Advanced Rectal Carcinoma Research Articles

1164P The influence of neoadjuvant radiotherapy on surgical management and prognostic outcomes in locally advanced rectal neuroendocrine carcinoma

1164P The influence of neoadjuvant radiotherapy on surgical management and prognostic outcomes in locally advanced rectal neuroendocrine carcinoma

The mode of circumferential margin involvement in rectal cancer determines its impact on outcomes: A population-based study

BackgroundThe clinical value of different modes of CRM involvement in rectal cancer patients is unclear. This study aims to determine the clinical impact of different modes of circumferential resection margin (CRM) involvement in patients with a locally advanced rectal carcinoma. Patients and methodsA cohort of patients who were diagnosed with stage III rectal cancer between June 2014 and June 2020 was selected from the prospective Dutch nationwide pathology databank (PALGA). Histopathological and clinical data were analyzed according to the nature of CRM involvement (via primary tumor invasion, lymph node metastasis, tumor deposit, multiple factors) and analyses on recurrence and overall survival (OS) were performed. Results3020 patients were included, of whom 12.4 % had a positive CRM. The majority of these patients (63.2 %) had CRM involvement by primary tumor invasion and in 9 % of patients multiple factors caused the positive CRM. The rates of local recurrence and distant metastasis were related to the nature of the CRM involvement, with lowest rate for lymph node metastasis and highest rate for multiple factors. On multivariate analysis, CRM involvement by primary tumor invasion, tumor deposits and multiple factors, but not by lymph node metastasis, were associated with poor OS. ConclusionThis nationwide population based study highlights the clinical importance of reporting the nature of CRM involvement in rectal cancer patients. Lymph node metastasis involving the CRM does not bear the same risks for local recurrence, distant metastases and OS as CRM involvement by primary tumor invasion or CRM involvement by multiple factors.

Evaluating postoperative hernia incidence and risk factors following pelvic exenteration

Pelvic exenteration (PE) is a technically challenging surgical procedure. More recently, quality of life and survivorship following PEs are being increasingly acknowledged as important patient outcomes. This includes evaluating major long-term complications such as hernias, defined as the protrusion of internal organs through a facial defect (The PelvEx Collaborative in Br J Surg 109:1251–1263, 2022), for which there is currently limited literature. The aim of this paper is to ascertain the incidence and risk factors for postoperative hernia formation among our PE cohort managed at a quaternary centre.MethodA retrospective cohort study examining hernia formation following PE for locally advanced rectal carcinoma and locally recurrent rectal carcinoma between June 2010 and August 2022 at a quaternary cancer centre was performed. Baseline data evaluating patient characteristics, surgical techniques and outcomes was collated among a PE cohort of 243 patients. Postoperative hernia incidence was evaluated via independent radiological screening and clinical examination.ResultsA total of 79 patients (32.5%) were identified as having developed a hernia. Expectantly, those undergoing flap reconstruction had a lower incidence of postoperative hernias. Of the 79 patients who developed postoperative hernias, 16.5% reported symptoms with the most common symptom reported being pain. Reintervention was required in 18 patients (23%), all of which were operative.ConclusionThis study found over one-third of PE patients developed a hernia postoperatively. This paper highlights the importance of careful perioperative planning and optimization of patients to minimize morbidity.

Treatment Outcome in Locally Advanced Rectal Carcinoma and Its Correlation with Hypo-Fractionated Radiotherapy and Concurrent Chemoradiotherapy

