Low Rectal Cancer Research Articles

Impact of visceral fat area on short-term outcomes in robotic surgery for mid and low rectal cancer.

Rectal cancer is one of the most prevalent cancers that arise in the digestive tract. The purpose of this retrospective study was to investigate the impact of visceral fat area (VFA) on postoperative outcomes in mid and low rectal cancer patients undergoing robotic surgery (RS). Data were collected on patients who underwent robotic anterior rectal resection in a single center from December 2019 to October 2023. Clinical pathology information was analyzed. Statistical analysis was done on the computed tomography (CT) imaging data. A total of 277 patients were included in the study, including 121 cases with visceral obesity (VO) and 156 cases without VO. There was no statistically significant disparity in the lymph node dissection count, blood loss, duration of hospitalization, time to first liquid diet, early postoperative complications, histopathologic specimen indices (quality of TME and CRM involvement rate), and or the rate of conversion to open surgery between VO and non-VO group (P>0.05). Nevertheless, the group of individuals with VO experienced a lengthier duration of surgery (P<0.001) and a delayed time until the first passage of flatus (P<0.001) in comparison to the group without VO. The study suggests that VO does not significantly impact early complications or the quality of surgical outcomes in mid and low rectal cancer patients undergoing robotic surgery. The findings support the continued use of RS as an optimal strategy for technically demanding patients.

Laparoscopic total mesorectal excision versus transanal total mesorectal excision for mid and low rectal cancer: A systematic review and meta-analysis.

Laparoscopic total mesorectal excision (LaTME) and transanal total mesorectal excision (TaTME) are popular mid and low rectal cancer trends. However, there is currently no systematic comparison between LaTME and TaTME of mid and low rectal cancer. Therefore, we systematically study the perioperative and pathological outcomes of LaTME and TaTME in mid and low rectal cancer. Articles included searching through the Embase, Cochrane Library, PubMed, Medline, and Web of science for articles on LaTME and TaTME. We calculated pooled standard mean difference (SMD), relative risk (RR), and 95% confidence intervals (CIs). The protocol for this review has been registered on PROSPERO (CRD42022380067). There are 8761 participants included in 33 articles. Compared with TaTME, patients who underwent LaTME had no statistical difference in operation time (OP), estimated blood loss (EBL), postoperative hospital stay, over complications, intraoperative complications, postoperative complications, anastomotic stenosis, wound infection, circumferential resection margin, distal resection margin, major low anterior resection syndrom, lymph node yield, loop ileostomy, and diverting ileostomy. There are similarities between LaTME and TaTME for 2-year DFS rate, 2-year OS rate, distant metastasis rat, and local recurrence rate. However, patients who underwent LaTME had less anastomotic leak rates (RR 0.82; 95% CI: 0.70-0.97; I2 = 10.6%, P = .019) but TaTME had less end colostomy (RR 1.96; 95% CI: 1.19-3.23; I2 = 0%, P = .008). This study comprehensively and systematically evaluated the differences in safety and effectiveness between LaTME and TaTME in the treatment of mid and low rectal cancer through meta-analysis. Patients who underwent LaTME had less anastomotic leak rate but TaTME had less end colostomy. There is no difference in other aspects. Of course, in the future, more scientific and rigorous conclusions need to be drawn from multi-center RCT research.

Articulating forceps in laparoscopic total mesorectal excision: A video comparison with robotic surgery

AbstractIntroductionTotal mesorectal excision (TME) is an established standard procedure for rectal surgery; however, it is technically challenging because of the deep and narrow pelvis. Minimally invasive surgeries have gained prominence for TME with favorable outcomes but come with limitations. Laparoscopic surgery often has dexterity restrictions because of the use of straight forceps, whereas robotic surgery is impeded by high costs and extended operative times. Articulating forceps aim to bridge the gap between these methods by offering enhanced dexterity at a lower cost.Patients and Surgical TechniqueThis video study involves two female patients diagnosed with lower rectal cancer. One patient underwent laparoscopic intersphincteric resection (Lap‐ISR) using the ArtiSential articulating forceps (LIVSMED Inc.), and the other underwent robot‐assisted low anterior resection (Rob‐LAR) using the da Vinci Xi System. Both operations involved similar mesorectal dissection steps, except for the anastomosis. The standard port placement was used, and dissection was performed circumferentially down to the perianal region.DiscussionThe ArtiSential demonstrated effectiveness comparable with the da Vinci Xi system in TME surgery, with the potential advantage of improved cost‐effectiveness.

