mrEMVI-negative patients, there were no significant differences in RFS between the nCRT and surgery-alone groups. Among mrCRM-positive patients, nCRT tended to improve the RFS (HR, 0.70; 95 % CI, 0.46-1.06; P = 0.089). Among mrEMVI-positive patients, nCRT significantly prolonged the RFS (HR, 0.62; 95 % CI, 0.38-1.00; P = 0.048).

CONCLUSIONS

Compared to surgery alone, nCRT did not significantly improve RFS in the overall population but significantly improved RFS in mrEMVI-positive patients.

Review of definition and treatment of upper rectal cancer

While the treatment of locally advanced lower and middle rectal cancer with total mesorectal excision (TME) after neoadjuvant therapy is now well defined, the treatment of locally advanced upper rectal cancer (LAURC) remains controversial. Although most teams and academic societies recommend upfront surgery (US) with partial mesorectal excision (PME), as this appears to be sufficient for these tumors, the literature remains conflicting regarding the additional use of neoadjuvant therapy and TME. Current recommendations for the treatment of LAURC do not reflect actual clinical practice. Notably, there is a paucity of published data specific to the treatment of LAURC since most of the data are from sub-analyses of different cohorts. Another important point responsible for the inconsistent data situation is the fact that the current definition of upper rectal cancer is based on anatomical criteria that are difficult to reproduce and therefore also differ between international professional societies. The aim of this review is to provide a deeper insight into the issues surrounding the treatment of LAURC based on an analysis of the current literature, including anatomic and embryologic data.

Upper Rectal Cancer: To Irradiate or Not?

Introduction This study examines the ongoing debate surrounding treatment strategies for upper rectal cancer. While neoadjuvant chemoradiotherapy (NCRT) is well established for mid and low rectal cancers, its efficacy for upper rectal cancers remains contentious. The objective of this study was to evaluate the safety, clinical outcomes, and oncologic results of chemoradiation in upper rectal cancer. Methods A retrospective cohort study was conducted at Rambam Health Care Hospital in Haifa, Israel, involving patients aged 18 and older diagnosed with locally advanced upper rectal cancer, defined as tumors located 11 to 15 cm from the anal verge, between 2013 and 2022. Patients were categorized into two groups: those who received NCRT prior to surgery and those who underwent surgery directly. The primary outcome measured was the incidence of postoperative complications, while secondary outcomes included mortality rates and the occurrence of local or distant recurrence. Results A total of 31 patients were included in the study, with 18 in the NCRT group and 13 in the surgery-first group. The two groups were comparable in terms of demographics and initial staging. The NCRT group exhibited a higher incidence of postoperative complications (66.7% vs. 38.5%), although this difference was not statistically significant. There were no significant differences in mortality rates or local recurrence between the groups. However, the NCRT group had a significantly higher incidence of low anterior resection syndrome (LARS) (27.8% vs. 0%). Discussion The findings suggest that NCRT does not enhance local control in upper rectal cancer compared to surgery alone. The increased incidence of LARS in the NCRT group underscores potential adverse effects associated with this treatment. These results are consistent with other studies that challenge the benefits of NCRT for upper rectal cancers, indicating a need for cautious interpretation and further research through larger, prospective studies. Conclusions NCRT for upper rectal cancer does not significantly improve local control and is associated with higher rates of LARS. Future studies should aim to optimize treatment protocols to balance efficacy and quality of life for patients with upper rectal cancer.

Tailoring treatment for locally advanced rectal cancer

The management of locally advanced rectal cancer (LARC) requires personalized treatment to improve outcomes and maintain quality of life. This narrative review examines the recent developments in management, focusing on non-operative management, radiotherapy choices or omission, chemotherapy sequencing, and the role of immunotherapy and brachytherapy boost. Non-operative management can be an option for select patients, and the use of long-course chemoradiation (LCCRT) with consolidation chemotherapy or brachytherapy boost has been shown to enhance rectal preservation rates. For patients requiring surgery, the choice between LCCRT and SCRT depends on the risk of local recurrence and patient preferences. MSI-high LARC patients benefit significantly from single-agent immunotherapy, and early clinical trials show promising results for the application of immunotherapy in MSS tumors. By stratifying patients based on individual and tumor risk factors, clinicians can tailor treatment plans to improve oncologic outcomes and quality of life for patients with LARC.

Total Neoadjuvant Therapy Versus Neoadjuvant Chemoradiation for Locally Advanced Rectal Cancer: A Multi-Institutional Real-World Study

Total neoadjuvant therapy (TNT) has emerged as a promising approach for managing locally advanced rectal cancer (LARC), aiming to enhance resectability, increase pathological complete response (pCR), improve treatment compliance, survival, and sphincter preservation. This study compares the clinical outcomes of TNT, with either induction or consolidation chemotherapy, to those of the standard chemoradiotherapy (CRT). In this retrospective multi-institutional study, patients with stage II-III LARC who underwent CRT or TNT from seven oncology centers between 2021 and 2024 were retrospectively analyzed. The TNT group was categorized into induction or consolidation groups based on the sequence of chemotherapy and radiotherapy. Clinical and pathological data and treatment outcomes, including pCR, event-free survival (EFS), and overall survival (OS), were analyzed. Among the 276 patients, 105 received CRT and 171 underwent TNT. The TNT group showed significantly higher pCR (21.8% vs. 2.9%, p < 0.001) and lower lymphatic (26.3% vs. 42.6%, p = 0.009), vascular (15.8% vs. 32.7%, p = 0.002), and perineural invasion rates (20.3% vs. 37.6%, p = 0.003). Furthermore, 16.9% of TNT patients opted for non-operative management (NOM), compared to 0.9% in the CRT group (p < 0.001). The median interval between the end of radiotherapy and surgery was longer in the TNT group (17.6 weeks vs. 8.8 weeks, p < 0.001). The 3-year EFS was 58.3% for CRT and 71.1% for TNT (p = 0.06). TNT is associated with higher pCR, lower lymphatic and vascular invasion rates, and higher rates of NOM compared to CRT. This supports the use of TNT as a viable treatment strategy for LARC, offering potential benefits in quality of life.

Local excision vs. proctectomy in patients with ypT0-1 rectal cancer following neoadjuvant therapy: a propensity score matched analysis of the National Cancer Database

BACKGROUND

We aimed to evaluate outcomes of organ preservation by local excision (LE) compared to proctectomy following neoadjuvant therapy for rectal cancer.

METHODS

This retrospective observational study using the National Cancer Database (NCDB) included patients with locally advanced non-metastatic rectal cancer (ypT0-1 tumors) treated with neoadjuvant therapy between 2004 and 2019. Outcomes of patients who underwent LE or proctectomy were compared. 1:1 propensity score matching including patient demographics, clinical and therapeutic factors was used to minimize selection bias. Main outcome was overall survival (OS).