Introduction: Rectal cancer is the second most common type within the large intestine, posing significant health risks globally. In Bangladesh, it ranks high among diagnosed cancers. Improved diagnostic methods aid in early detection, which is crucial for effective management. Treatment typically involves a combination of surgery, radiotherapy, and chemotherapy. Preoperative chemoradiotherapy is a standard approach. However, newer methods like preoperative hypo-fractionated radiotherapy with surgery promise better outcomes, including reduced recurrence rates and enhanced survival, with potential cost and time savings. Aim of the Study: The study aims to evaluate and contrast the efficacy of hypofractionated radiotherapy and concurrent chemoradiotherapy in patients with locally advanced rectal carcinoma. Methods: The study, conducted at the Department of Clinical Oncology at Bangabandhu Sheikh Mujib Medical University Shahbagh, Dhaka, Bangladesh and the Department of Radiation Oncology at the National Institute of Cancer Research and Hospital (NICR&H) in Mohakhali, Dhaka, Bangladesh, aimed to compare treatments for locally advanced rectal cancer over 1.5 years (From January 2018 to June 2019). A total of 80 patients were divided into two groups; Group A received hypofractionated radiotherapy, while Group B received oral capecitabine alongside external beam radiotherapy. Inclusion criteria involved confirmed adenocarcinoma within specified stages, with ethical clearances obtained. Patients underwent evaluations before treatment and response assessments posttreatment. Treatment modalities were defined, focusing on radiotherapy and chemotherapy. Data were analyzed using SPSS software, employing various statistical tests. Results aimed to address study objectives while minimizing biases. Result: The study involved 80 patients, divided into Groups A and B, each with 40 individuals. Group A mainly comprised individuals aged 41-50 (45%), followed by 31-40 (25%). Group B had the highest proportion aged 31-40 (30%) and 41-50 (32.50%). Both groups showed male predominance (1.3:1). Moderately differentiated tumors were common, with Group A having more poorly differentiated tumors. Stage III was predominant pre-treatment (65% Group A, 70% Group B). Most patients presented with per rectal bleeding (80%) and alteration of bowel habits (56.25%). Response rates to treatment were similar between groups. Tumor downsizing was more frequent in Group B. Sphincter-sparing surgery was feasible in both groups with no significant difference. Conclusion: The study comparing preoperative hypofractionated radiotherapy (RT) to concurrent chemoradiotherapy (CCRT) for locally advanced rectal carcinoma found similar efficacy in tumor response, downsizing, and sphincter preservation. Statistical analysis showed no significant differences. Both approaches showed acceptable short-term outcomes, offering clinicians options based on patient and resource considerations.

Coverage of complex pararectal pelvic defects: role of the free myocutaneous musculus vastus lateralis flap

In the event of an advanced rectal carcinoma, an evisceration with rectal amputation may become necessary. The resulting defects, due to their extent, depth, or local tissue damage from previous surgeries and radiation, can in many cases only be closed through free microvascular tissue transfer. In this case series, we demonstrate the successful combination of a musculocutaneous musculus vastus lateralis flap (MVL) with a direct connection to the superior gluteal artery. Over a 47-month period, we retrospectively examined 11 cases of patients with dorsal pelvic defects after evisceration and rectal amputation that could not be closed using local or regional means. In cases of extensive defects with deep pararectal wound cavities, all these patients underwent defect coverage through a free myocutaneous MVL flap with a direct vascular anastomosis to the superior gluteal vessels. The mean defect size was 290.0 cm² (SD: 131.2; range: 200-600 cm²). The mean defect depth was 10.5 cm, necessitating MVL flap reconstruction with an average size of 336.3 cm². Three operative revisions were required due to postoperative bleeding. There were no arterial or venous thromboses, and no flap loss occurred. Only one necrosis of a distal flap tip was observed, which could be corrected secondarily by direct suturing. The case-mix evaluation yielded an average value of 24.251 (SD: 21.699; range: 7.036-65.748) points, emphasizing the complexity of the cases. Our results indicate that a free microvascular MVL flap is a viable therapeutic option for pararectal defects that cannot be closed by local or regional methods. The superior gluteal artery proves to be a safe and sufficient vascular connection. In combination, even extensive defects can be successfully closed.

Lateral Lymph Node Dissection for Locally Advanced Rectal Carcinoma: A Step-by-Step Description of Surgical Anatomical Planes During Cadaveric Dissection and Minimally Invasive Surgery.

Total mesorectal excision (TME) is accepted as gold standard method in rectal cancer globally. But there is no standard for lateral lymph nodes. Combination of neoadjuvant treatment plus lateral lymph node dissection (LLND) in select patients might be a promising method. Our purpose is to describe the anatomic landmarks of LLND on cadavers and minimally invasive surgery. Local advanced rectal cancer and lateral lymph node (LLN) metastasis are accepted as an indication of neoadjuvant treatment. LLND was performed according to preoperative imaging after radiochemotherapy. Twenty-eight (10.5%) of 267 patients with rectal cancer who had suspected lateral lymph node metastasis (LLNM) with magnetic resonance imaging (MRI) underwent LLND in addition to TME after neoadjuvant chemoradiotherapy. Eight of them had LLNM. Three patients had bilateral LLND and only 1 had LLNM. The median number of harvested lymph nodes was 6. The rates of LLNM increased with the presence of poor prognosis markers. One regional and 1 distant recurrence were detected in patients who had no LLN metastasis compared with2 regional and 4 distant recurrences in the LLN-positive group. Local advanced rectal cancer cases may benefit from LLND, but it does not appear to have an effect on overall survival. There is no consensus whether size and/or morphologic criteria in MRI are the ideal guide for LLND.