Effect of laparoscopy-assisted vs open surgery on 3-year disease-free survival in patients with low rectal cancer: The LASRE randomized clinical trial.

8 Background: Laparoscopic surgery has been increasingly used for low rectal cancer due to short-term benefits versus open surgery, but the long-term oncologic outcomes have not been fully established. Methods: This is a multicenter, noninferiority trial. Surgeons who had completed ≥100 laparoscopic TME surgeries from 22 high-volume centers in China participated in this trial. A total of 1070 patients scheduled for curative-intent resection of low rectal cancer (lower margin &lt;5.0 cm dentate line) were randomized at a 2:1 ratio to undergo laparoscopic or open surgery from November 2013 to June 2018.The primary outcome was 3-year DFS; the noninferiority margin was 10% in the modified intent-to-treat population. Secondary outcomes included 3-year overall survival (OS) and locoregional recurrence. Results: The final analysis included 1039 patients (median age: 57 years, 620 men; 685 and 354 in laparoscopic and open groups, respectively). Clinical TNM stage was II/III in 659 patients, and I in the remaining 380 patients. The 3-year DFS rate was 81.4% in the laparoscopic group versus 79.8% in the open group (HR, 0.9 [95% CI, 0.7 to 1.2]; log-rank P = .558). The absolute difference was 1.6% (1-sided 97.5% CI, -3.34% to ∞), not exceeding the noninferiority . The 3-year OS rate was 91.7% in the laparoscopic group versus 93.7% in the open group (95% CI, -5.12% to1.54%, log-rank P = .243). The 3-year locoregional recurrence rate was 3.8% and 2.4%, respectively (95% CI, -1.07% to 3.45%, log-rank P = .209). Results of the per-protocol and as-treated analysis were consistent with the main analysis. Conclusions: Among patients with low rectal cancer, laparoscopic surgery performed by experienced surgeons is not inferior to open surgery concerning 3-year disease-free survival. These results support laparoscopic surgery as a safe, minimally invasive approach for low rectal cancer. Clinical trial information: NCT01899547 .

The efficacy of adjuvant chemotherapy after total mesorectal excision with selective lateral pelvic node dissection for lower rectal cancer.

50 Background: The standard strategy for lower rectal cancer (LRC) is neoadjuvant chemoradiotherapy (CRT) plus total mesorectal excision (TME) in Western countries. TME with or without lateral pelvic node dissection (LND) followed by adjuvant chemotherapy is the standard treatment for LRC in Japan. However, the efficacy of adjuvant chemotherapy for LRC after TME without LND remains unclear. The aim of this study was to assess the efficacy of adjuvant chemotherapy for LRC after TME without LND. Methods: We retrospectively reviewed patients who underwent R0 resection by TME without LND and received adjuvant chemotherapy between 2010 and 2020 at our institution. The inclusion criteria were as follows: age ≥ 20 years; histologically confirmed adenocarcinoma; pathological stage III (UICC 8th); lower rectal cancer (Ra/Rb); patients who received adjuvant chemotherapy after R0 resection without LND and no prior treatment before surgery. We evaluated relapse free survival (RFS) and overall survival (OS) in patients with LRC. Prognostic impact of location, adjuvant chemotherapy regimens, T factor, and N factor on RFS was explored by a multivariate analysis. Results: From a total of 197 patients, 117 patients were eligible. Median age was 65 years (range 26–82) and 54 patients (46%) were male. Tumor location was 67 (57%)/50 (43%) for Ra/Rb and pathologic stage was 47(40%) /61(52%)/ 9(8%) for IIIA/IIIB/IIIC. Eighty patients (68%) received fluoropyrimidine monotherapy (single agent) and 37 patients (32%) received oxaliplatin based therapy (doublet) as adjuvant chemotherapy. The 3-year RFS rate and 3-year OS rate were 70.7% (95% CI, 59.0-81.1%) and 94.5% (95% CI, 89.0-98.1%). The 3-year RFS rates according to tumor location (Ra/Rb) and adjuvant chemotherapy regimen (single agent/doublet) were 76.9%/70.7% and 71.8%/68.5%, respectively. The 3-year RFS rates based on pathological stage (IIIA/IIIB/IIIC) were 76.7%/68.4%/64.8%. In a multivariate analysis, T3/4 were identified as an independent poor prognostic factor for RFS (p&lt;0.05). Conclusions: TME without LND followed by adjuvant chemotherapy for patients with LRC demonstrated favorable 3-year RFS rate. adjuvant chemotherapy regimens after TME without LND suggested no additive efficacy of oxaliplatin on RFS.

