Management Of Rectal Cancer Research Articles

The Ongoing Development of Watch and Wait

AbstractThe nonoperative management of rectal cancer, known as watch and wait (W&W), has gained increasing acceptance in recent years. This approach is based on using complete clinical response (cCR) as a marker for complete pathological response (pCR) following neoadjuvant chemoradiation (nCRT). Advances in nCRT regimens have resulted in higher tumor regression rates, making W&W a viable option for selected patients. This study presents the historical evolution and efficacy of the W&W strategy and offers modern recommendations based on recent clinical findings. Key findings include an 85 to 92% 5-year disease-free survival rate in patients achieving cCR, highlighting the potential for improved quality of life and reduced morbidity without compromising survival outcomes.

Cross-Sectional National Survey of Practice Patterns in Radiotherapy for Rectal Cancer: A Snapshot of India.

The information on the practice of radiotherapy, including intensity-modulated radiotherapy (IMRT) use for rectal cancer in India, is lacking. This national survey was planned to understand the current status of knowledge, attitudes, and practice among radiation oncologists, specifically concerning the practice of IMRT for rectal cancers. A national survey was sent to radiation oncologists through e-mail or a WhatsApp message, where feasible, with a request letter containing the link to the survey questionnaire. The survey questionnaire was adapted from the UK IMRT survey with permission from the authors. It explored rectal cancer management, IMRT use, reasons for nonadoption, total neoadjuvant therapy (TNT), dose fractionation schedules and radiotherapy processes like radiotherapy simulation, target volume/organ at risk definition, and treatment planning, evaluation, and verification. Descriptive statistics is used to present the results. Over 300 radiation oncologists were approached, and 182 (60.6%) of the 153 institutes responded. Around 88% (160 of 182) indicated using IMRT or volumetric modulated arc therapy (VMAT) to treat rectal cancer, of whom 32% used exclusively IMRT/VMAT in all their patients. The reasons for not adopting IMRT were affordability/lack of insurance, resource constraints, and lack of guidelines. Long-course chemoradiation (capecitabine-based) followed by surgery was the most common neoadjuvant approach, with short course and TNT in less than a third of patients. Daily verification feasibility was reported by 60%. Seventy-three percent emphasized the need for a national IMRT guidance document. This national survey from India indicates a scope of routine implementation of IMRT in rectal cancer, highlighting the urgent need for a national IMRT guidance document, which could significantly enhance the quality of care for patients with rectal cancer in India.

Emerging MRI Biomarkers for Prognostication in Rectal Cancer

Abstract: Rectal cancer is a significant health concern with substantial morbidity and mortality rates. Magnetic Resonance Imaging (MRI) plays a crucial role in the diagnosis and management of rectal cancer, providing detailed anatomical and functional information. However, traditional MRI techniques have limitations in prognosticating tumor behavior and treatment response. The study emphasizes the importance of emerging techniques such as Diffusion-Weighted Imaging (DWI), mrDEC scoring system, Dynamic Contrast-Enhanced MRI (DCE-MRI), Radiomics, and Machine Learning. By examining recent research and clinical trials, we aim to offer a comprehensive overview of the current landscape, challenges, and future directions associated with the incorporation of these MRI biomarkers in predicting outcomes for rectal cancer patients. This review paper aims to provide an overview of the emerging MRI biomarkers that hold the potential for prognostication of rectal cancer.

Histological and photoacoustic evaluation of rectal cancer after neoadjuvant therapy using microvascular density.

As non-operative management of rectal cancer proliferates, re-staging and surveillance methods are critical in selecting appropriate patients for organ preservation versus proctectomy. In previous work, the authors have shown that transrectal acoustic resolution photoacoustic microscopy (ARPAM) co-registered with ultrasound can differentiate residual cancer from complete tumoural response to neoadjuvant therapy. We hypothesize that these findings are due to changes in microvascular density (MVD). Patients with rectal adenocarcinoma who underwent neoadjuvant therapy, transrectal photoacoustic imaging and resection were included. We first compared immunohistochemical staining with erythroblast transformation-specific-related gene (ERG) immunostain to standard CD31 to confirm adequate identification of endothelium. Tissue sections from identical blocks were stained with CD31 and ERG, and then a correlation was calculated between manually labelled CD31-stained vessels and ERG nuclei density. Second, representative tissue blocks from responders, partial responders and non-responders were stained with ERG. ERG nuclei density was quantified as a proxy for MVD. CD31 MVD and ERG nuclei density were strongly correlated (R2 = 0.87; P < 0.01). In the tumour bed of patients after neoadjuvant therapy, MVD of complete responders (599 nuclei/mm2; 95% CI 434-764) is significantly higher (P < 0.01) than that of partial responders (185 nuclei/mm2; 95% CI 64-306) and non-responders (117 nuclei/mm2; 95% CI 42-192). No significant difference was found between the partial responders and non-responders (P = 0.60). Microvascular density appears highest in cases of complete tumour response to neoadjuvant therapy, similar to normal rectal tissue. The histological microvascular patterns seen in treated tissue may explain the imaging patterns seen in photoacoustic microscopy.