RESULTS

11,256 of 318,548 patients were included, 526 (4.6%) of whom underwent LE. After matching, mean 5-year OS was similar between the groups (54.1 vs. 54.2 months; p = 0.881). Positive resection margins (1.2% vs. 0.6%; p = 0.45), pathologic T stage (p = 0.07), 30-day mortality (0.6% vs. 0.6%; p = 1), and 90-day mortality (1.5% vs. 1.2%; p = 0.75) were comparable between the groups. Length of stay (1 vs. 6 days; p < 0.001) and 30-day readmission rate (5.3% vs. 10.3%; p = 0.02) were lower in LE patients. Multivariate analysis of predictors of OS demonstrated male sex (HR 1.38, 95% CI 1.08-1.77; p = 0.009), higher Charlson score (HR 1.52, 95% CI 1.29-1.79; p < 0.001), poorly differentiated carcinoma (HR 1.61, 95% CI 1.08-2.39; p = 0.02), mucinous carcinoma (HR 3.53, 95% CI 1.72-7.24; p < 0.001), and pathological T1 (HR 1.45, 95% CI 1.14-1.84; p = 0.002) were independent predictors of increased mortality. LE did not correlate with worse OS (HR 0.91, 95% CI 0.42-1.97; p = 0.82).

CONCLUSION

Our findings show no overall significant survival difference between LE and total mesorectal excision, including ypT1 tumors. Moreover, patients with poorly differentiated or mucinous adenocarcinomas generally had poorer outcomes, regardless of surgical method.

Effect of radiotherapy on long-term quality of life in recurrence-free rectal cancer survivors (LaTE study): nationwide inverse probability of treatment-weighted registry-based cohort study and survey

BACKGROUND

Radiotherapy reduces local recurrence in locally advanced rectal cancer, but may cause harm in patients who do not experience recurrence. The aim was to investigate the impact of radiotherapy on long-term quality of life after curative treatment for rectal cancer, i.e. in patients without a recurrence during the follow-up.

METHODS

All patients operated on for rectal cancer in Norway under 75 years of age between 30 September 2007 and 1 October 2020 were identified using the Cancer Registry of Norway. Exclusion criteria were distant metastasis, recurrence and dementia. The primary outcome measure was the Gastrointestinal Quality of Life Index. Secondary outcome measures included the 36-item Short Form Survey. Inverse probability weights based on a multiple logistic regression model were used to balance prechosen covariates between the radiotherapy and no radiotherapy groups when assessing differences in outcomes.

RESULTS

Of 5014 invited patients, 2142 (43%) eligible patients answered the questionnaires. Of these 762 (36%) were treated with neoadjuvant radiotherapy plus surgery and 1380 (64%) with surgery alone. The mean follow-up time was 6.4 and 7.4 years respectively. After propensity score matching, the Gastrointestinal Quality of Life Index differed significantly between irradiated and non-irradiated patients ((mean(s.d.), mean score 103.8(19.4) versus 110.8(19.6) respectively, mean difference: -6.96 (95% c.i. -8.72 to -5.19); P < 0.001). Among patients without a stoma the mean difference was -8.1 points, whereas it was -5.7 for patients with a stoma. The radiotherapy group also scored significantly lower in 7 of 8 36-item Short Form Survey domains compared with the surgery alone group.

CONCLUSION

Long-term quality of life was significantly lower in patients without a recurrence during the follow-up who received radiotherapy compared with patients who did not. These findings warrant a critical re-evaluation of the use of radiotherapy both in traditional neoadjuvant treatment and in modern organ-preserving treatment regimens.

Interrater Agreement of Height Assessment by Rigid Proctoscopy/Rectoscopy for Rectal Carcinoma

BACKGROUND

Some guidelines for rectal carcinoma consider 12 cm, measured by rigid endoscopy, to be the cutoff tumor height for optional neoadjuvant chemoradiation therapy. Measuring differences of only a few centimeters may predetermine the choice of further therapy. However, rigid endoscopy may exhibit similar operator dependence to most other clinical examination methods.

OBJECTIVES

Evaluation of concordance of rigid rectoscopic tumor height measurements performed by 4 experienced examiners, 2 measuring with patients in the lithotomy position and 2 in the left lateral position. Assessment of tumor palpability and distance of the anal verge to the anocutaneous line were also evaluated.

DESIGN

This study used a prospective observational design.

SETTING

This study was conducted at an academic teaching hospital that is a referral center for colorectal surgery.

PATIENTS

There were 50 patients, of whom 35 were men (70%). The median age was 72.5 years (53-88 years).

MAIN OUTCOME MEASURES

Interrater agreement of tumor height assessment and tumor height of less than or greater than the 12-cm height limit.

RESULTS

With an intraclass correlation coefficient of 0.947 (95% CI, 0.918-0.967, p < 0.001), interrater reliability of tumor height assessment was statistically rated "excellent." Despite this, in 26% of patients, there was no agreement regarding the allocation of the tumor <12- or >12-cm height limit. Furthermore, there was also considerable disagreement concerning tumor palpability and the distance of the anal verge to the anocutaneous line. Patient positioning was not found to influence results.

LIMITATIONS

Single-center study.

CONCLUSIONS

Rigid rectal endoscopy may not be a sound pivotal basis for the consideration of optional chemoradiation therapy in rectal carcinoma. Application of a universally valid height limit ignores biological variability in body frame, gender, and acquired pelvic descent. Eligibility for neoadjuvant therapy should not rely on height measurements alone. Uniform MRI or CT imaging protocols, based on agreed upon terminology, including factors such as tumor height relative to the pelvic frame and peritoneal reflection, may be an important diagnostic addition to such a decision. See Video Abstract .Clinical trial registration: DRKS00012758 (German National Study Registry), ST-D 406 (German Cancer Society).

