Variation in the Height of Rectal Cancers According to the Diagnostic Modalities

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.

Defining the tumor location in rectal cancer - Practice variations and impact on treatment decision making

OBJECTIVE

To summarize differences in current guideline recommendations for rectal tumor localization and generate an overview of published MRI measurement methods and their correlation with endoscopy.

SUMMARYOF BACKGROUND DATA

Rectal tumor location is a well-known factor that impacts treatment planning, but there is currently no consensus on the optimal method to define it.

METHODS

A literature search was conducted to retrieve clinical and radiological rectal cancer guidelines as well as original research studies on MRI-based measurements. Guidelines were assessed for definitions, landmarks, modalities and measurement methods to define tumor location, and how these impact treatment planning. Research studies were evaluated to compare MRI-methods and their correlation with endoscopy.

RESULTS

18 clinical and 6 radiological guidelines were retrieved. In 83 % of clinical guidelines tumor location (low/middle/high) is included in the treatment algorithm as a factor impacting surgical and/or neoadjuvant treatment. Measurement cut-offs and landmarks vary significantly with the anal verge being the most commonly used landmark (28 %). Thirty-nine percent of clinical guidelines offer no definitions to define rectal tumor location. The majority of research studies (67 %) reported good-excellent agreement between MRI and endoscopy, though measurement differences of up to 2.5 cm were reported.

CONCLUSION

There is substantial variation in definitions and landmarks recommended in current guidelines to measure and classify rectal tumor location. This may affect treatment planning as well as trial inclusions, highlighting the need for standardized methods that better align between clinical and radiological guidelines.

The efficacy of open transanal drainage tube against anastomotic leakage in left-sided colorectal cancer surgery: a propensity score matching study

BACKGROUND/AIM

The effectiveness of a transanal drainage tube (TAT) for the prevention of anastomotic leakage after double stapling technique (DST) anastomosis in colorectal cancer has been reported. Previously, TATs had been placed and connected to drainage bags. It was considered that a higher decompression effect could be expected by inserting an open-type TAT, without connection to a drainage bag. In this study, the relation between anastomotic leakage and the application of this type of TAT in left-sided colorectal cancer surgery was investigated, using propensity score matching (PSM).

MATERIALS AND METHODS

From January 2016 to July 2023, 233 consecutive patients underwent radical surgery for sigmoid colon and rectal cancers and reconstruction using DST at Osaka Metropolitan University Hospital. Patients were divided into two groups: those who had a closed TAT inserted (CLOSED group), and those who had an open TAT inserted (OPEN group).

RESULTS

Overall, open TATs were inserted in 43 patients, and closed TATs were inserted in 190 patients. PSM was performed between the OPEN and CLOSED groups on the basis of the following 13 factors: age, sex, BMI, diabetes mellitus (DM), smoking history, modified Glasgow prognostic score (mGPS), ASA-PS, location of distal tumor edge, operative procedure, surgical approach, operative time, intraoperative blood loss, and pathological stage. The multivariate analysis of significant factors identified a BMI of 25 or more, a location of distal edge on middle to lower rectum, and a closed TAT, as independent risk factors for anastomotic leakage (HR: 8.72; p = 0.038, HR: 10.06; p = 0.034 and HR: 17.43; p = 0.033).

CONCLUSION

An open TAT may be effective in preventing anastomotic leakage in left-sided colorectal cancer surgery.

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.

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.

Chinese national clinical practice guidelines on prevention, diagnosis and treatment of early colorectal cancer

BACKGROUND

The incidence and mortality of colorectal cancer (CRC) in China are increasing in recent years. The clarified pathogenesis and detectable precancerous lesions of CRC make it possible to prevent, screen, and diagnose CRC at an early stage. With the development of endoscopic and surgical techniques, the choice of treatment for early CRC is also worth further discussion, and accordingly, a standard follow-up program after treatment needs to be established.

METHODS

This clinical practice guideline (CPG) was developed following the recommended process of the World Health Organization, adopting Grading of Recommendations Assessment, Development and Evaluation (GRADE) in assessing evidence quality, and using the Evidence to Decision framework to formulate clinical recommendations, thereby minimizing bias and increasing transparency of the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guides to ensure the guideline's completeness and transparency.

RESULTS

This CPG comprises 46 recommendations concerning prevention, screening, diagnosis, treatment, and surveillance of CRC. In these recommendations, we have indicated protective and risk factors for CRC and made recommendations for chemoprevention. We proposed a suitable screening program for CRC based on the Chinese context. We also provided normative statements for the diagnosis, treatment, and surveillance of CRC based on existing clinical evidence and guidelines.

CONCLUSIONS

The 46 recommendations in this CPG are formed with consideration for stakeholders' values and preferences, feasibility, and acceptability. Recommendations are generalizable to resource-limited settings with similar CRC epidemiology pattern as China.