Node-sparing modified short-course radiotherapy combined with CAPOX and tislelizumab for locally advanced MSS of middle and low rectal cancer (mRCAT): An open-label, single-arm, prospective, multicentre clinical trial.

TPS233 Background: Neoadjuvant chemoradiotherapy followed by total mesorectal excision is a standard treatment for locally advanced rectal cancer. Mismatch repair-deficient locally advanced rectal cancer was highly sensitive to PD-1 blockade. However, most rectal cancers are mismatch repair-proficient or microsatellite stable subtypes for which PD-1 blockade is ineffective. Radiation can trigger the activation of CD8+ T cells, further enhancing the responses of microsatellite stable rectal cancer to PD-1 blockade. Radioimmunotherapy offers a promising therapeutic modality for rectal cancer. Progenitor T exhausted cells are abundant in tumour-draining lymph nodes and play an important role in immunotherapy. Conventional irradiation fields include the mesorectum and regional lymph nodes, which might cause considerable damage to T lymphocytes and radiation-induced fibrosis, ultimately leading to a poor response to immunotherapy and rectal fibrosis. This study investigated whether node-sparing modified short-course irradiation combined with chemotherapy and PD-1 blockade could be effective in patients with microsatellite stable locally advanced rectal cancer. Methods: Our clinical trial investigates the safety and efficacy of node-sparing modified short-course radiotherapy combined with CAPOX and tislelizumab for microsatellite stable locally advanced middle and low rectal cancer. This phase II study will recruit 32 patients to receive node-sparing modified short-course radiotherapy (the irradiated planned target volume only included the primary tumour bed but not the tumour-draining lymph nodes, 25 Gy/5f, 5 Gy/f) followed by CAPOX and tislelizumab. 2 of planned 32 patients have been enrolled. CAPOX and tislelizumab will be started two days after the completion of radiotherapy: oxaliplatin 130 mg/m2 intravenous infusion, day 1; capecitabine 1000 mg/m2 oral administration, days 1-14; and tislelizumab 200 mg, intravenous infusion, day 1. There will be three 21-day cycles. TME will be performed at weeks 11-12. We will collect blood, tumour, and lymphoid specimens; perform flow cytometry and in situ multiplexed immunofluorescence detection; and analyse the changes in various lymphocyte subsets. The primary endpoint is the rate of pathological complete response. The organ preservation rate, tumour regression grade, local recurrence rate, disease-free survival, overall survival, adverse effects, and quality of life will also be analysed. Clinical trial information: NCT05972655 .

Artificial intelligence-based model for recurrence prediction after local excision on whole slide images in T1 low rectal cancer.

24 Background: According to current guidelines, patients with resected specimens showing high-risk features are recommended for additional surgery after local excision of T1 colorectal cancer, despite the low incidence (~7%) of recurrence. However, surgical resection in patients with low rectal cancer (RC) is challenging and may compromise anal function, leading to a low quality of life. To reduce unnecessary surgical resection for these patients, we utilized artificial intelligence to develop and validate a prediction model for the risk of recurrence in T1 low rectal cancer patients. Methods: H&amp;E-stained whole slide images (WSIs) were scanned for local excision (endoscopically or transanally minimally) specimens of 507 consecutive patients with T1 low rectal cancers that were locally resected at 4 hospitals between 2005 and 2015. The area under the receiver operating characteristic curve (AUROC), specificity and sensitivity were used to evaluate the performance of the model for the risk of recurrence, and an external validation cohort was to verify the applicability of the model. Results: We constructed a prediction model using convolutional neural networks (CNN) without incorporating clinical features. The model yielded good discrimination and calibration, achieving a 5-year recurrence-free survival AUROC of 0.90 (95% confidence interval [CI]: 0.86–0.93), sensitivity of 0.91 (95% CI: 0.84–0.96), and specificity of 0.82 (95% CI: 0.78–0.88) through fivefold cross-validation. Additionally, the AI avoided 25.7% of unnecessary additional surgery compared to the current guidelines. Conclusions: We proposed a novel prediction model for the risk of recurrence in T1 low RC patients to assist physicians in determining whether additional surgery is required after local excision of T1 low RC.