ACUERDO ENTRE EVALUADORES EN LA EVALUACIN DE LA ALTURA MEDIANTE PROCTO/ RECTOSCOPIA RGIDA PARA EL CARCINOMA DE RECTO

ANTECEDENTES:Algunas guías para el carcinoma de recto consideran que 12 cm, medidos mediante endoscopia rígida, es la altura de corte del tumor para la quimiorradiación neoadyuvante opcional. Por lo tanto, una diferencia de medición de sólo unos pocos centímetros puede predeterminar la elección de una terapia adicional. Sin embargo, la endoscopia rígida puede presentar una dependencia del operador similar a la de la mayoría de los demás métodos de examen clínico.OBJETIVOS:Evaluación de la concordancia de las mediciones de la altura del tumor rectoscópico rígido realizadas por cuatro examinadores experimentados, dos en litotomía y dos en posición lateral izquierda. También se evaluó la evaluación de la palpabilidad del tumor y la distancia del borde anal a la línea anocutánea.DISEÑO:Estudio observacional prospectivo.LUGAR:Hospital universitario, centro de referencia para cirugía colorrectal.PACIENTES:50 pacientes, 35 varones (70%), mediana de edad 72,5 años (53-88 años).PRINCIPALES MEDIDAS DE RESULTADOS:Acuerdo entre evaluadores en la evaluación de la altura del tumor y la asignación del tumor por debajo o más allá del límite de altura de 12 cm.RESULTADOS:Con un coeficiente de correlación intraclase de 0,947 (IC del 95%: 0,918-0,967, p < 0,001), la confiabilidad entre evaluadores de la evaluación de la altura del tumor se calificó estadísticamente como "excelente". A pesar de esto, en el 26% de los pacientes no hubo acuerdo sobre la asignación del tumor por debajo o por encima del límite de 12 cm de altura. Además, también hubo un considerable desacuerdo con respecto a la palpabilidad del tumor y la distancia del borde anal a la línea anocutánea. No se encontró que la posición del paciente influyera en los resultados.LIMITACIONES:Estudio unicéntrico.CONCLUSIONES:La endoscopia rectal rígida puede no ser una base sólida y fundamental para considerar la quimiorradiación opcional en el carcinoma de recto. La aplicación de un límite de altura universalmente válido obviamente ignora la variabilidad biológica en la constitución corporal, el género y el descenso pélvico adquirido. La elegibilidad para la terapia neoadyuvante no debe depender únicamente de las mediciones de altura. Los protocolos uniformes de imágenes por resonancia magnética o tomografía computarizada, basados en una terminología acordada, incluidos factores como la altura del tumor en relación con la estructura pélvica y la reflexión peritoneal, pueden ser una adición diagnóstica importante para tal decisión. (Traducción-Yesenia Rojas-Khalil )Clinical trial registration: DRKS00012758 (German National Study Registry), ST-D 406 (German Cancer Society).

Current State of Neoadjuvant Therapy for Locally Advanced Rectal Cancer

ABSTRACT

In locally advanced rectal cancer, neoadjuvant treatment has evolved from no preoperative treatment to the addition of radiation and systemic therapy and ultimately total neoadjuvant therapy. Total neoadjuvant therapy is the completion of preoperative radiation or chemoradiation and chemotherapy before surgery in order to maximize tumor response and improve survival outcomes. This review summarizes the literature of the neoadjuvant approaches related to locally advanced rectal cancer and highlights the nuances of selecting the appropriate treatment.

T3N0 Rectal Cancer: Radiation for All, None, or Some?

ABSTRACT

The optimal management of T3N0 rectal cancer is an area of active debate that has withstood multiple decades of research. In this comprehensive review, we delve into the many nuances that come with treating T3N0 rectal cancer, particularly examining the role and evolution of radiation therapy. We review both the historical paradigms and latest advances in treatment and highlight the significance of precise preoperative staging. As the field continues to evolve, this review highlights a shift toward more tailored treatments, considering both patient goals and the desire for optimal oncologic outcomes. In the current era, clinical decision-making for T3N0 rectal cancer requires a patient-centric approach that balances effective therapy while minimizing undue side effects.

Radiotherapy for Rectal Cancer: How Much is Enough?

Though resection has been the mainstay of treatment for nonmetastatic rectal cancer over the past century, radiation has become an increasingly integral component of care for locally advanced disease. Today, two predominant radiotherapy approaches-hyperfractionated chemoradiotherapy and "short-course" radiation-are widely utilized to reduce local recurrence and, in some cases, cure disease. Both have been incorporated into total neoadjuvant therapy (TNT) regimens and achieved excellent local control and superior complete response rates compared to chemoradiation alone. Additionally, initial results of "watch and wait" protocols utilizing either radiation modality have been promising. Yet, differences do exist; though short course is cheaper and more convenient for patients, recently published data may show superior complete response and local recurrence rates with chemoradiation. Ultimately, direct comparisons of short-course radiotherapy against chemoradiation within the TNT framework are needed to identify optimal radiation regimens in the treatment of locally advanced rectal cancer.

Nonoperative Management for Rectal Cancer

ABSTRACT

The treatment paradigm for rectal cancer has been shifting toward de-escalated approaches to preserve patient quality of life. Historically, the standard treatment in the United States for locally advanced rectal cancer has standardly comprised preoperative chemoradiotherapy coupled with total mesorectal excision. Recent data challenge this "one-size-fits-all" strategy, supporting the possibility of omitting surgery for certain patients who achieve a clinical complete response to neoadjuvant therapy. Consequently, patients and their physicians must navigate diverse neoadjuvant options, often in the context of pursuing organ preservation. Total neoadjuvant therapy, involving the administration of all chemotherapy and radiation before total mesorectal excision, is associated with the highest rates of clinical complete response. However, questions persist regarding the optimal sequencing of radiation and chemotherapy and the choice between short-course and long-course radiation. Additionally, meticulous response assessment and surveillance are critical for selecting patients for nonoperative management without compromising the excellent cure rates associated with trimodality therapy. As nonoperative management becomes increasingly recognized as a standard-of-care treatment option for patients with rectal cancer, ongoing research in patient selection and monitoring as well as patient-reported outcomes is critical to guide personalized rectal cancer management within a patient-centered framework.

Mechanism of the Radioresistant Colorectal Cancer Cell Line SW480RR Established after Fractionated X Irradiation

Radioresistant cancer cells are risk factors for recurrence and are occasionally detected in recurrent tumors after radiotherapy. Intratumor heterogeneity is believed to be a potential cause of treatment resistance. Heterogeneity in DNA content has also been reported in human colorectal cancer; however, little is known about how such heterogeneity changes with radiotherapy or how it affects cancer radioresistance. In the present study, we established radioresistant clone SW480RR cells after fractionated X-ray irradiation of human colorectal cancer-derived SW480.hu cells, which are composed of two cell populations with different chromosome numbers, and examined how cellular radioresistance changed with fractionated radiotherapy. Compared with the parental cell population, which mostly comprised cells with higher ploidy, the radioresistant clones showed lower ploidy and less initial DNA damage. The lower ploidy cells in the parental cell population were identified as having radioresistance prior to irradiation; thus, SW480RR cells were considered intrinsically radioresistant cells selected from the parental population through fractionated irradiation. This study presents a practical example of the emergence of radioresistant cells from a cell population with ploidy heterogeneity after irradiation. The most likely mechanism is the selection of an intrinsically radioresistant population after fractionated X-ray irradiation, with a background in which lower ploidy cells exhibit lower initial DNA damage.

Impact of adjuvant chemotherapy on survival after pathological complete response in rectal cancer: a meta-analysis of 31,558 patients

BACKGROUND

Locally advanced rectal cancer (LARC) typically involves neoadjuvant chemoradiotherapy (nCRT) followed by surgery (total mesorectal excision, TME). While achieving a complete pathological response (pCR) is a strong indicator of a positive prognosis, the specific benefits of adjuvant chemotherapy after pCR remain unclear. To address this knowledge gap, we conducted a systematic review and meta-analysis to assess the potential advantages of adjuvant therapy in patients who achieve pCR.