The Place of Surgery in the Management of Rectal Cancer

The Place of Surgery in the Management of Rectal Cancer

From Insight to Impact: Improving Mesorectal Evaluation Standards through Resident Educational Intervention

Abstract Introduction/Objective The completeness of total mesorectal excision (TME) and involvement of the circumferential radial margin (CRM) significantly impact local recurrence and survival rates in rectal cancer. Accurate gross examination to assess mesorectal status is crucial, not only for patient prognosis but also for evaluating surgical quality. Methods/Case Report We implemented a quality assurance initiative to enhance mesorectal quantification and CRM assessment by pathology trainees. Low anterior resection specimens received between January 2022 and December 2023 were included, with 2022 as the pre-intervention period and 2023 post-intervention. In December 2022, an educational session was conducted, emphasizing rectal resection specimens’ types and the importance of mesorectal and CRM assessment. Periodic reminder emails reinforced these concepts. Results (if a Case Study enter NA) We identified a total of 35 cases in the study: 20 pre-intervention arm and 15 post-intervention arm. Mesorectal quantification and CRM assessment and documentation improved significantly post- education, rising from 70% (14 of 20 cases) to 93% (14 of 15 cases) (p &amp;lt; 0.0001). Conclusion In conclusion, our study underscores the critical role of meticulous gross examination in assessing mesorectal status, serving not only as a prognostic indicator but also in guiding surgical precision and rectal cancer management. Further, our findings emphasize the transformative potential of education-driven interventions in enhancing the quality of mesorectal evaluation, reinforcing the pivotal role of pathologists and pathology trainees in shaping therapeutic strategies and ultimately improving rectal cancer patient care.

Predictive factors of major low anterior resection syndrome after surgery for rectal tumors.

To describe the epidemiological and clinical data of impaired functional outcome secondary to anterior resection of the rectum and to identify the predictive factors of major low anterior resection syndrome (LARS) Methods: This retrospective study considered patients operated on for rectal tumors in surgical department in our hospital, between January 1st,2009 and December 31st, 2021. The primary outcome measure was the development of a major LARS immediately or after stoma closure. In order to identify independent predictors of major LARS, patients were divided into two groups: the "Major LARS" group and the "No Major LARS" group, and then we carried out a descriptive study, followed by an analytical study with logistic regression. We enrolled 42 patients operated for rectal tumor and had an anterior resection. Half of our patients developed LARS of which 14 developed major LARS. The median time to onset of LARS symptoms was 9 [2 -24] months. At the end of this study, 2 factors were retained: age (OR=2.48; CI95% [1.2- 5.10], p=0.012) and pT3T4 stage (OR=5.95; CI95% [1.07- 33.33], p=0.041) as independent predictive factors of a major LARS. Neoadjuvant therapy was also a risk factor for major LARS in our study with a statistically significant difference (p=0.025) between the two groups "Major LARS" and "No major LARS". LARS should be appropriately considered in the management of rectal cancer. Based on our results and data from the literature, age and mesorectal invasion were found to be independent predictors of major LARS.

"Defendit Numerus": A Pooled Analysis of 6145 Locally Advanced Rectal Cancer Treated with Preoperative Chemoradiotherapy.

Objective: The optimal management of rectal cancer remains a subject of ongoing research. This meta-analysis of individual patient data assessed the benefit of chemoradiotherapy (fluorouracil-based) in local advanced rectal cancer: disease-free survival and overall survival. Methods: We pooled the data of 6145 patients from 24 studies of rectal cancer who received neoadjuvant radiotherapy with concomitant fluorouracil or capecitabine and surgery. The PRISMA 2020 abstract checklist was followed. Individual participant survival was reconstructed with an algorithm from published Kaplan-Meier curves. Results: The median OS was not reached; the mean survival time was 135.4 months (127.9-141.5). The median DFS was 176.9 months, and the mean disease-free survival time was 122.6 months (111.7-131.9). Conclusions: We provided a benchmark for future studies on rectal cancer treatment. The present results can be used in decision-making for locally advanced rectal cancer patients.