Recurrence in the pelvic side wall after lateral lymph node dissection for rectal cancer.

49 Background: Locally advanced rectal cancer poses a persistent challenge due to the risk of local recurrence, which impacts patient outcomes and quality of life. To address this, lateral pelvic lymph node dissection (LPND) has emerged as a surgical approach to improve local control. However, comprehensive studies evaluating the outcomes and patterns of recurrence after LPND are limited. This retrospective study aimed to fill this gap and provide insights into the effectiveness of LPND. Methods: We conducted a retrospective analysis of 515 patients diagnosed with stage II-III lower rectal cancer who underwent TME and LPND between January 2005 and August 2022. Clinicopathological data were collected, and tumor staging followed the TNM classification system. Recurrence patterns, survival rates, and factors influencing lateral pelvic recurrence were assessed. Results: In our cohort, 18.8% of patients had pathologically positive lateral lymph nodes. Patients with lateral lymph node metastasis exhibited significantly lower 5-year relapse-free survival (31.6%) and overall survival (47.8%) rates compared to those without metastasis (69.5% and 84.7%, respectively). Local recurrence occurred in 20.1% of all patients, with 6.7% experiencing lateral pelvis recurrence (LPR) and 17.4% central pelvis recurrence. Multivariate analysis identified age over 75, lateral lymph node metastasis, and adjuvant chemotherapy as independent risk factors for LPR. Conclusions: Lateral pelvic lymph node dissection remains a valuable tool in managing locally advanced rectal cancer. Our findings underscore the importance of surgeon expertise in performing LPND and the potential benefits of combining treatments to further reduce lateral recurrence. LPND should continue to be explored and refined to enhance patient outcomes in this challenging clinical scenario.

Treatment planning for patients with low rectal cancer in a multicenter prospective organ preservation study

BackgroundNon-surgical management of rectal cancer relies on (chemo)radiotherapy as the definitive treatment modality. This study reports and evaluates the clinical high dose radiotherapy treatment plans delivered to patients with low resectable rectal cancer in a Danish multicenter trial. MethodsThe Danish prospective multicenter phase II Watchful Waiting 2 trial (NCT02438839) investigated definitive chemoradiation for non-surgical management of low rectal cancer. Three Danish centers participated in the trial and committed to protocol-specified treatment planning and delivery requirements. The protocol specified a dose of 50.4 Gy in 28 fractions to the elective volume (CTV-/PTV-E) and a concomitant boost of 62 Gy in 28 fractions to the primary target volume (CTV-/PTV-T). ResultsThe trial included 108 patients, of which 106 treatment plans were available for retrospective analysis. Dose coverage planning goals for the main target structures were fulfilled for 94% of the treatment plans. However, large intercenter differences in doses to organs-at-risk (OARs) were seen, especially for the intestines. Five patients had a V60Gy>10 cm3 for the intestines and two patients for the bladder. ConclusionPrescribed planning goals for target coverage were fulfilled for 94% of the treatment plans, however analysis of OAR doses and volumes indicated intercenter variations. Dose escalation to 62 Gy (as a concomitant boost to the primary tumor) introduced no substantial high dose volumes (>60 Gy) to the bladder and intestines. The treatment planning goals may be used for future prospective evaluation of highdose radiotherapy for organ preservation for low rectal cancer.

A novel Foley catheter made of high-intensity near-infrared fluorescent silicone rubber for image-guided surgery of lower rectal cancer