METHODS

In this study, we searched Medline, Embase, and Web of Science databases for relevant research. We focused on binary outcomes, analyzing them using odds ratios (ORs) with 95% confidence intervals (CIs). To account for potential variability between studies, all endpoints were analyzed with DerSimonian and Laird random-effects models. We assessed heterogeneity using the I2 statistic and employed the R statistical software (version 4.2.3) for all analyses.

RESULTS

Thirty-four studies, comprising 31,558 patients, were included. The outcomes demonstrated a significant difference favoring the AC group in terms of overall survival (OS) (HR 0.75; 95% CI 0.60-0.94; p = 0.015; I2 = 0%), and OS in 5 years (OR 1.65; 95% CI 1.21-2.24; p = 0.001; I2 = 39%). There was no significant difference between the groups for disease-free survival (DFS) (HR 0.94; 95% CI 0.76-1.17; p = 0.61; I2 = 17%), DFS in 5 years (OR 1.19; 95% CI 0.82-1.74; p = 0.36; I2 = 43%), recurrence-free survival (RFS) (HR 1.10; 95% CI 0.87-1.40; p = 0.39; I2 = 0%), and relapse-free survival (OR 1.08; 95% CI 0.78-1.51; p = 0.62; I2 = 0%).

CONCLUSION

This systematic review and meta-analysis found a significant difference in favor of the ACT group in terms of survival after pCR. Therefore, the administration of this treatment as adjuvant therapy should be encouraged in clinical practice.

Long-term restoration of bowel continuity after rectal cancer resection and the influence of surgical technique: A nationwide cross-sectional study

AIM

Literature on nationwide long-term permanent stoma rates after rectal cancer resection in the minimally invasive era is scarce. The aim of this population-based study was to provide more insight into the permanent stoma rate with interhospital variability (IHV) depending on surgical technique, with pelvic sepsis, unplanned reinterventions and readmissions as secondary outcomes.

METHOD

Patients who underwent open or minimally invasive resection of rectal cancer (lower border below the sigmoid take-off) in 67 Dutch centres in 2016 were included in this cross-sectional cohort study.

RESULTS

Among 2530 patients, 1470 underwent a restorative resection (58%), 356 a Hartmann's procedure (14%, IHV 0%-42%) and 704 an abdominoperineal resection (28%, IHV 3%-60%). Median follow-up was 51 months. The overall permanent stoma rate at last follow-up was 50% (IHV 13%-79%) and the unintentional permanent stoma rate, permanent stoma after a restorative procedure or an unplanned Hartmann's procedure, was 11% (IHV 0%-29%). A total of 2165 patients (86%) underwent a minimally invasive resection: 1760 conventional (81%), 170 transanal (8%) and 235 robot-assisted (11%). An anastomosis was created in 59%, 80% and 66%, with corresponding unintentional permanent stoma rates of 12%, 24% and 14% (p = 0.001), respectively. When corrected for age, American Society of Anesthesiologists classification, cTNM, distance to the anorectal junction and neoadjuvant (chemo)radiotherapy, the minimally invasive technique was not associated with an unintended permanent stoma (p = 0.071) after a restorative procedure.

CONCLUSION

A remarkable IHV in the permanent stoma rate after rectal cancer resection was found. No beneficial influence of transanal or robot-assisted laparoscopy on the unintentional permanent stoma rate was found, although this might be caused by the surgical learning curve. A reduction in IHV and improving preoperative counselling for decision-making for restorative procedures are required.

Comparative analysis of preoperative chemoradiotherapy and upfront surgery in the treatment of upper-half rectal cancer: oncological benefits, surgical outcomes, and cost implications

The value of neoadjuvant chemoradiotherapy (CRT) is not absolutely clear for upper-half (> 7-15 cm) rectal cancer. This study aimed to compare the efficacy and safety of radical surgery with preoperative CRT vs. upfront surgery (US) in Chinese patients with stage II and III upper-half rectal cancer. A total of 809 patients with locally advanced upper-half rectal cancer between 2017 and 2021 were enrolled retrospectively (280 treated with CRT and 529 treated with US). Through 1:1 propensity score matching, the CRT (172 patients) and US (172 patients) groups were compared for short-term postoperative results and long-term oncological and functional outcomes. In the entire cohort, patients in the CRT group had a younger age, lower distance from the anal verge (DAV), and higher rates of cT4 stage, cN2 stage, mrCRM positivity, EMVI positivity, CEA elevation, and CA-199 elevation than those in the US group. The 5-year disease-free survival (DFS) was lower in the CRT group than in the US group (76% vs. 84%, p = 0.022), while the 5-year overall survival (OS) was comparable between the two groups (85% and 88%, p = 0.084). The distant metastasis rate was higher in the CRT group than in the US group (12.5% vs. 7.8%, p = 0.028), though the local recurrence rate was similar between the two groups (1.1% and 1.3%, p = 1.000). After performing PSM, the 5-year OS (86% vs. 88% p = 0.312), the 5-year DFS (79% vs. 80%, p = 0.435), the local recurrence rate (1.2% vs. 1.7%, p = 1.000), and the distant metastasis rate (11.0% vs. 9.3%, p = 0.593) were comparable between the two groups. Notable pathological downstaging was observed in the CRT group, with a pathological complete response (PCR) rate of 14.5%. In addition, patients in the CRT group had a lower proportion of pT3 (61.6% vs. 77.9%, p < 0.001), pN + (pN1, 15.1% vs. 30.2%, pN2, 9.3% vs. 20.3%, p < 0.001), stage III (24.4% vs. 50.6%, p < 0.001), perineural invasion (19.8% vs. 32.0%, p = 0.014), and lymphovascular invasion (9.3% vs. 25.6%, p < 0.001) than those in the US group. Postoperative complications and long-term functional results were similar, yet there was a trend toward a higher conversion to laparotomy rate (5 (2.9%) vs. 0 (0.0%), p = 0.061) and higher rates of robotic surgery (11.6% vs. 4.7%, p < 0.001), open surgery (7.0% vs. 0.6%, p < 0.001), diverting stoma (47.1% vs. 25.6%, p < 0.001), and surgery costs (1473.6 ± 106.5 vs. 1140.3 ± 54.3$, p = 0.006) in the CRT group. In addition, EMVI (OR = 2.516, p = 0.001) was the only independent risk factor associated with poor response to CRT, and in subgroup analysis of EMVI + , CRT group patients presented a lower 5-year DFS (72.9% vs. 80.5%, p = 0.025) compared to US group patients. CRT prior to surgery has no additional oncological benefits over US in the treatment of upper-half rectal cancer. In contrast, CRT is associated with increased rates of conversion to laparotomy, stoma creation and higher surgery costs. Surgeons tend to favor robotic surgery in the treatment of complex cases such as radiated upper-half rectal cancers. Notably, EMVI + patients with upper-half rectal cancer should be encouraged to undergo upfront surgery, as preoperative CRT may not provide benefits and may lead to delayed treatment effects.