The Role of Predictive and Prognostic MRI-Based Biomarkers in the Era of Total Neoadjuvant Treatment in Rectal Cancer.

The role of magnetic resonance imaging (MRI) in rectal cancer management has significantly increased over the last decade, in line with more personalized treatment approaches. Total neoadjuvant treatment (TNT) plays a pivotal role in the shift from traditional surgical approach to non-surgical approaches such as 'watch-and-wait'. MRI plays a central role in this evolving landscape, providing essential morphological and functional data that support clinical decision-making. Key MRI-based biomarkers, including circumferential resection margin (CRM), extramural venous invasion (EMVI), tumour deposits, diffusion-weighted imaging (DWI), and MRI tumour regression grade (mrTRG), have proven valuable for staging, response assessment, and patient prognosis. Functional imaging techniques, such as dynamic contrast-enhanced MRI (DCE-MRI), alongside emerging biomarkers derived from radiomics and artificial intelligence (AI) have the potential to transform rectal cancer management offering data that enhance T and N staging, histopathological characterization, prediction of treatment response, recurrence detection, and identification of genomic features. This review outlines validated morphological and functional MRI-derived biomarkers with both prognostic and predictive significance, while also exploring the potential of radiomics and artificial intelligence in rectal cancer management. Furthermore, we discuss the role of rectal MRI in the 'watch-and-wait' approach, highlighting important practical aspects in selecting patients for non-surgical management.

FP1.8 - Optimizing Rectal Cancer Treatment: Comprehensive response to Neoadjuvant therapy

Abstract Aims This study aimed to assess the outcomes and feasibility of a watch-and-wait strategy in patients with rectal cancer showing a complete response to neoadjuvant chemoradiotherapy (CRT). The primary objectives included evaluating the oncological results, disease-free interval, and survival rates in patients who underwent the watch-and-wait approach after a complete clinical response. Methods The study involved a retrospective analysis of last 10 years of rectal cancer patients enrolled in a complete responder surveillance program in an acute general hospital. Cohort characteristics, including age, performance status, tumor histology, distance from the anal verge, and treatment modalities, were documented. Results The median age was 74 (57-90), and the median performance status was 1, with the age at diagnosis being 69. All cohort members had a histologically confirmed rectal adenocarcinoma. The median tumor-to-anal-verge distance was 5 cm (1-10 cm). Neoadjuvant chemotherapy was administered to 55% of patients. All patients underwent long-course radiotherapy, and 35% received papillon contact brachytherapy. Total neoadjuvant therapy was received by 10%. The median follow-up involved approximately 9 colonoscopies. During follow-up, 25% of patients experienced recurrence, with a median disease-free interval of 3.5 years. Conclusion The findings of this study, in addition to ongoing prospective clinical trials and insights from databases such as EURECCA and OnCore, indicate that a watch-and-wait approach can be safe and effective for selected rectal cancer patients who have achieved a complete response to neoadjuvant CRT. This study highlights the significance of additional research to identify appropriate patients for this approach and to refine its implementation in rectal cancer management.

A Review of Neoadjuvant Therapy and the Watch-and-Wait Protocol in Rectal Cancer: Current Evidence and Future Directions.

The treatment of rectal cancer underwent a significant change with the introduction of total mesorectal excision (TME), which substantially improved recurrence rates. However, TME is associated with complications such as fecal incontinence and poor bladder control, especially in tumors located near the anal verge. The watch-and-wait (WW) protocol has emerged as an alternative for patients achieving a clinical complete response (cCR) following neoadjuvant radiochemotherapy. This narrative review, developed according to the Scale for the Assessment of Narrative Review Articles guidelines, evaluates neoadjuvant treatments and the WW protocol for rectal cancer. Literature was sourced from the PubMed database using specific search terms related to neoadjuvant therapy and the WW protocol, resulting in 63 articles selected for discussion. Neoadjuvant treatment, including chemoradiation and short-course radiotherapy, is indicated for T3 and T4 rectal adenocarcinomas. Studies like the German Rectal Cancer Study Group and the PRODIGE 23 trial have shown the benefits of preoperative treatment, including improved disease-free survival and reduced local recurrence rates. However, challenges in adopting the WW protocol include the risk of local regrowth and distant metastasis. Immune checkpoint inhibitors have shown promise in mismatch repair-deficient patients, yet the data are insufficient to fully endorse WW for these cases. The WW protocol is viable for selected rectal cancer patients, with ongoing debates regarding criteria for inclusion. Key challenges include accurately identifying cCR and managing patients with near-complete responses. MRI and endoscopic evaluation are crucial for assessing treatment response, although achieving a pathological complete response remains uncertain. The WW strategy offers a potential organ-preserving approach in rectal cancer management but requires careful patient selection and comprehensive risk-benefit discussions. Further research is needed to refine criteria for inclusion and optimize treatment protocols, enhancing outcomes while minimizing invasive interventions.