BackgroundUrethral injury occurs in 1–6 % of male cases during minimally invasive surgery of lower rectal cancer. A Foley catheter emitting near-infrared (NIR) fluorescence of sufficient intensity has been expected to locate the urethra during image-guided surgery. Although it has been difficult to impart NIR fluorescent properties to biocompatible thermosetting polymers, we have recently succeeded in developing a NIR fluorescent compound for silicone rubber and a NIR fluorescent Foley catheter (HICARL). Here, we evaluated its NIR fluorescence properties and visibility performance using porcine anorectal isolation specimens. MethodsThe HICARL catheter was made of a mixture of solid silicone rubber and a NIR fluorescent compound that emits fluorescence with a wavelength of 820–880 nm, while a conventional transparent Foley catheter was made of solid silicone rubber only. As a standard for comparison of the intensity of NIR fluorescence, a transparent Foley catheter the lumen of which was filled with a mixture of indocyanine green (ICG) and human plasma was used. As a comparison to assess the visibility performance of the HICARL catheter, a transparent Foley catheter into which a commercially available NIR fluorescent polyurethane ureteral catheter (NIRC) was placed was used. ResultsA NIR fluorescence quantitative imaging analysis revealed that the Foley-NIRC catheter and the HICARL catheter emitted 3.42 ± 0.42 and 6.43 ± 0.07 times more fluorescence than the Foley-ICG catheter, respectively. The location of the HICARL catheter placed in the anorectum with a wall thickness of 3.8 ± 0.1 mm was clearly delineated in its entirety by NIR fluorescence, while that of the Foley-NIRC catheter was faintly or only partially visible. ConclusionsThe HICARL catheter emitting NIR fluorescence of sufficient intensity is a promising and easy-to-use tool for urethral visualization during image-guided surgery of lower rectal cancer.

Transanal Endoscopic Microsurgery (TEM) is a surgical option to preserve fecal continence in selected low rectal cancers

Despite its existence for more than 40 years, the TEM method has not become widespread. The main reasons are the high acquisition costs, the sophisticated technology and alternative procedures (especially radical resection procedures), which provide greater oncological safety. However, avoiding major abdominal surgery with the creation of a stoma and higher complication rates can outweigh the higher risk of recurrence for some patients. We examined the results using V-TEM with reduced acquisition costs in the resection of adenomas and carcinomas and discussed its importance by literature . From 2003 to 2019, 154 patients with 170 findings were operated by V-TEM technology. Data on the operation and follow-up were collected and analyzed retrospectively. The median age was 67 years, 89 patients were male and 65 female. V-TEM was performed on 79 carcinomas, 77 adenomas and 14 other findings. The complication rate was 21.2%. R0 resection was achieved in 78.8%. The adenoma recurrence rate was 7.3%, the overall recurrence rate for carcinomas 11.9%, local recurrences were observed in 6.8%. The disease-specific survival is 100% at 5 years and 94.2% at ten years. The successful use of TEM in adenomas and early carcinomas is undisputed. When treating carcinomas from a T1 high risk stage using TEM, recurrence rates higher than 10% must be expected. Better results can be achieved with radical procedures, this is why they are considered the therapy of choice in these cases. However, there are no differences in terms of survival rates and TEM offers proven better postoperative quality of life. In particular, the combination of neoadjuvant procedures with TEM delivered promising results in more advanced stages. Further studies on TEM and the possibility of lower acquisition costs through modification to V-TEM could make the method more popular in the future.

A Complete Pathological Response to Neoadjuvant Chemoradiotherapy in A Young Female with Local-Progressed Low Rectal Cancer Following ‘Wait-And-Watch’ Surveillance: A Case Report

Low rectal cancer is a common malignant tumor around the world, and the incidence rate is increasing over years. The abdominoperineal resection, known as the Miles procedure, combined with postoperative chemotherapy and radiotherapy are recommended for the low rectal cancer, that sacrifices the sphincter and can severely affect patient’s quality of life post-surgery. There is a young-onset tendency, and the young patients are more concerned about sphincter-preserving and life-quality post-surgery. With the advances in neoadjuvant therapy, the patient’s options without sacrificing sphincter are expanded. We hereby report a 31-year-old female patient with ultra-low rectal adenocarcinoma, 1.4 cm to the anus edge, was treated through Neoadjuvant chemoradiotherapy (nCRT), which combined CAPEOX chemotherapy and radiotherapy. The initial staging of the tumor was cT3N1M0, and the MRI indicated a threatened circumferential resection margin (CRM). After three cycles of treatment the tumor lesion was completely gone on MRI and colonoscopy, and a complete pathological response (cPR) was yielded then a ‘Wait-and-Watch’ surveillance was being pursued. We aim to advance further studies on the particular molecular and genetic mechanism for neoadjuvant therapy complete remission in young adult patients with low rectal cancer, so as to increase anal preservation rate in the population.

The effectiveness and safety of rectal modular dissection for male middle and low rectal cancer after neoadjuvant chemoradiation therapy: the short-term outcome.