Quality of Life in Locally Advanced Carcinoma Rectum Patients During Various Phases of NACRT: An Indian Perspective.

In low- and middle-income countries (LMICs) including India, cancer patients have a poor prognosis because of late diagnosis and cases already grown to advanced stages, low cancer awareness and skewed cancer care facilities. In India, the incidence of colorectal cancer (CRC) is ranked the 4th most common (6.4%) in males and the 5th most common (3.4%) in females. The improvement in the cure rate of rectal cancer has increased life expectancy, and assessment of the quality of life (QoL) in these patients has become a fundamental requirement. Little is known about how the patients perceive these adverse effects during curatively intended radiotherapy. Although studies have investigated the various adverse effects that can occur with radiotherapy and chemotherapy in carcinoma rectum patients, these have not yet been critically appraised and synopsized to form a comprehensive review of their prevalence and effects on QoL. The study was designed to explore the QoL issues in locally advanced carcinoma rectum patients during various phases of neoadjuvant concurrent chemo-radiotherapy (NACCRT). The study was performed over a period of 2years at a single super speciality cancer hospital in North India. Patients were selected as per the inclusion criteria and followed up with a standard questionnaire incorporating various aspects depicting QoL. The interview technique was used for collecting QoL data at four points, at baseline, midway during treatment, at the end of treatment and 4weeks after completion of NACCRT, using EORTC QLQ C30, for QLQ CR29. Special care was taken to avoid observer bias in cases of language issues, and interpreters' services were utilised, and compared with the baseline pre-treatment scores, patients reported a statistically significant and large clinically meaningful change in the global health status, social functioning, fatigue (FACIT-F), appetite loss, anxiety, sore skin and male and female sexual function at the post-treatment time point. Statistically significant changes with moderate clinically meaningful changes were reported for the functional scales-physical, role and emotional functioning of the QLQ C30 questionnaire and body image and weight of the CR29 questionnaire. Similar moderate clinical changes were found in the symptom scales-fatigue, nausea and vomiting, insomnia, constipation and diarrhoea of QLQ C30 and stool frequency, embarrassment with bowel function, impotence and dyspareunia. These parameters returned to almost the pre-treatment values after 4weeks of completion of NACRT. Since QoL is a relatively subjective variable, differences in human race, culture, education and social environment will have impacts on the results. International cooperation is needed to study the QoL in patients with multiple cultural backgrounds. The existing QoL questionnaire tools have been designed with Western countries in mind, and we did face multiple social issues. We suggest that many similar multicentre studies shall be required to essentially tap the accurate QoL-related issues keeping in mind the diverse social, economic, racial and educational backgrounds. As we deal with the ever-increasing cancer menace and better life expectancy, QoL issues shall be a major determinant of treatment success besides primary treatment. These factors should form an integral part of treatment modality, and adequate counselling must be performed prior to initiation of care.

Performance and Dimensionality of Pretreatment MRI Radiomics in Rectal Carcinoma Chemoradiotherapy Prediction.

(1) Background: This study aimed to develop a machine learning model based on radiomics of pretreatment magnetic resonance imaging (MRI) 3D T2W contrast sequence scans combined with clinical parameters (CP) to predict neoadjuvant chemoradiotherapy (nCRT) response in patients with locally advanced rectal carcinoma (LARC). The study also assessed the impact of radiomics dimensionality on predictive performance. (2) Methods: Seventy-five patients were prospectively enrolled with clinicopathologically confirmed LARC and nCRT before surgery. Tumor properties were assessed by calculating 2141 radiomics features. Least absolute shrinkage selection operator (LASSO) and multivariate regression were used for feature selection. (3) Results: Two predictive models were constructed, one starting from 72 CP and 107 radiomics features, and the other from 72 CP and 1862 radiomics features. The models revealed moderately advantageous impact of increased dimensionality, with their predictive respective AUCs of 0.86 and 0.90 in the entire cohort and 0.84 within validation folds. Both models outperformed the CP-only model (AUC = 0.80) which served as the benchmark for predictive performance without radiomics. (4) Conclusions: Predictive models developed in this study combining pretreatment MRI radiomics and clinicopathological features may potentially provide a routine clinical predictor of chemoradiotherapy responders, enabling clinicians to personalize treatment strategies for rectal carcinoma.

