Nonoperative Management for Rectal Cancer

Developing a multivariable prediction model of global health-related quality of life in patients treated for rectal cancer: a prospective study in five countries

PURPOSE

Rectal cancer and its treatment have a negative impact on health-related quality of life (HRQoL). If risk factors for sustained low HRQoL could be identified early, ideally before the start of treatment, individualised interventions could be identified and implemented to maintain or improve HRQoL. The study aimed to develop a multivariable prediction model for global HRQoL 12 months after rectal cancer treatment.

METHODS

Within COLOR II, a randomised, multicentre, international trial of laparoscopic and open surgery for rectal cancer, a sub-study on HRQoL included 385 patients in 12 hospitals and five countries. The HRQoL study was optional for hospitals in the COLOR II trial. EORTC QLQ-C30 and EORTC QLQ-CR38 were analysed preoperatively and at 1 and 12 months postoperatively. In exploratory analyses, correlations between age, sex, fatigue, pain, ASA classification, complications, and symptoms after surgery to HRQoL were studied. Bivariate initial analyses were followed by multivariate regression models.

RESULTS

Patient characteristics and clinical factors explained 4-10% of the variation in global HRQoL. The patient-reported outcomes from EORTC QLQ-C30 explained 55-65% of the variation in global HRQoL. The predominant predictors were fatigue and pain, which significantly impacted global HRQoL at all time points measured.

CONCLUSION

We found that fatigue and pain were two significant factors associated with posttreatment global HRQoL in patients treated for rectal cancer T1-T3 Nx. Interventions to reduce fatigue and pain could enhance global HRQoL after rectal cancer treatment.

TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov No. NCT00297791.

Effects of remifentanil combined with propofol on hemodynamics and oxidative stress in patients undergoing resection of rectal carcinoma

BACKGROUND

Rectal carcinoma (RC) treatment primarily involves laparoscopic surgery, which may induce significant hemodynamic changes and weaken immune function. Certain anesthetic approaches using opioid drugs (including remifentanil and sufentanil) pose risks, such as hypotension.

AIM

To determine the effects of remifentanil combined with propofol on hemodynamics and oxidative stress in patients undergoing RC resection.

METHODS

A total of 211 patients one hundred and four patients with RC treated at the First Affiliated Hospital of Dalian Medical University between November 2018 and November 2022 were retrospectively analyzed. Among them, the remifentanil group included 45 patients receiving remifentanil with propofol anesthesia and the sufentanil group included 59 patients receiving sufentanil with propofol anesthesia. Changes in the hemodynamic index, oxidative stress index, general data, consumption of remifentanil, and use of vasoactive drugs were compared. The incidences of adverse reactions were calculated.

RESULTS

The two groups did not significantly differ in terms of operation, anesthesia, and extubation times (P > 0.05). At 1 min after intubation, the sufentanil group showed a notably higher heart rate, systolic blood pressure (SBP), diastolic blood pressure, and mean arterial pressure (MAP) compared with the remifentanil group (P < 0.05), whereas the sufentanil group showed a notably higher SBP and MAP compared with the remifentanil group at 5 min after pneumoperitoneum (P < 0.05). Thirty minutes after surgery, the remifentanil group showed significantly lower plasma cortisol, noradrenaline, and glucose levels than the sufentanil group (P < 0.001). The remifentanil group consumed significantly less remifentanil than the sufentanil group (P < 0.05), and the adoption frequency of ephedrine was lower in the remifentanil group than that in the sufentanil group (P < 0.05). The incidence of hypotension was notably higher in the sufentanil group than that in the remifentanil group (P < 0.05).

CONCLUSION

Remifentanil combined with propofol can improve hemodynamics and relieve oxidative stress in patients undergoing RC resection.

Total neoadjuvant therapy in rectal cancer: the evidence and expectations

Current management of locally advanced rectal cancer achieves high cure rates, distant metastatic spread being the main cause of patients' death. Total neoadjuvant therapy (TNT) employs (chemo)radiotherapy and combined chemotherapy prior to surgery to improve the treatment outcomes. TNT has been shown to reduce significantly distant metastases, increase disease-free survival by 5 - 10% in 3 years, and finally also overall survival (≈ 5% in 7 years). It proved to double the rate of pathologic complete responses, making it an attractive strategy for non-operative management to avoid permanent colostomy in patients with distal tumors. In addition, it endorses adherence to the therapy due to better tolerance and, potentially, shortens its overall duration. A number of questions related to TNT remain currently unresolved including the indications, preferred radiotherapy and chemotherapy regimens, their sequence, timing of surgery, and role of adjuvant therapy. A stratified approach may be the optimal way to go.