Background: The purpose of this study was to assess the efficacy and safety of rectal modular dissection (RMD) in male patients with middle and low rectal cancer. RMD is a technique used to guide the surgical procedure for rectal mobilization, with the ultimate goal of achieving total mesorectal excision. In order to evaluate the effectiveness of RMD, a single-center, non-inferiority randomized clinical trial was carried out. Methods: Eligible patients were randomly assigned into two groups: the RMD group and the traditional rectal mobilization (TRM) group. Demographic characteristics, perioperative data and pathological results of the surgical specimens were collected for analysis. additionally, assessments of urogenital function and defecation function were conducted for all participants. Results: A total of 103 patients (RMD group 53 patients and TRM group 50 patients) were included to analyzed. There were no significant differences in age, body mass index, ASA classification, and tumor characteristics between two groups. The RMD group had significantly lower blood loss (P = 0.00), shorter operative duration (P = 0.00), and shorter hospital stay (P = 0.04) compared to the TRM group. The complete rate of mesorectal excision was higher in the RMD group (98.1%) compared to the TRM group (86.0%, P = 0.02). In terms of functional outcomes, the RMD group had better evaluation scores for urethral function (IPSS score, P = 0.01), erectile function (IIEF-5 score, P = 0.00) and defecation function (LARS score, P = 0.00) at the one-year postoperative follow-up. The 1-year disease-free survival rate was similar between the two groups (P = 0.28). Conclusions: These results suggest that RMD is an effective and safe approach for achieving total mesorectal excision while promoting better functional outcomes for patients. The trial was registered in Chinese Clinical Trial Registry (ChiCTR2100052094).

Distal margin distance in radical resection of locally advanced rectal cancer after neoadjuvant therapy.

Colorectal cancer has a high incidence and mortality rate in China, with the majority of cases being middle and low rectal cancer. Surgical intervention is currently the main treatment modality for locally advanced rectal cancer, with the common goal of improving oncological outcomes while preserving function. The controversy regarding the circumferential resection margin distance in rectal cancer surgery has been resolved. With the promotion of neoadjuvant therapy concepts and advancements in technology, treatment strategies have become more diverse. Following tumor downstaging, there is an increasing trend towards extending the safe distance of distal rectal margin. This provides more opportunities for patients with low rectal cancer to preserve their anal function. However, there is currently no consensus on the specific distance of distal resection margin.

Intersphincteric resection of low rectal cancer: a retrospective study

Background The use of sphincter-saving resection without a permanent stoma in place of abdominoperineal resection (APR) has been one of the greatest advancements in the area of surgical therapy for low rectal cancer. Aim To assess the oncological and functional outcomes of inter-sphincteric resection of low rectal cancer in order to achieve radicality and a standard of living. Patients and methods At the hospitals affiliated with Menoufia University, a retrospective analysis was done. Forty patients with rectum cancer who were undergoing general surgery at Menoufia University Hospitals were the subject of this investigation. We comprised: older than 18 years old, sexes of both genders, low rectum and anal canal, with internal sphincter or rectal wall restriction on magnetic resonance imaging, differentiated tumour, tumour diameter of 1–5, and good continence. Results Mean operative time was 261.8 (±96.6 SD), the mean blood loss was 185.8 (±156.5 SD). Mean postoperative hospital stay was 11.2 (±4.1S D), the mean pain severity 1 h postoperatively was 5.5 (±1.0 SD), the mean 1 day postoperatively was 5.9 (±1.5 SD), the mean 5 day postoperatively was 3.3 (±1.2 SD), there were three with Anastomotic leakage, two with wound infection, two with hemorrhage, one with urinary tract infection, one with ileus. Regarding complications, mean score of micturition problems was 28.2 (±4.1 SD), the mean GIT symptoms was 32.2 (±3.1 SD), the mean weight loss was 5.5 (±1.0 SD), the mean CTX side effects was 13.9 (±1.5 SD), the mean body image was 70.3±6.2. Conclusion The intersphincteric resection approach improves the rate of sphincter preservation while maintaining oncological and functional results. Symptom-specific quality of life may be adversely affected by preoperative radiation.

Survival outcomes according to the tumor location and prognostic factor in metastatic rectal cancer: a multicenter retrospective cohort study.