Lone-Star retractor perineal exposure method for laparoscopic abdominal perineal resection of rectal cancer.

The abdominal perineal resection (APR), historically referred to as Mile's procedure, stands as a time-honored surgical intervention for rectal cancer management. Advancements in surgical techniques and the advent of neoadjuvant therapies have significantly improved the rate of sphincter preservation among patients afflicted with rectal cancer, including those with ultralow rectal cancer. Despite these improvements, APR maintains its irreplaceable role in the clinical landscape, particularly for cases involving low rectal cancer with encroachment on the external anal sphincter or levator ani muscles. Optimal perineal exposure stands as a pivotal phase in APR, given that the precision of this maneuver is directly correlated with both the safety of the surgery and the patient's subsequent long-term prognosis. To evaluate the value of Lone-Star retractor (LSR) perineal exposure method in the treatment for laparoscopic APR of rectal cancer. We reviewed the records of 38 patients with rectal cancer at Anqing Municipal Hospital from January 2020 to December 2023, including 20 patients who underwent the APR procedure with a LSR perineal exposure method (LSR group) and 18 patients who underwent the APR procedure with a conventional perineal exposure method (control group). In the LSR group, following incision of the skin and subcutaneous tissue, the LSR was placed and dynamically adjusted according to the surgical plane to fully expose the perineal operative field. A total of 38 patients underwent laparoscopic APR, none of whom were found to have distant metastasis upon intraoperative exploration. Perineal blood loss, the postoperative hospital stays and the wound pain scores in the LSR group were significantly lower than those in the control group. A single surgeon completed the perineal operation significantly more often in the LSR group than in the control group (P < 0.05). The incidence of infection via the perineal incision in the LSR group was significantly lower than that in the control group (P < 0.05). No cases of distant metastasis or local recurrence were found among the patients at the postoperative follow-up. The application of the LSR technique might be helpful for performing perineal exposure during APR for rectal cancer and could reduce the incidence of perineal complications, shorten the postoperative hospital stay, improve postoperative pain, and allow one surgeon to perform the perineal operation.

Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: How to Select the Most Suitable?

Rectal cancer shows specific characteristics in terms of pattern of recurrence, which occurs commonly at both local and distant sites. The standard of care for locally advanced rectal cancer (LARC) including neoadjuvant chemoradiotherapy, followed by surgery based on the total mesorectal excision principles leads to a reduction in the rates of local recurrences to 6-7% at 5 years. However, the outcomes among those with high-risk lesions remain unsatisfactory. On the contrary, neoadjuvant chemoradiotherapy results in long-term morbidities among those with low-risk lesions. Furthermore, the overall survival benefit of neoadjuvant therapy is still a subject to be debated, except for patients with complete or near-complete response to neoadjuvant therapy. Total neoadjuvant therapy (TNT) is a new paradigm of management of high-risk rectal cancer that includes early administration of the most effective systemic therapy either before or after neoadjuvant radiotherapy with or without chemotherapy prior to surgery with or without adjuvant chemotherapy. TNT potentially improves disease-free survival, even though whether it can prolong survival has been debatable. Recently, neoadjuvant chemotherapy only has been proved to be non-inferior to neoadjuvant chemoradiotherapy in patients with low-risk lesions. This review intends to review the current evidences of neoadjuvant therapy and propose a more customized paradigm of management of LARC.

Essential knowledge and technical tips for total mesorectal excision and related procedures for rectal cancer.