Future direction of total neoadjuvant therapy for locally advanced rectal cancer

Despite therapeutic advancements, disease-free survival and overall survival of patients with locally advanced rectal cancer have not improved in most trials as a result of distant metastases. For treatment decision-making, both long-term oncologic outcomes and impact on quality-of-life indices should be considered (for example, bowel function). Total neoadjuvant therapy (TNT), comprised of chemotherapy and radiotherapy or chemoradiotherapy, is now a standard treatment approach in patients with features of high-risk disease to prevent local recurrence and distant metastases. In selected patients who have a clinical complete response, subsequent surgery might be avoided through non-operative management, but patients who do not respond to TNT have a poor prognosis. Refined molecular characterization might help to predict which patients would benefit from TNT and non-operative management. Specifically, integrated analysis of spatiotemporal multi-omics using artificial intelligence and machine learning is promising. Three prospective trials of TNT and non-operative management in Japan, the USA and Germany are collaborating to better understand drivers of response to TNT. Here, we address the future direction for TNT.

Prediction of survival after neoadjuvant therapy in locally advanced rectal cancer - a retrospective analysis

Purpose

The aim of this retrospective analysis was to determine if the response to preoperative radio(chemo)therapy is predictive for survival among patients with locally advanced rectal cancer and may act as a potential surrogate endpoint for disease free survival and overall survival.

Results

Eight hundred seventy-eight patients from five centers were analyzed. There were 304 women and 574 men; the median age was 64.7 years. 77.6% and 22.4% of patients received neoadjuvant radiochemotherapy or short-course radiotherapy, resulting in a pathological complete response in 7.3%. T-downstaging and N-downstaging occurred in 50.5% and 37% of patients after neoadjuvant therapy. In patients with T-downstaging, the 10-year DFS and 10-year OS were 64.8% and 66.8% compared to 37.1% and 45.9% in patients without T-downstaging. N-downstaging resulted in 10-year DFS and 10-year OS in 56.2% and 62.5% compared to 47.3% and 52.3% without N-downstaging. Based on routinely evaluated clinical parameters, an absolute risk prediction calculator was generated for 5-year disease-free survival, and 5-year overall survival.

Conclusion

T-downstaging and N-downstaging after neoadjuvant radiochemotherapy or short-course radiotherapy resulted in better DFS and OS compared to patients without response. Based on clinical parameters, 5-year DFS, and 5-year OS can be predicted using a prediction calculator.

MicroRNA-298 determines the radio-resistance of colorectal cancer cells by directly targeting human dual-specificity tyrosine(Y)-regulated kinase 1A

BACKGROUND

Radiotherapy stands as a promising therapeutic modality for colorectal cancer (CRC); yet, the formidable challenge posed by radio-resistance significantly undermines its efficacy in achieving CRC remission.

AIM

To elucidate the role played by microRNA-298 (miR-298) in CRC radio-resistance.

METHODS

To establish a radio-resistant CRC cell line, HT-29 cells underwent exposure to 5 gray ionizing radiation that was followed by a 7-d recovery period. The quantification of miR-298 levels within CRC cells was conducted through quantitative RT-PCR, and protein expression determination was realized through Western blotting. Cell viability was assessed by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay and proliferation by clonogenic assay. Radio-induced apoptosis was discerned through flow cytometry analysis.

RESULTS

We observed a marked upregulation of miR-298 in radio-resistant CRC cells. MiR-298 emerged as a key determinant of cell survival following radiation exposure, as its overexpression led to a notable reduction in radiation-induced apoptosis. Intriguingly, miR-298 expression exhibited a strong correlation with CRC cell viability. Further investigation unveiled human dual-specificity tyrosine(Y)-regulated kinase 1A (DYRK1A) as miR-298's direct target.

CONCLUSION

Taken together, our findings underline the role played by miR-298 in bolstering radio-resistance in CRC cells by means of DYRK1A downregulation, thereby positioning miR-298 as a promising candidate for mitigating radio-resistance in CRC.

Update on Dosing and Fractionation for Neoadjuvant Radiotherapy for Localized Soft Tissue Sarcoma

OPINION STATEMENT

Neoadjuvant radiotherapy (RT) over 5-6 weeks with daily doses of 1.8-2.0 Gy to a total dose of 50-50.4 Gy is standard of care for localized high-grade soft tissue sarcomas (STS) of the extremities and trunk wall. One exception is myxoid liposarcomas where the phase II DOREMY trial applying a preoperative dose of 36 Gy in 2 Gy fractions (3-4 weeks treatment) has achieved excellent local control rates of 100% after a median follow-up of 25 months.Hypofractionated preoperative RT has been investigated in a number of phase II single-arm studies suggesting that daily doses of 2.75-8 Gy over 1-3 weeks can achieve similar oncological outcomes to conventional neoadjuvant RT. Prospective data with direct head-to-head comparison to conventional neoadjuvant RT investigating oncological outcomes and toxicity profiles is eagerly awaited.For the entire group of retroperitoneal sarcomas, RT is not the standard of care. The randomized multi-center STRASS trial did not find a benefit in abdominal recurrence-free survival by the addition of preoperative RT. However, for the largest histological subgroup of well-differentiated and grades I and II dedifferentiated liposarcomas, the STRASS trial and the post-hoc propensity-matched STREXIT analysis have identified a possible benefit in survival by preoperative RT. These patients deserve to be informed about the pros and cons of preoperative RT while the longer follow-up data from the STRASS trial is awaited.

Neoadjuvant Short- Vs. Long-Course Radiation for Locally Advanced Rectal Cancer: How to Choose

OPINION STATEMENT

Over the past decades, the treatment of locally advanced rectal cancer has evolved dramatically due to improvements in diagnostic imaging, surgical technique, and the addition of radiotherapy and/or chemotherapy. Fractionation of neoadjuvant radiotherapy with or without concurrent chemotherapy remains the subject of discussion and the question multiple recent trials have aimed to answer. In light of recent data and concern for locoregional recurrence, our institution favors long-course chemoradiation in most cases, especially in low-lying primaries, threatened circumferential resection margin, consideration of non-operative management, or if the surgeon has concerns for resectability. Exceptions would include cases of oligometastatic disease planned for metastasectomy in which curative-intent treatment was pursued or if additional factors required a reduction in treatment time.

Efficacy and Safety of Preoperative Transcatheter Rectal Arterial Chemoembolisation in Patients with Locally Advanced Rectal Cancer: Results from a Prospective, Phase II PCAR Trial

AIMS

The PCAR study aimed to assess the efficacy and safety of preoperative transcatheter rectal arterial chemoembolisation (TRACE) in patients with locally advanced rectal cancer (LARC).

MATERIALS AND METHODS

This was a single-centre, prospective, phase II trial conducted in China. Eligible patients were adults aged 18 years and older with histologically confirmed stage II or III rectal carcinoma and an Eastern Cooperative Oncology Group performance status of 0-1. Patients received TRACE with oxaliplatin, followed by radiotherapy with a cumulative dose of 45 Gy (1.8 Gy/time/day, five times a week for 5 weeks) and received oral S1 capsules twice daily (7 days a week for 4 weeks). Patients underwent total mesorectal excision 4-8 weeks after the completion of chemoradiotherapy, followed by mFOLFOX6 or CAPOX regimens for 4-6 months. The hypothesis of this study was that adding TRACE to preoperative neoadjuvant chemoradiotherapy would improve tumour regression and prognosis. The primary end point was the pathological complete response rate; secondary end points included the major pathological response rate, anal preservation rate, 5-year disease-free survival (DFS), 5-year overall survival and treatment-related adverse events.