95P Interim results of a prospective randomized controlled study to compare the clinical outcomes of total neoadjuvant therapy vs long course chemoradiotherapy in locally advanced carcinoma rectum

95P Interim results of a prospective randomized controlled study to compare the clinical outcomes of total neoadjuvant therapy vs long course chemoradiotherapy in locally advanced carcinoma rectum

GRECCAR 14 - a multicentric, randomized, phase II-III study evaluating the tailored management of locally advanced rectal carcinoma after a favourable response to induction chemotherapy: Study protocol.

Total neoadjuvant treatment (TNT) is becoming standard in patients with locally advanced rectal carcinoma (LARC). Preoperative chemoradiotherapy (CRT) has proven side effects on bowel and genitourinary function. An early tumoral response to induction chemotherapy demonstrates its high prognostic value. Tailored management could be used as an alternative to systematic CRT. The GRECCAR 14 trial will attempt to personalize treatment strategy according to the patient's early tumour response to intensive chemotherapy with the aim of achieving the best toxicity-efficiency ratio. GRECCAR 14 is a multicentric, randomized, two-arm, phase II-III noninferiority trial. Patients with mid or low LARC with a predictive circumferential resection margin ≤2 mm or T3c-d stage with extramural venous invasion will be included. Evaluation of the tumoral response will be performed after six courses of high-dose FOLFIRINOX chemotherapy. Good responders (GRs) will be defined by a 60% decrease in tumoral volume on magnetic resonance imaging. Patients will be randomized to CRT before surgery. The primary endpoints will be R0 resection for phase II and the 3-year disease-free survival (DFS) for phase III. Tailored management of LARC is becoming an exciting challenge for the modality of neoadjuvant treatment and for the type of surgery or its omission. Neoadjuvant FOLFIRINOX has established efficacy, with a significant increase in the 3-year DFS. Better control of systemic disease must be accompanied by the same locoregional control, with the lowest morbidity. Our previous GRECCAR 4 trial demonstrated the high value of the early tumoral response after induction chemotherapy and the long-term safety of tailored management for GRs. If GRECCAR 14 demonstrates the ability to tailor TNT for LARC, this could lead to changes in clinical practice.

Evaluation of Response and Toxicity in Patients with Locally Advanced Rectal Cancer Treated with Neoadjuvant Chemoradiation

Purpose: To study the response after neoadjuvant chemoradiation in patients with locally advanced rectal cancer with capecitabine 825 mg/m2 daily PO bid with radiation at a dose of 45Gy/20#/4 weeks, to study the clinical profile of different patients with locally advanced rectal cancer, and to assess the toxicity of patients treated with neoadjuvant chemoradiationtherapy. Materials and Methods: A prospective observational study was conducted in 60 patients with histopathologically proven locally advanced rectal carcinoma from October 2018 to April 2020 . Neoadjuvant chemoradiation was planned with capecitabine 825 mg/m2 PO bid with radiation at a dose of 45 Gy/20#/4 weeks. Radiological response was assessed 6 weeks after treatment completion, and surgery was planned according to the response. Results: Thirty-seven patients underwent definitive surgery. Pathological complete response was observed in one patient, near complete response in seven, partial response in 27, and poor or no response in two patients. Of 37 patients who have undergone surgery, 30% of patients received sphincter preserving surgery. Radiation-induced acute skin and lower gastrointestinal tract lesions were observed. Capecitabine-induced diarrhea, hematological toxicities, and a few patients with hand foot syndrome were observed. Conclusion: In locally advanced rectal cancer, preoperative radio-chemotherapy with capecitabine improves local control and reduces the risks of acute and late toxicity compared to postoperative radiochemotherapy. Thus, preoperative radiochemotherapy with capecitabine is safe and well tolerated in locally advanced rectal cancer, especially in tumors of the lower and middle rectum.