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).

Comparison of flexible endoscopy and magnetic resonance imaging in determining the tumor height in rectal cancer

BACKGROUND

Several modalities are available for the diagnosis of rectal cancer, including conventional gold standard rigid endoscopy and recent flexible endoscopy and magnetic resonance imaging (MRI). Each modality affects the management of these patients.

AIM

To compare the accuracy of flexible endoscopy and MRI in the measurement of tumor height in patients with rectal cancer.

METHODS AND RESULTS

This study included 174 patients with rectal cancer who underwent flexible endoscopy and MRI for the measurement of tumor height. Data on patient demographics, comorbidities, treatment, and histopathology were identified and collected. We evaluate intraclass correlation coefficient (ICC) and Bland-Altman plot to test the agreement between the measurements. ICC were excellent with an ICC of 89% (95%CI 48%-99%). The mean ± standard deviation of the distance from the anal verge to the distal part of the tumor was 7.73 ± .47 for flexible endoscopy and 6.21 ± 0.39 for MRI, with mean difference of 1.52 (p ˂ .001). The accordance between the two modalities was not affected by sex, age, body mass index, histopathology, or metastasis.

CONCLUSION

Excellent agreement between flexible endoscopy and MRI was noted, and no factor was found to affect such concordance.

How do they measure up: Assessing the height of rectal cancer with digital rectal exam, endoscopy, and MRI,

Background

Outcomes in rectal cancer are dependent on tumor height. Modalities for assessing tumor height include MRI, endoscopy, and digital rectal exam (DRE). We seek to identify correlations between these modalities.

Methods

Retrospective analysis of 120 rectal cancer patients at a single institution. Correlation coefficients and distance of the tumor to anal verge between MRI, endoscopy, and DRE were compared by region.

Results

The distances of tumor (cm) from anal verge were: MRI: 6.2 ± 3.0, endoscopy: 5.9 ± 2.9, DRE: 5.4 ± 2.4 (p = 0.238). Endoscopy and DRE strongly correlated with MRI (spearman coefficient 0.899 and 0.842, respectively). Endoscopy and DRE also strongly correlated (spearman coefficient 0.876). Correlation coefficients were highest in the middle rectum, weak in the low rectum, and non-correlated in the upper rectum.

Conclusions

MRI, endoscopy, and DRE strongly correlated overall. DRE demonstrated the lowest average distance. Correlations differed by region, suggesting high or low rectal tumors are difficult to characterize.

Measuring Rectal Cancer Tumor Height: Concordance Between Clinical Examination and MRI

BACKGROUND

Rectal cancer is categorized into categories on the basis of tumor height measurements. Tumor height is used to guide initial treatment and determines the eligibility for clinical trials.

OBJECTIVE

This study aimed to determine the concordance between tumor heights measured by MRI and by clinical examination.

DESIGN

This was an institutional review board-approved retrospective analysis of MRI and the clinical measurements of tumor height.

SETTING

This study was conducted at a single university center that was accredited by the Commission on Cancer National Accreditation Program for Rectal Cancer.

PATIENTS

Ninety-five patients who were treated between 2015 and 2019 and who had an MRI and clinical evaluation were included.

MAIN OUTCOME MEASUREMENTS

The mean difference of tumor height between MRI and clinical examination was calculated. Secondary outcomes were to assess whether position in the rectum, age, BMI, or sex would affect the difference and how the measurements would change eligibility for rectal cancer trials.

RESULTS

Tumor height measurement by MRI and clinical examination had a good correlation, with r = 0.89 and p < 0.001. The mean absolute difference of measurement of tumor height was 1.56 cm. Higher tumors had a larger absolute difference between measurements. Body mass index was significantly associated with the difference in measurements. The discordance in measurements led to a change in eligibility for clinical trials for 38.9% of patients. Clinical trial eligibility was not significantly associated with tumor height category, sex, or patient age.

LIMITATIONS

This study was conducted at a single center with retrospective methodology.

CONCLUSIONS

Although MRI and clinical measurements showed a strong correlation, nearly 40% of our patients had a change in clinical trial eligibility depending on measurement modality. We suggest that trial investigators be consistent in establishing measurement technique as their inclusion criterion. See Video Abstract at http://links.lww.com/DCR/B756.