Total mesorectal excision (TME) has greatly improved rectal cancer surgery outcomes by reducing local recurrence and enhancing patient survival. This review outlines essential knowledge and techniques for performing TME. TME emphasizes the complete resection of the mesorectum along embryologic planes to minimize recurrence. Key anatomical insights include understanding the rectal proper fascia, Denonvilliers fascia, rectosacral fascia, and the pelvic autonomic nerves. Technical tips cover a step-by-step approach to pelvic dissection, the Gate approach, and tailored excision of Denonvilliers fascia, focusing on preserving pelvic autonomic nerves and ensuring negative circumferential resection margins. In Korea, TME has led to significant improvements in local recurrence rates and survival with well-adopted multidisciplinary approaches. Surgical techniques of TME have been optimized and standardized over several decades in Korea, and minimally invasive surgery for TME has been rapidly and successfully adopted. The review emphasizes the need for continuous research on tumor biology and precise surgical techniques to further improve rectal cancer management. The ultimate goal of TME is to achieve curative resection and function preservation, thereby enhancing the patient's quality of life. Accurate TME, multidisciplinary-based neoadjuvant therapy, refined sphincter-preserving techniques, and ongoing tumor research are essential for optimal treatment outcomes.

Feasibility of a tailored operative strategy from organ preservation to pelvic exenteration for cT4 rectal cancer depending on neoadjuvant response

PurposeImprovements in neoadjuvant therapy for locally advanced cT4 rectal cancer have led to improved tumour response and thus a variety of suitable management strategies. The aim of this study was to report management and outcomes of patients with cT4 rectal cancer undergoing a spectrum of treatment strategies from organ preservation (OP) to pelvic exenteration (PE).MethodsPatients who underwent elective treatment for cT4 rectal cancer between 2016 and 2021 were included. All patients were treated with curative intent. Surgical management was adapted to tumour response. Kaplan–Meier curves were generated to compare 3-year overall survival (3y-OS), local recurrence (3y-LR) and distant metastases (3y-DM) between different strategies.ResultsAmong 152 patients included, 13 (8%) underwent OP, 71 (47%) TME and 68 (45%) APR/PE. The median follow-up was 31.3 months. Patients undergoing OP had a lower tumour pretreatment (p < 0.001). Compared to patients with TME, those with APR/PE had a higher rate of ypT4 (p = 0.001) with a lower R0 rate (p = 0.044). The 3y-OS and 3y-DM were 78% and 15.1%, respectively, without significant differences. The 3y-LR was 6.6%, and patients with OP had a significantly worse 3y-local regrowth compared to 3y-LR in patients with TME and APR/PE (30.2% vs. 5.4% vs. 2%, p = 0.008).ConclusioncT4 tumours may be suitable for the full spectrum of rectal cancer management from organ preservation to pelvic exenteration depending on tumour response to neoadjuvant therapy. However, careful attention is required in OP as local regrowth in up to 30% of cases reinforces the need for sustained active surveillance in Watch&Wait programmes.

Deciphering the Dilemma: Choosing the Optimal Total Neoadjuvant Treatment Strategy for Locally Advanced Rectal Cancer.

Rectal cancer management has evolved significantly, particularly with neoadjuvant treatment strategies. This narrative review examines the development and effectiveness of these therapies for locally advanced rectal cancer (LARC), highlighting the historical quest that led to current neoadjuvant alternatives. Initially, trials showed the benefits of adding radiotherapy (RT) and chemotherapy (CT) to surgery, reducing local recurrence (LR). The addition of oxaliplatin to chemoradiotherapy (CRT) further improved outcomes. TNT integrates chemotherapy and radiotherapy preoperatively to enhance adherence, timing, and systemic control. Key trials, including PRODIGE 23, CAO/ARO/AIO 12, OPRA, RAPIDO, and STELLAR, are analyzed to compare short-course and long-course RT with systemic chemotherapy. The heterogeneity and difficulty in comparing TNT trials due to different designs and outcomes are acknowledged, along with their promising long-term results. On the other hand, it briefly discusses the potential for non-operative management (NOM) in select patients, a strategy gaining traction due to favorable outcomes in specific trials. As a conclusion, this review underscores the complexity of rectal cancer treatment, emphasizing individualized approaches considering patient preferences and healthcare resources. It also highlights the importance of interpreting impressive positive or negative results with caution due to the variability in study designs and patient populations.

Modified delayed coloanal anastomosis following TME for mid and low rectal cancer: 19 consecutive patients from a single center.