RESULTS

In total, 111 LARC patients received TRACE and subsequent scheduled treatment plans. The pathological complete response and major pathological response rates were 20.72% and 48.65%, respectively. The 5-year DFS and 5-year overall survival were 61.89% (95% confidence interval 51.45-74.45) and 74.80% (95% confidence interval 65.05-86.01), respectively. Grade 3-4 toxicities were reported in 29 patients (26.13%). The postoperative complication rate was 21.62%, without serious surgical complications. Multivariate Cox regression analysis showed that ypN stage (hazard ratio = 4.242, 95% confidence interval 2.101-8.564, P = 0.00017) and perineural invasion (hazard ratio = 2.319, 95% confidence interval 1.058-5.084, P = 0.0487) were independent risk factors associated with DFS, whereas ypN stage (hazard ratio = 3.164, 95% confidence interval 1.347-7.432, P = 0.0101), perineural invasion (hazard ratio = 4.118, 95% confidence interval 1.664-10.188, P = 0.0134) and serum carbohydrate antigen 199 (CA199; hazard ratio = 4.142, 95% confidence interval 1.290-13.306, P = 0.0344) were independent predictors for overall survival.

CONCLUSION

The current study provides evidence that adding TRACE to neoadjuvant chemoradiotherapy can improve the pathological remission rate in LARC patients with acceptable toxicity. Given its promising effectiveness and safe profile, incorporating TRACE into the standard treatment strategy for patients with LARC should be considered.

Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer: A 9-year review

BACKGROUND

Colorectal cancer is the third most common cancer and the second highest cause of cancer-related mortality worldwide. About 5%-10% of patients are diagnosed with locally advanced rectal cancer (LARC) on presentation. For LARC invading into other structures (i.e. T4b), multivisceral resection (MVR) and/or pelvic exenteration (PE) remains the only potential curative surgical treatment. MVR and/or PE is a major and complex surgery with high post-operative morbidity. Minimally invasive surgery (MIS) has been shown to improve short-term post-operative outcomes in other gastrointestinal malignancies, but there is little evidence on its use in MVR, especially so for robotic MVR.

AIM

To assess the feasibility and safety of minimally invasive MVR (miMVR), and compare post-operative outcomes between robotic and laparoscopic MVR.

METHODS

This is a single-center retrospective cohort study from 1st January 2015 to 31st March 2023. Inclusion criteria were patients diagnosed with cT4b rectal cancer and underwent MVR, or stage 4 disease with resectable systemic metastases. Patients who underwent curative MVR for locally recurrent rectal cancer, or metachronous rectal cancer were also included. Exclusion criteria were patients with systemic metastases with non-resectable disease. All patients planned for elective surgery were enrolled into the standard enhanced recovery after surgery pathway with standard peri-operative management for colorectal surgery. Complex surgery was defined based on technical difficulty of surgery (i.e. total PE, bladder-sparing prostatectomy, pelvic lymph node dissection or need for flap creation). Our primary outcomes were the margin status, and complication rates. Categorical values were described as percentages and analysed by the chi-square test. Continuous variables were expressed as median (range) and analysed by Mann-Whitney U test. Cumulative overall survival (OS) and recurrence-free survival (RFS) were analysed using Kaplan-Meier estimates with life table analysis. Log-rank test was performed to determine statistical significance between cumulative estimates. Statistical significance was defined as P < 0.05.

RESULTS

A total of 46 patients were included in this study [open MVR (oMVR): 12 (26.1%), miMVR: 36 (73.9%)]. Patients' American Society of Anesthesiologists score, body mass index and co-morbidities were comparable between oMVR and miMVR. There is an increasing trend towards robotic MVR from 2015 to 2023. MiMVR was associated with lower estimated blood loss (EBL) (median 450 vs 1200 mL, P = 0.008), major morbidity (14.7% vs 50.0%, P = 0.014), post-operative intra-abdominal collections (11.8% vs 50.0%, P = 0.006), post-operative ileus (32.4% vs 66.7%, P = 0.04) and surgical site infection (11.8% vs 50.0%, P = 0.006) compared with oMVR. Length of stay was also shorter for miMVR compared with oMVR (median 10 vs 30 d, P = 0.001). Oncological outcomes-R0 resection, recurrence, OS and RFS were comparable between miMVR and oMVR. There was no 30-d mortality. More patients underwent robotic compared with laparoscopic MVR for complex cases (robotic 57.1% vs laparoscopic 7.7%, P = 0.004). The operating time was longer for robotic compared with laparoscopic MVR [robotic: 602 (400-900) min, laparoscopic: Median 455 (275-675) min, P < 0.001]. Incidence of R0 resection was similar (laparoscopic: 84.6% vs robotic: 76.2%, P = 0.555). Overall complication rates, major morbidity rates and 30-d readmission rates were similar between laparoscopic and robotic MVR. Interestingly, 3-year OS (robotic 83.1% vs 58.6%, P = 0.008) and RFS (robotic 72.9% vs 34.3%, P = 0.002) was superior for robotic compared with laparoscopic MVR.

CONCLUSION

MiMVR had lower post-operative complications compared to oMVR. Robotic MVR was also safe, with acceptable post-operative complication rates. Prospective studies should be conducted to compare short-term and long-term outcomes between robotic vs laparoscopic MVR.

Contemporary management of rectal cancer

The management of rectal cancer has undergone significant changes over the past 50 years, and this has been associated with major improvements in overall outcomes and quality of life. From standardization of total mesorectal excision to refinements in radiation delivery and shifting of chemoradiotherapy treatment to favor a neoadjuvant approach, as well as the development of targeted chemotherapeutics, these management strategies have continually aimed to achieve locoregional and systemic control while limiting adverse effects and enhance overall survival. This article highlights evolving aspects of rectal cancer therapy including improved staging modalities, total neoadjuvant therapy, the role of short-course and more selective radiotherapy strategies, as well as organ preservation. We also discuss the evolving role of minimally invasive surgery and comment on lateral pelvic lymph node dissection.

Key message

Rectal cancer management is constantly evolving through refinements in radiation timing and delivery, modification of chemoradiotherapy treatment schedules, and increasing utilization of minimally invasive surgical techniques and organ preservation strategies. This manuscript aims to provide a synopsis of recent changes in the management of rectal cancer, highlighting contemporary modifications in neoadjuvant approaches and surgical management to enhance the knowledge of surgeons who care for this challenging population.