MEDICIN DE LA ALTURA DEL TUMOR DE CNCER DE RECTO CONCORDANCIA ENTRE EL EXAMEN CLNICO Y LA RESONANCIA MAGNTICA

ANTECEDENTES:El cáncer de recto se clasifica en categorías basadas en las mediciones de la altura del tumor. La altura del tumor se usa para guiar el tratamiento inicial y determina la elegibilidad para los ensayos clínicos.OBJETIVO:Determinar la concordancia entre la altura de los tumores medida por resonancia magnética (RMN) y por examen clínico.DISEÑO:Este fue un análisis retrospectivo aprobado por el IRB de la resonancia magnética y las mediciones clínicas de la altura del tumor.AJUSTE:Esto se llevó a cabo en un único centro universitario que fue acreditado por el Programa Nacional de Acreditación del Cáncer de Recto de la Comisión de Cáncer.PACIENTE:Se incluyeron 95 pacientes que fueron atendidos entre 2015 y 2019 y que tuvieron una resonancia magnética y evaluación clínica.PRINCIPALES MEDIDAS DE RESULTADOS:Se calculó la diferencia media de la altura del tumor entre la resonancia magnética y el examen clínico. Los resultados secundarios fueron evaluar si la posición en el recto, la edad, el índice de masa corporal (IMC) o el sexo afectarían la diferencia y cómo las mediciones cambiarían la elegibilidad para los ensayos de cáncer de recto.RESULTADOS:La medición de la altura del tumor por resonancia magnética y el examen clínico tuvo una buena correlación con r = 0,89 y p < 0,001. La diferencia absoluta media de medición de la altura del tumor fue de 1,56 cm. Los tumores más altos tenían una diferencia absoluta más grande entre las mediciones. El IMC se asoció significativamente con la diferencia en las mediciones. La discordancia en las mediciones llevó a un cambio en la elegibilidad para los ensayos clínicos para el 38,9% de los pacientes. La elegibilidad para ensayos clínicos no se asoció significativamente con la categoría de altura del tumor, el sexo o la edad del paciente.LIMITACIONES:Se realizó en un solo centro con metodología retrospectiva.CONCLUSIONES:Aunque la resonancia magnética y las mediciones clínicas mostraron una fuerte correlación, casi el 40% de nuestros pacientes tuvieron un cambio en la elegibilidad para los ensayos clínicos según la modalidad de medición. Sugerimos que los investigadores del ensayo sean coherentes al establecer la técnica de medición como criterio de inclusión. Consulte Video Resumen en http://links.lww.com/DCR/B756.

Robotic Intersphincteric Resection for Low Rectal Cancer: Technical Controversies and a Systematic Review on the Perioperative, Oncological, and Functional Outcomes

Intersphincteric resection (ISR) is the ultimate anus-sparing technique for low rectal cancer and is considered an oncologically safe alternative to abdominoperineal resection. The application of the robotic approach to ISR (RISR) has been described by few specialized surgical teams with several differences regarding approach and technique. This review aims to discuss the technical aspects of RISR by evaluating point by point each surgical controversy. Moreover, a systematic review was performed to report the perioperative, oncological, and functional outcomes of RISR. Postoperative morbidities after RISR are acceptable. RISR allows adequate surgical margins and adequate oncological outcomes. RISR may result in severe bowel and genitourinary dysfunction affecting the quality of life in a portion of patients.

Measurement of rectal tumor height from the anal verge on MRI: a comparison of internal versus external anal sphincter

PURPOSE

To determine the most accurate measurement technique to assess rectal tumor height on MRI using two different anatomic landmarks for the anal verge.

INTRODUCTION

Accurate measurements and standardized reporting of MRI for rectal cancer staging is essential. It is not known whether measurements starting from the internal anal sphincter (IAS) or external anal sphincter (EAS) more closely correlate with tumor height from the anal verge on endoscopy.

METHODS

This retrospective study included baseline staging MRI examinations for 85 patients after exclusions. Two radiologists blinded to endoscopic results measured the distance of rectal tumors from the internal anal sphincter and external anal sphincter on sagittal T2 images. The reference standard was endoscopic measurement of tumor height; descriptive statistics were performed.

RESULTS

For reader 1, the mean difference in measurement of tumor height between MRI and endoscopy was - 0.45 cm (SD ± 1.76 cm, range - 6.0 to 3.9 cm) for the IAS and 0.51 cm (SD ± 1.75 cm range - 4.7 to 4.8 cm) for the EAS. For reader 2, the mean difference in measurement of tumor height between MRI and endoscopy was - 0.57 (STD ± 1.81, range - 5.9 to 4.8 cm) for the IAS and 0.52 cm (STD ± 1.85, range - 4.3 to 5.6 cm) for the EAS. Interobserver ICC was excellent between reader 1 and reader 2 for measurements from both the IAS (0.955 95% CI 0.931-0.97) and EAS (0.952, 95% CI 0.928, 0.969).

CONCLUSION

Measurement of tumor height on MRI was highly reproducible between readers; beginning measurements from the EAS tends to slightly overestimate tumor height on average and from the IAS tends to slightly underestimate tumor height on average.