Surgery and management of rectal cancer have made significant progress in recent decades. However, there is still no coloanal anastomosis technique that offers a good compromise between functionality and low morbidity. The aim of this study is to evaluate the safety and efficiency of the modified delayed coloanal anastomosis (mDCA). In this retrospective study, we analyzed the morbi-mortality as well as functional outcomes of 19 patients treated with mDCA, out of 73 colorectal cancer patients treated at our institution from September 2021 to June 2023. The inclusion criteria were cancer of the mid and low rectum (tumor less than 10cm from the anal verge). Morbidity represented by complications of Clavien-Dindo grade III or higher was estimated at 5.2%. Only one patient experienced an asymptomatic anastomotic leak (AL) grade A. Ischemia of the colonic stump occurred in one patient, taken back to the OR on the 5th postoperative day. No stump retraction was noted. Anastomotic stenosis appeared in one patient (5.2%) during the 90-day postoperative period, and was treated by instrumental dilation. Perioperative mortality was nil. The mean St Marks incontinence score at 90days was 13.2 points. At the 3-month follow-up, 15 patients (78.9%) had major low anterior resection syndrome (LARS), three (15.7%) had minor LARS, and one patient (5.2%) had no LARS. None of the patients had a diversion loop ileostomy. The mDCA, by decreasing the rate of AL, without the need for diversion ileostomy, might be an interesting alternative to the conventional immediate coloanal anastomosis (ICA), for restoring the GI tract after proctectomy for cancer.

Evaluation of the role of neoadjuvant chemotherapy in the management of rectal cancer

Evaluation of the role of neoadjuvant chemotherapy in the management of rectal cancer

Anatomic Basis of Rectal Cancer Staging: Clarifying Controversies and Misconceptions.

Rectal MRI provides a detailed depiction of pelvic anatomy; specifically, the relationship of the tumor to key anatomic structures, including the mesorectal fascia, anterior peritoneal reflection, and sphincter complex. However, anatomic inconsistencies, pitfalls, and confusion exist, which can have a strong impact on interpretation and treatment. These areas of confusion include the definition of the rectum itself, specifically differentiation of the rectum from the anal canal and the sigmoid colon, and delineation of the high versus low rectum. Other areas of confusion include the relative locations of the mesorectal fascia and peritoneum and their significance in staging and treatment, the difference between the mesorectal fascia and circumferential resection margin, involvement of the sphincter complex, and evaluation of lateral pelvic lymph nodes. The impact of these anatomic inconsistencies and sources of confusion is significant, given the importance of MRI in depicting the anatomic relationship of the tumor to critical pelvic structures, to triage surgical resection and neoadjuvant chemoradiotherapy with the goal of minimizing local recurrence. Evolving treatment paradigms also place MRI central in management of rectal cancer. ©RSNA, 2024.

Comparison of outcomes of abdominoperineal resection vs low anterior resection in very-low rectal cancer

BackgroundThe management of very-low rectal cancer is one of the most challenging issues faced by general and colorectal surgeons. Many feel compelled to pursue abdominoperineal resection (APR) over low anterior resection (LAR) to optimize oncologic outcomes. This study aimed to determine differences in long-term oncologic outcomes between patients undergoing APR or LAR for very-low rectal cancer. MethodsThe United States Rectal Cancer Consortium (2010–2016) was queried for adults who underwent either APR or LAR for stage I-III rectal cancers < 5 cm from anorectal junction and met inclusion criteria. The primary outcome was disease-free survival. Secondary outcomes included overall survival, length of stay, complications, recurrence location, and perioperative factors. ResultsA total of 431 patients with very-low rectal cancer who underwent APR or LAR were identified; 154 (35.7%) underwent APR. The overall recurrence rate was 19.6%. The median follow-up was 42.5 months. An analysis adjusted for demographics and pathologic stage observed no difference in disease-free survival between operative types (APR-hazard ratio [HR] = 0.90, 95% CI: 0.53–1.52, P = .70). Secondary outcomes demonstrated no significant difference between operation types, including overall survival (HR = 1.29, 95% CI: 0.71–2.32, P = .39), complications (OR = 1.53, 95% CI: 0.94–2.50, P = .12), or length of stay (estimate: 0.04, SE = 0.25, P = .54). ConclusionWe observed no significant difference in disease-free survival or overall survival between patients undergoing APR or LAR for very-low rectal cancer. This analysis supports the treatment of very-low rectal cancer, without sphincter involvement, by either APR or LAR.