Quality of life and clinical outcomes in rectal cancer patients treated on a 1.5T MR-Linac within the MOMENTUM study

Background and purpose

This study assessed quality of life (QoL) and clinical outcomes in rectal cancer patients treated with magnetic resonance (MR) guided short-course radiation therapy (SCRT) on a 1.5 Tesla (T) MR-Linac during the first 12 months after treatment.

Materials and methods

Rectal cancer patients treated with 25 Gy SCRT in five fractions with curative intent in the Netherlands (2019-2022) were identified in MOMENTUM (NCT04075305). Toxicity (CTCAE v5) and QoL (EORTC QLQ-C30 and -CR29) was primarily analyzed in patients without metastatic disease (M0) and no other therapies after SCRT. Patients who underwent tumor resection were censored from surgery. A generalized linear mixed-model was used to investigate clinically meaningful (≥10) and significant (P < 0.05) QoL changes. Clinical and pathological complete response (cCR and pCR) rates were calculated in patients in whom response was documented.

Results

A total of 172 patients were included, of whom 112 patients were primarily analyzed. Acute and late radiation-induced high-grade toxicity were reported in one patient, respectively. CCR was observed in 8/64 patients (13 %), 14/37 patients (38 %) and 13/16 patients (91 %) at three, six and twelve months; pCR was observed in 3/69 (4 %) patients. After 12 months, diarrhea (mean difference [MD] -17.4 [95 % confidence interval [CI] -31.2 to -3.7]), blood and mucus in stool (MD -31.1 [95 % CI -46.4 to -15.8]), and anxiety (MD -22.4 [95 % CI -34.0 to -10.9]) were improved.

Conclusion

High-field MR-guided SCRT for the treatment of patients with rectal cancer is associated with improved disease-related symptom management and functioning one year after treatment.

A pilot study on the safety and efficacy of neoadjuvant chemo‑adoptive immunotherapy for locally advanced rectal cancer

The safety and efficacy of combination therapy of immune cell therapy and chemotherapy [chemo-adoptive immunotherapy (CAIT)] for patients with stage IV or recurrent colorectal cancer have been reported. In the present study, the safety and efficacy of neoadjuvant CAIT were investigated for preoperative therapy of locally advanced rectal cancer. The study included patients with cT3/T4 or cN (+) rectal adenocarcinoma scheduled for curative surgery. Six patients who consented to participate in the current study were selected as subjects. Neoadjuvant CAIT involves administration of activated autologous lymphocytes, αβ T cells, and mFOLFOX6 every 2 weeks for six courses, followed by surgery 4-6 weeks thereafter. Common Terminology Criteria for Adverse Events grade 3 neutropenia was observed in one patient. Neoadjuvant CAIT and curative surgery were performed on all the patients. The confirmed response rate was 67%. Downstaging was confirmed in five patients (83%). Regarding histological effects, two patients were grade 1a and four were grade 2. Regarding immunological reactions, both CD4+ and CD8+ T cell infiltration rates increased after treatment in three patients on tumor-infiltrating lymphocyte (TIL) analysis. In peripheral blood analysis, the total lymphocyte count was maintained in all patients, and the CD8+ T cell count increased by ≥3 times on the pretreatment count in two patients but may not be associated with changes in TILs. During the median postoperative follow-up duration of 24 months, liver and lung metastases occurred in one patient, but all patients survived. In conclusion, neoadjuvant CAIT (αβ T cells + mFOLFOX6) can be safely administered for the treatment of advanced rectal cancer. Verification of the efficacy of comprehensive immune cell therapy, especially the induction of antitumor immunity for the prevention of recurrence, will be maintained. The current study is registered with the Japan Registry of Clinical Trials (jRCT; ID, jRCTc030190248; January 21, 2019).

Knockdown of hCINAP sensitizes colorectal cancer cells to ionizing radiation

Colorectal cancer (CRC) poses a significant challenge in terms of treatment due to the prevalence of radiotherapy resistance. However, the underlying mechanisms responsible for radio-resistance in CRC have not been thoroughly explored. This study aimed to shed light on the role of human coilin interacting nuclear ATPase protein (hCINAP) in radiation-resistant HT-29 and SW480 CRC cells (HT-29-IR and SW480-IR) and investigate its potential implications. Firstly, radiation-resistant CRC cell lines were established by subjecting HT-29 and SW480 cells to sequential radiation exposure. Subsequent analysis revealed a notable increase in hCINAP expression in radiation-resistant CRC cells. To elucidate the functional role of hCINAP in radio-resistance, knockdown experiments were conducted. Remarkably, knockdown of hCINAP resulted in an elevation of reactive oxygen species (ROS) generation upon radiation treatment and subsequent activation of apoptosis mediated by mitochondria. These observations indicate that hCINAP depletion enhances the radiosensitivity of CRC cells. Conversely, when hCINAP was overexpressed, it was found to enhance the radio-resistance of CRC cells. This suggests that elevated hCINAP expression contributes to the development of radio-resistance. Further investigation revealed an interaction between hCINAP and ATPase family AAA domain containing 3A (ATAD3A). Importantly, ATAD3A was identified as an essential factor in hCINAP-mediated radio-resistance. These findings establish the involvement of hCINAP and its interaction with ATAD3A in the regulation of radio-resistance in CRC cells. Overall, the results of this study demonstrate that upregulating hCINAP expression may improve the survival of radiation-exposed CRC cells. Understanding the intricate molecular mechanisms underlying hCINAP function holds promise for potential strategies in targeted radiation therapy for CRC. These findings emphasize the importance of further research to gain a comprehensive understanding of hCINAP's precise molecular mechanisms and explore its potential as a therapeutic target in overcoming radio-resistance in CRC. By unraveling the complexities of hCINAP and its interactions, novel therapeutic approaches may be developed to enhance the efficacy of radiation therapy and improve outcomes for CRC patients.

Is radiotherapy necessary for upper rectal cancer underwent curative resection? A retrospective study of 363 patients

BACKGROUND

To investigate the impact of radiotherapy (RT) on recurrence and survival in patients with locally advanced upper rectal cancer underwent curative resection.

METHODS

363 locally advanced upper rectal cancer cases were identified from the database of our hospital from 2010 to 2018. All patients underwent curative resection and had the lower margin of the tumor located 10-15 cm from the anal verge, among them, 69 patients received pre- or post-operative radiotherapy and 294 patients without. Local control and survivals were compared, and stratification grouping based on European Society for Medical Oncology risk factors were further compared. 1:2 propensity score matching analysis was used to reduce the impact of confounding factors.

RESULTS

There were 207 patients after 1:2 matching (RT group:non-RT group = 69:138). The 5-year overall survival (OS) of the RT group and non-RT group after matching was 84.1% and 80.9%, respectively(P = 0.440); the 5-year local recurrence-free survival (LRFS) was 96.5% and 94.7%, respectively(P = 0.364); the 5-year distant metastasis-free survival (DMFS) was 76.8% and 76.9%, respectively(P = 0.531). Subgroup analysis showed that radiotherapy could not significantly improve the overall survival, local recurrence, and distant metastasis with or without poor prognostic features. In the high-risk subgroup, the 5-year OS was 76.9% and 79.6% for patients treated with radiotherapy and without (P = 0.798), LRFS was 94.8% and 94.2%, respectively (P = 0.605), DMFS 68.7% and 74.7%, respectively (P = 0.233).