Prognostic factors of metastatic rectal cancer are not well known. We aim to determine prognostic factors affecting survival for metastatic rectal cancer patients and also to investigate the effect of tumor localization on overall survival. Metastatic rectal cancer patients who received treatment in 5 different centers between 2012 and 2022 were included. Prognostic factors for survival were evaluated using univariate and multivariate analysis. The statistical methods included Pearson's chi-square test, Fisher exact test, Log-rank test, and Cox regression model. A total of 283 patients with metastatic rectal cancer were included in the study. The median OS was not significantly different among the three groups (upper rectum 30.1 months, middle rectum 28.3 months, and low rectum cancer 24.8 months; log-rank p = 0.25). In univariate analysis, Grade 3, ECOG performance status 2, the presence of multiple metastatic sites, the presence of KRAS mutation, the presence of liver metastases, the presence of nonregional lymph node metastases, and the presence of bone metastases were significant predictors of poor survival. In multivariate analysis, Grade 3, ECOG performance status 2, and the presence of multiple metastatic sites were determined as indicators of worse prognosis. Our findings, primary tumor location did not affect survival in metastatic rectal cancer. The most important factors affecting survival were multiple metastatic sites, tumor grade, and ECOG performance status.

Patient-Reported Sexual Function, Bladder Function and Quality of Life for Patients with Low Rectal Cancers with or without a Permanent Ostomy.

Despite the increasing utilization of sphincter and/or organ-preservation treatment strategies, many patients with low-lying rectal cancers require abdominoperineal resection (APR), leading to permanent ostomy. Here, we aimed to characterize overall, sexual-, and bladder-related patient-reported quality of life (QOL) for individuals with low rectal cancers. We additionally aimed to explore potential differences in patient-reported outcomes between patients with and without a permanent ostomy. We distributed a comprehensive survey consisting of various patient-reported outcome measures, including the FACT-G7 survey, ICIQ MLUTS/FLUTS, IIEF-5/FSFI, and a specific questionnaire for ostomy patients. Descriptive statistics and univariate comparisons were used to compared demographics, treatments, and QOL scores between patients with and without a permanent ostomy. Of the 204 patients contacted, 124 (60.8%) returned completed surveys; 22 (18%) of these had a permanent ostomy at the time of survey completion. There were 25 patients with low rectal tumors (≤5 cm from the anal verge) who did not have an ostomy at the time of survey completion, of whom 13 (52%) were managed with a non-operative approach. FACTG7 scores were numerically lower (median 20.5 vs. 22, p = 0.12) for individuals with an ostomy. Sexual function measures IIEF and FSFI were also lower (worse) for individuals with ostomies, but the results were not significantly different. MLUTS and FLUTS scores were both higher in individuals with ostomies (median 11 vs. 5, p = 0.06 and median 17 vs. 5.5, p = 0.01, respectively), suggesting worse urinary function. Patient-reported ostomy-specific challenges included gastrointestinal concerns (e.g., gas, odor, diarrhea) that may affect social activities and personal relationships. Despite a limited sample size, this study provides patient-centered, patient-derived data regarding long-term QOL in validated measures following treatment of low rectal cancers. Ostomies may have multidimensional negative impacts on QOL, and these findings warrant continued investigation in a prospective setting. These results may be used to inform shared decision making for individuals with low rectal cancers in both the settings of organ preservation and permanent ostomy.

Impact of robotic total mesorectal excision upon pathology metrics in overweight males with low rectal cancer: a pooled analysis of 836 cases.

The aim of this pooled analysis was to evaluate the impact of robotic total mesorectal excision (TME) on pathology metrics in Male Overweight patients with Low rectal cancer (MOL). This was a multicenter retrospective pooled analysis of data. Two groups were defined: MOL (Male, Overweight, Low rectal cancer) and non-MOL. Overweight was defined as BMI ≥ 25kg/m2. Low rectal cancer was defined as cancer within 6cm from the anal verge. The primary endpoints of this study were histopathological metrics, namely circumferential resection margin (CRM) (mm), CRM involvement rate (%), and the quality of TME. Circumferential resection margin (CRM) was involved if < 1mm. 836 (106 MOL and 730 non-MOL) patients that underwent robotic TME by six surgeons over 3years were compared. No significant differences in demographics and perioperative variables were found, except for operating time, distal margin, and number of lymph nodes harvested. CRM involvement rate did not significantly differ (7.5% vs. 5.5%, p = 0.395). Mean CRM was statistically significantly narrower in MOL patients (6.6 vs. 7.7mm, p = 0.04). Quality of TME did not differ. Distance of tumor from the anal verge was the only independent predictor of CRM involvement. Robotic TME may provide optimal pathology metrics in overweight males with low rectal cancer. Although CRM was a few millimeters narrower in MOL, the values were within the range of uninvolved margins making the difference statistically significant, but not clinically. Being MOL was not a risk factor for involvement of circumferential resection margin.