MRI with diffusion-weighted imaging in staging and restaging of cancer rectum

Abstract Background Magnetic Resonance Imaging (MRI) has emerged as one of the most reliable noninvasive methods for staging rectal carcinoma, due to its ability to precisely delineate rectal tumors. Aim The aim of this study is to assess role of diffusion-weighted (DW) imaging in primary staging and restaging of locally advanced rectal cancers. Patients and methods 40 cases with rectal cancer were included in the research referred to the Radio diagnosis department throughout the period from December 2018 to March 2022. Pelvic MRI with DW imaging was done for all cases. Results According to this studies adding DW imaging to conventional MRI among group I (patients with resectable rectal cancer) increased the diagnostic accuracy to 93.6%, sensitivity to 91%, and specificity to 100%. In group II (patients with locally advanced rectal carcinoma) there was significant increase in the diagnostic accuracy to 83.6%, giving also high negative predictive value as we were able to differentiate between complete responder and nonresponder. Furthermore, the diagnostic accuracy in the evaluation of the mesorectal fascia involvement was much improved after the addition of DW imaging. Conclusion DW imaging yields better diagnostic accuracy than using conventional MR imaging alone in initial staging and restaging of cases with locally advanced rectal cancer.

Applying a neoscore in locally advanced rectal cancer is beneficial in predicting local recurrences after surgery.

The current study was undertaken to provide more detailed prognostic models for early prediction of local recurrences and local recurrence free survival (RFS) using different radiologic and pathologic features of locally advanced rectal carcinomas treated with neoadjuvant chemoradiation (CRT). One hundred patients with locally advanced rectal carcinomas decided to receive neoadjuvant CRT were retrospectively recruited, Hazard ratios (HR) were determined in the two cox regression models and only significant ratios were considered for pointing, Models were built to determine their important effects of different predictors including: pathologic T (T), pathologic N (N), grade (G), clinical stage (cTNM), site (S), perineural invasion (PNI), and response to CRT (R) on 3-year RFS, goodness of performance of each model was measured by Harrell's C index. HR of 1st group of models: T+N, T+N+G, T+N+G+S, T+N+G+S+PNI, and T+N+G+S+PNI+R were summated and categorized into scores, these scores were significantly correlated with the risk of recurrence (Somer's D = 0.5, p<0.0001) & Harrell's C index = 0.751, (Somer's D = 0.6, p<0.0001) & its Harrell's C index = 0.794, (Somer's D = 0.7, p<0.0001) & C index = 0.826, Somer's D = 0.7, p<0.0001) & C index = 0.827, and (Somer's D = 0.7, p<0.0001) & C index = 0.843 respectively. The 2nd group of models including: cTNM stage, cTNM+G, cTNM+G+S, cTNM+G+S+PNI, cTNM+G+S+PNI+R scores which were significantly correlated with the HR of LRR (Somer's D = 0.2, 0.5, 0.6, 0.6, & 0.6 respectively), (p = 0.006, <0.0001, <0.0001, <0.0001, <0.0001 respectively), the corresponding Harrell's C indices were 0.595, 0.743, 0.782, 0.795, & 0.813 respectively. We propose that the addition of biologic factors to staging of rectal cancer provide precise stratification and association with local recurrences in patients received preoperative CRT.

RECTAL CARCINOMA TO DELTOID MUSCLE – A MUSCULOSKELETAL METASTASIS

Metastasis in advanced rectal carcinoma is common and is usually seen to liver. Nevertheless, few cases of muscle metastasis have been reported in the past. In this case report, we are reporting a rare case of metastasis from adenocarcinoma of rectum to deltoid muscle and a review of previously reported cases. A middle aged men diagnosed advanced rectal cancer for which he previously operated for diversion sigmoidostomy. Then undergone course of chemotherapy and radiotherapy. After some time during the course he presented with left upper arm swelling which after excision suggest tissue originated from rectal adenocarcinoma. Patient died of carcinoma after one year and six months

Bone marrow sparing RapidArc treatment in locally advanced rectal cancer – can it reduce haematological toxicity?