CONCLUSIONS

Our results suggest that radiotherapy could not improve local control and survival for locally advanced upper rectal cancer patients underwent curative resection, even in the cases with poor prognostic features.

Adoption of Total Neoadjuvant Therapy in the Treatment of Locally Advanced Rectal Cancer

Local and metastatic recurrence are primary concerns following the treatment of locally advanced rectal cancer (LARC). Chemoradiation (CRT) can reduce the local recurrence rates and has subsequently moved to the neoadjuvant setting from the adjuvant setting. Pathological complete response (pCR) rates have also been noted to be greater in patients treated with neoadjuvant CRT prior to surgery. The standard approach to treating LARC would often involve CRT followed by surgery and optional adjuvant chemotherapy and remained the treatment paradigm for almost two decades. However, patients were often unable to complete adjuvant chemotherapy due to a decreased tolerance of chemotherapy following surgery, which led to upfront treatment with both CRT and chemotherapy, and total neoadjuvant therapy, or TNT, was created. The efficacy outcomes of local recurrence, disease-free survival, and pCR have improved in patients receiving TNT compared to the standard approach. Additionally, more recent data suggest a possible improvement in overall survival as well. Patients with a complete clinical response following TNT have the opportunity for watch-and-wait surveillance, allowing some patients to undergo organ preservation. Here, we discuss the clinical trials and studies that led to the adoption of TNT as the standard of care for LARC, with the possibility of watch-and-wait surveillance for patients achieving complete responses. We also review the possibility of overtreating some patients with LARC.

Lateral Pelvic Nodal Management and Patterns of Failure in Patients Receiving Short-Course Radiation for Locally Advanced Rectal Cancer

BACKGROUND

Management of lateral pelvic lymph nodes in locally advanced rectal cancer is controversial, with limited data indicating the optimal approach. In addition, no data exist regarding the treatment of lateral nodes in the setting of short-course radiation and nonoperative intent.

OBJECTIVE

To evaluate a novel approach incorporating simultaneous integrated boost to suspicious lateral nodes.

DESIGN

A retrospective study.

SETTING

This study was conducted at a large tertiary referral center.

PATIENTS

Patients treated with radiation therapy and consolidation chemotherapy were included. All primary tumors underwent biopsy confirmation and disease staging with pelvic MRI.

INTERVENTIONS

Primary tumors were biopsy proven and staged with pelvic MRI. A subset of lateral pelvic lymph node patients received a simultaneous integrated boost of 35 Gy in 5 fractions. Then, chemotherapy was administered, with the majority receiving modified folinic acid, fluorouracil, and oxaliplatin. Clinical partial response required total mesorectal excision.

MAIN OUTCOME MEASURES

Patterns of failure and survival analyses by subgroup were assessed. Outcomes based on receipt of radiation were compared across node status.

RESULTS

Between January 2017 and January 2022, 155 patients were treated with short-course chemotherapy, with 121 included in the final analysis. Forty-nine percent of patients underwent nonoperative management. The median follow-up was 36 months and the median age was 58 years. Thirty-eight patients (26%) had positive lateral pelvic lymph nodes. Comparing lateral node status, progression-free survival was significantly worse for patients with positive disease ( p < 0.001), with a trend for worse overall survival. Receipt of nodal boost in patients with lateral nodes resulted in meaningful locoregional control. Nodal boost did not contribute to additional acute or late GI toxicity.

LIMITATIONS

Limitations include retrospective nature and lack of lateral node pathology; however, a thorough radiographic review was performed.

CONCLUSIONS

Lateral node-positive rectal cancer is correlated with worse oncologic outcomes and higher locoregional failure. Boost to clinically positive lateral nodes is a safe approach in the setting of short course radiation and in those receiving nonoperative intent. See Video Abstract.

MANEJO DE LOS GANGLIOS PLVICOS LATERALES Y PATRONES DE FALLA EN PACIENTES QUE RECIBEN RADIACIN DE CICLO CORTO PARA EL CNCER DE RECTO LOCALMENTE AVANZADO

ANTECEDENTES:El manejo de los ganglios linfáticos pélvicos laterales en el cáncer de recto localmente avanzado es controvertido, con datos limitados que indiquen el abordaje óptimo. Además, no existen datos sobre el tratamiento de los ganglios linfáticos laterales en el contexto de la radiación de curso corto y la intención no operatoria.OBJETIVO:Evaluamos un enfoque novedoso que incorpora sobreimpresión integrada simultánea (SIB) a los linfonodos laterales sospechosos.DISEÑO:Este fue un estudio retrospectivo.ESCENARIO:Este estudio se realizó en un gran centro de referencia terciario.PACIENTES:Se incluyeron pacientes tratados con radiación y quimioterapia de consolidación. Todos los tumores primarios se confirmaron mediante biopsia y la enfermedad se estadificó con resonancia magnética pélvica.INTERVENCIONES:Los tumores primarios se confirmaron mediante biopsia y se estadificaron con RM pélvica. Un subconjunto de pacientes con linfonodos pélvicos laterales (LPLN) recibió SIB a 35 Gy en 5 fracciones. Luego, se administró quimioterapia y la mayoría recibió mFOLFOX. La respuesta clínica parcial requirió la escisión total del mesorrecto.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron los patrones de fracaso y los análisis de supervivencia por subgrupo. Los resultados basados en el esquema de radiación se compararon según el estado de los ganglios.RESULTADOS:Entre enero de 2017 y enero de 2022, 155 pacientes fueron tratados con ciclo corto y quimioterapia con 121 incluidos en el análisis final. El 49% se sometió a manejo no operatorio. La mediana de seguimiento fue de 36 meses y la mediana de edad fue de 58 años. 38 pacientes (26%) tuvieron LPLN positivos. Comparando el estado de los ganglios laterales, la supervivencia libre de progresión fue significativamente peor para los pacientes con LPLN positiva ( p < 0,001) con una tendencia a una peor supervivencia global. La recepción de refuerzo nodal en pacientes con nodos laterales dio como resultado un control locorregional significativo. La sobreimpresión ganglionar no contribuyó a la toxicidad GI aguda o tardía adicional.LIMITACIONES:Las limitaciones incluyeron la naturaleza retrospectiva y la falta de patología de los ganglios linfáticos laterales; sin embargo, se realizó una revisión radiográfica exhaustiva.CONCLUSIONES:El cáncer de recto con ganglio lateral positivo se correlaciona con peores resultados oncológicos y mayor fracaso locorregional. La sobreimpresión a los ganglios laterales clínicamente positivos es un enfoque seguro en el contexto de un curso corto y en aquellos que siguen un manejo no operatorio. (Traducción-Dr. Felipe Bellolio ).