Establishment of a nomogram model for prediction of postoperative heterochronous liver metastasis in young and middle-aged patients with rectal cancer

BACKGROUND

The incidence of rectal cancer is increasing year by year. Radical surgery is often used for the treatment of rectal cancer in clinical practice, but postoperative liver metastasis has become an important reason for the increase in mortality. Therefore, establishing a model to predict the trend of metachronous liver metastasis has become a research focus. Nomogram model has been widely used in the medical field, but there has been no widely accepted nomogram model available for prediction of metachronous liver metastasis after rectal cancer surgery.

AIM

To constuct a nomogram model based on the risk factors for postoperative metachronous liver metastasis in young and middle-aged patients with rectal cancer, and to evaluate the performance of the model for predicting the risk of postoperative metachronous liver metastasis, so as to provide some guidance for clinical prevention and treatment.

METHODS

A total of 120 young and middle-aged patients with rectal cancer admitted to our hospital from March 2019 to February 2022 were selected as research subjects to observe the incidence of postoperative heterochronous liver metastasis. Univariate and multivariate Logistic regression analyses were performed to identify the risk factors for postoperative heterochronous liver metastasis and to construct a nomogram model. ROC curve, decision curve, and correction curve analyses were used to verify the value of nomogram model for the prediction of postoperative heterochronous liver metastasis.

RESULTS

The incidence of anomalous liver metastasis 1 year after surgery was 23.33% in 120 young and middle-aged patients with rectal cancer. Low differentiation, lymph node metastasis, depth of invasion (T3/T4), margin width of primary cancer < 2 cm, high expression of peripheral blood telomerase reverse transcriptase (hTERT), and elevated serum levels of carcinoembryonic antigen (CEA), vascular endothelial growth factor (VEGF), lemur tyrosine kinase-3 (LMTK3), squamous cell carcinoma-associated antigen (SCC-Ag), and axon-guided factor-1 (Netrin-1) were identified to be risk factor for postoperative hetero-chronic liver metastasis (P < 0.05). The C-index and area under the curve of the nomogram model were 0.860 and 0.957, respectively, and the net benefit value was high (P < 0.05).

CONCLUSION

Low differentiation, lymph node metastasis, depth of invasion (T3/T4), margin width of primary cancer < 2 cm, high expression of hTERT in peripheral blood, and elevated levels of serum CEA, VEGF, LMTK3, SC-AG and Netrin-1 are risk factors for postoperative xenotemporal liver metastasis in young and middle-aged patients with rectal cancer. Based on the above risk factors, a nomogram model has been established to predict postoperative heterochronous liver metastasis in such patients.

Prognostic Impact of TP53 Mutations and Tumor Mutational Load in Colorectal Cancer

The DNA damage response (DDR) is critical for maintaining genome stability, and abnormal DDR—resulting from mutations in DNA damage-sensing and repair proteins—is a hallmark of cancer. Here, we aimed to investigate the predictive power of DDR gene mutations and the tumor mutational load (TML) for survival outcomes in a cohort of 22 rectal cancer patients who received pre-operative neoadjuvant therapy. Univariate analysis revealed that TML-high and TP53 mutations were significantly associated with worse overall survival (OS) with TML-high retaining significance in multivariate analyses. Kaplan–Meier survival analyses further showed TML-high was associated with worse disease-free (p = 0.036) and OS (p = 0.024) results in our patient cohort. A total of 53 somatic mutations were identified in 22 samples with eight (36%) containing mutations in DDR genes, including ATM, ATR, CHEK2, MRE11A, RAD50, NBN, ERCC2 and TP53. TP53 was the most frequently mutated gene, and TP53 mutations were significantly associated with worse OS (p = 0.023) in Kaplan–Meier survival analyses. Thus, our data indicate that TML and TP53 mutations have prognostic value for rectal cancer patients and may be important independent biomarkers for patient management. This suggests that prognostic determination for rectal cancer patients receiving pre-operative neoadjuvant therapy should include consideration of the initial TML and tumor genetic status.