Abstract Context: Haematological toxicities are seen in rectal cancer patients receiving concurrent chemoradiotherapy (CRT) with capecitabine. Aims: To compare dose volume histogram (DVH) parameters and acute haematological toxicities using RapidArc with or without bone marrow constraints for rectal cancer patients receiving pelvic chemoradiation as part of curative treatment. Setting and designs: This is a prospective randomised controlled study including patients with rectal cancer initiated on chemoradiation. Patients were stratified into two arms, bone marrow sparing (BMS) arm and non-bone marrow sparing arm (NBMS). Materials and methods: DVH parameters and weekly toxicity data were collected. Grade 2 or more anaemia, leucopenia, neutropenia, or thrombocytopenia, any blood transfusions, colony-stimulating factor injection, platelet transfusions were considered as an event in acute haematological toxicity (HT). Statistical analysis: Independent t-test was used to compare quantitative parameters, and Mann–Whitney U-test was used for ordinal parameters between groups. Results: A total of 43 patients were enrolled. Bone marrow constraints were achieved without compromising the target coverage. There was a significant reduction in the bone marrow dose with BMS technique (p &lt; 0·05). A 16·7% reduction in the HT (33·3% versus 50%) and a 21·9% reduction in the grade 2 or more anaemia (19% versus 40·9%) were noted in the BMS arm when compared to NBMS arm, though not statistically significant. However, in the preoperative setting, a significant reduction in grade 2/more anaemia (7·1% versus 41·1%, p = 0·035) was noticed in the BMS arm. Conclusions: Pelvic BMS radiotherapy may benefit patients receiving chemoradiation for locally advanced carcinoma rectum as part of curative treatment.

Modified DCF (Docetaxel, Cisplatin and 5-fluorouracil) chemotherapy is effective for the treatment of advanced rectal squamous cell carcinoma.

Advanced rectal squamous cell carcinoma (rSCC) is a very rare and aggressive entity, and the best initial management is crucial for long survival as well as organ preservation and quality of life. Whereas local diseases are treated with chemo-radiotherapy and salvage surgery, data are scarce on how to treat more advanced diseases, and the role of induction chemotherapy is unknown. We retrospectively analyzed all consecutive patients with advanced rSCC and treated with modified DCF (docetaxel, cisplatin, 5-fluorouracil; mDCF) regimen, from January 2014 and December 2021 in two French centers. Exploratory endpoints were efficacy (overall survival, recurrence-free survival, response rate, organ preservation rate) and safety. Nine patients with locally advanced or metastatic diseases received a mDCF regimen and were included for analysis. The median age was 62.0 years, 7 patients (77.8%) were women, and all eight available tumors were positive for HPV, mostly (85.7%) to genotype 16. With a median follow-up of 33.1 months, 77.8% of patients were still alive and disease-free, and the median overall survival was not reached at six years. The objective response rate was 87.5% after mDCF, and the complete response rate was 25.0% after mDCF and was increased to 75.0% after chemoradiotherapy. Only one patient underwent surgery on the primary tumor, with a complete pathological response. The median mDCF cycle was eight over eight scheduled, and all patients received the complete dose of radiotherapy without interruptions. Induction mDCF chemotherapy followed by chemoradiotherapy is safe and highly effective in patients with advanced rSCC, and should be considered as an option in metastatic stage or locally advanced disease with an organ-preservation strategy.

Prognostic and Predictive Biomarkers in Patients with Locally Advanced Rectal Cancer (LARC) Treated with Preoperative Chemoradiotherapy.

Neoadjuvant chemoradiotherapy (CRT) is one of the standards of care in locally advanced rectal cancer (LARC). This retrospective study examines clinical, analytical, and pathological parameters collected from 77 patients with locally advanced (cT3-4 or cN+) rectal carcinoma diagnosed between 2007 and 2017 at our institution that were treated with preoperative CRT and surgery. In the prognosis analysis, lower hemoglobin levels (p = 0.008), lower lymphocyte/monocyte ratio (LMR) (p = 0.011), and higher platelet/lymphocyte ratio (PLR) (p = 0.029) in the second determination (Hb2, LMR2 and PLR2) were associated with the relapse group. The number of positive nodes after surgery (N+) showed a statistically significant association with relapse (p = 0.012). KRAS mutations were associated with a worse prognosis for 5 years progression-free and overall survival (p = 0.005 and 0.022; respectively). We propose a prognostic model based on four parameters (number of positive lymph nodes after surgery, hemoglobin levels, LMR, and PLR after neoadjuvant therapy) that can be a useful tool to estimate relapse risk. Moreover, bilirubin could be a useful parameter to predict the response to neoadjuvant CRT.

Oncological outcome after lateral pelvic lymphadenectomy for low rectal carcinoma: not only an N-status matter.