Current perspectives on the management of lateral pelvic lymph nodes in rectal cancer.

Significant controversies exist with regards to the optimal management of lateral pelvic lymph nodes metastases (mLLN) in patients with low rectal cancer. The differing views held by Japanese and Western clinicians on the management of mLLN have been well documented. However, the adequacy of pelvic lymph node dissection (PLND) or neoadjuvant chemoradiation (NACRT) alone in addition to total mesorectal excision (TME) have recently come into question, due to the relatively high incidence of lateral local recurrences following PLND and TME, or NACRT and TME alone. Recently, a more selective approach to PLND has been suggested, involving a combination of neoadjuvant therapy, followed by PLND only to patients in whom the oncological benefit is likely to outweigh the risk of potential adverse events. A number of studies have attempted to retrospectively identify certain nodal characteristics on preoperative imaging, such as nodal size, appearance, and size reduction following neoadjuvant therapy. However, no consensus has been reached regarding the optimal criteria for a selective approach to PLND, partly due to the heterogeneity and retrospective nature of most of these studies. This review aims to provide an overview of recent evidence with regards to the diagnostic challenges, considerations for, and outcomes of the current management strategies for mLLN in rectal cancer patients.

Short-term and long-term efficacy in robot-assisted treatment for mid and low rectal cancer: a systematic review and meta-analysis

ObjectiveThis study aims to conduct a meta-analysis to evaluate the short-term and long-term therapeutic effects of robot-assisted laparoscopic treatment in patients with mid and low rectal cancer.MethodsA comprehensive search strategy was employed to retrieve relevant literature from PubMed, NCBI, Medline, and Springer databases, spanning the database inception until August 2023. The focus of this systematic review was on controlled studies that compared the treatment outcomes of robot-assisted (Rob) and conventional laparoscopy (Lap) in the context of mid and low rectal cancer. Data extraction and literature review were meticulously conducted by two independent researchers (HMW and RKG). The synthesized data underwent rigorous analysis utilizing RevMan 5.4 software, adhering to established methodological standards in systematic reviews. The primary outcomes encompass perioperative outcomes and oncological outcomes. Secondary outcomes include long-term outcomes.ResultA total of 11 studies involving 2239 patients with mid and low rectal cancer were included (3 RCTs and 8 NRCTs); the Rob group consisted of 1111 cases, while the Lap group included 1128 cases. The Rob group exhibited less intraoperative bleeding (MD = −40.01, 95% CI: −57.61 to −22.42, P < 0.00001), a lower conversion rate to open surgery (OR = 0.27, 95% CI: 0.09 to 0.82, P = 0.02), a higher number of harvested lymph nodes (MD = 1.97, 95% CI: 0.77 to 3.18, P = 0.001), and a lower CRM positive rate (OR = 0.46, 95% CI: 0.23 to 0.95, P = 0.04). Additionally, the Rob group had lower postoperative morbidity rate (OR = 0.66, 95% CI: 0.53 to 0.82, P < 0.0001) and a lower occurrence rate of complications with Clavien–Dindo grade ≥ 3 (OR = 0.60, 95% CI: 0.39 to 0.90, P = 0.02). Further subgroup analysis revealed a lower anastomotic leakage rate (OR = 0.66, 95% CI: 0.45 to 0.97, P = 0.04). No significant differences were observed between the two groups in the analysis of operation time (P = 0.42), occurrence rates of protective stoma (P = 0.81), PRM (P = 0.92), and DRM (P = 0.23), time to flatus (P = 0.18), time to liquid diet (P = 0.65), total hospital stay (P = 0.35), 3-year overall survival rate (P = 0.67), and 3-year disease-free survival rate (P = 0.42).ConclusionRobot-assisted laparoscopic treatment for mid and low rectal cancer yields favorable outcomes, demonstrating both efficacy and safety. In comparison to conventional laparoscopy, patients experience reduced intraoperative bleeding and a lower incidence of complications. Notably, the method achieves comparable short-term and long-term treatment results to those of conventional laparoscopic surgery, thus justifying its consideration for widespread clinical application.