Tumour deposits (TDs), novel pathological entities, should be considered when estimating the regional and systemic spread of rectal carcinoma and formulating treatment strategies. In fact, TDs may have more severe prognostic impact than lymph node positivity or the lymph node ratio. The assessment of the presence of TDs can be performed only through accurate postoperative pathological examination; however, the detection of TDs is not part of any of the procedures currently used to assess preoperative or intraoperative staging. This review aims to analyse and discuss the impact of TDs on the oncological outcome of patients who undergo surgery for advanced low rectal carcinoma. No prospective study has evaluated the impact of lateral pelvic TDs on oncological outcomes following total mesorectal excision with lateral pelvic lymphadenectomy. Although adequate total mesorectal excision allows for the excision of intramesorectal TDs, lateral pelvic lymph node dissection cannot guarantee the removal of lateral pelvic TDs; moreover, it remains to be determined whether surgical excision of lateral pelvic TDs can impact long-term outcomes. However, the identification of lateral pelvic TDs strengthens the 'staging effect' and limits the 'therapeutic effect' of lateral pelvic lymphadenectomy, supporting the rationale for the use of neoadjuvant chemoradiotherapy for rectal cancer. When evaluating the oncological outcomes after total mesorectal excision with lateral pelvic lymphadenectomy, the impact of lateral pelvic TDs should be considered.

The Effect of Continuing Chemotherapy after Chemoradiotherapy during the Time to Surgery on Tumor Response and Survival for Local Advanced Rectal Cancer.

Aim The current standard treatment of locally advanced rectal carcinoma is total mesorectal excision and postoperative adjuvant chemotherapy after neoadjuvant concurrent chemoradiotherapy (NCRT). Many studies have shown that pathological complete response (pCR) is an important prognostic factor for patients receiving NCRT. Many studies have therefore been conducted to increase pCR rates by changing the perioperative treatment strategies. Prolonging the chemotherapy time may be a reasonable way to increase the effectiveness of NCRT, pCR, and survival rates. We investigated whether neoadjuvant consolidation chemotherapy had an effect on tumor response and survival. Methods The data of 163 patients diagnosed with locally advanced rectal carcinoma were evaluated. The data of 107 patients (Group 1) who were radiologically T3–T4 and/or N+ and received chemotherapy after NCRT until their operations were compared with the data of 56 patients (Group 2) who were operated after NCRT. Results Group 1 patients had tumor and node downstaging. Their pCR was found significantly higher than in Group 2 (p = 0.005). In Group 1 patients with T3, pCR was significantly higher than for those with T4. The elapsed time between NCRT and surgery was significantly longer in patients with pCR (respectively, p = 0.012 and p = 0.008). Conclusion Neoadjuvant consolidation chemotherapy after NCRT is a safe approach that can lead to higher pathological complete response rates. The time until surgery with neoadjuvant consolidation chemotherapy may provide the chance to follow the patient without surgery in addition to increasing pCR.

Extramural vascular invasion as an independent prognostic marker in locally advanced rectal cancer: propensity score match pair analysis.

In rectal cancers, presence of extramural vascular invasion on MRI (mrEMVI) is associated with poor survival. The independent influence of mrEMVI in the presence of other prognostic factors has not been previously analyzed using match pair analysis. Consecutive 92 patients having mrEMVI at presentation treated between January 2016 and December 2018 were matched with 92 patients (1:1) without mrEMVI. Matching parameters were T stage, mesorectal fascia involvement, and tumor differentiation. The presence and absence of mrEMVI were correlated to outcomes. An event was defined as locoregional failure or distant metastasis or poor response to chemoradiation rendering the rectal tumor as inoperable. At 3years, in the mrEMVI-positive cohort, 59% had an event and in the mrEMVI-negative cohort, 45% had an event (p = 0.026). Local control was 90.2% (12recurrences in 122 who underwent surgery), two recurrences in the mrEMVI-positive cohort and ten patients in the mrEMVI-negative cohort, which missed statistical significance (p = 0.06). Distant metastasis-free survival was significantly worse in the mrEMVI-positive cohort versus the mrEMVI-negative cohort (58.2% vs. 69.4%) (p = 0.022). Similarly, Overall survival was significantly inferior in mrEMVI-positive cohort compared to the mrEMVI-negative cohort (57% vs. 72.4%) (p = 0.02). The multivariate regression analysis confirmed the independent predictive value of mrEMVI. CONCLUSION: Extramural vascular invasion detected through MRI is an independent risk factor for distant metastasis in the locally advanced carcinoma rectum. Aggressive treatment regimens like total neoadjuvant treatment should be considered in these cases pending randomized control studies.