Management of rectal cancer: Times they are changing

Morbidity and oncological outcomes after intersphincteric resection of the rectum for low-lying rectal cancer: experience of a single center in a lower-middle-income country

BACKGROUND

Intersphincteric resection (ISR) of the rectum for low-lying rectal cancer with colo-anal anastomosis was introduced years ago, allowing for bowel continuity, and avoiding permanent stomas. The colorectal unit of Korle Bu Teaching Hospital adopted this procedure in 2014 when indicated, for the management of rectal cancers, where hitherto, abdominoperineal resection of the rectum with a permanent stoma was indicated. This study aimed to assess morbidity, mortality, and oncological outcomes associated with ISR of the rectum and determine the factors contributing to these.

METHODS

This was an observational study from prospectively stored data. All patients who underwent intersphincteric resection of the rectum due to low-lying rectal cancer from July 2014 to June 2021 were included in the study, and their records were assessed for intra-operative and 30-day postoperative complications, as well as mortality and their related risk factors and their oncological outcomes in terms of local recurrence at one year.

RESULTS

102 patients were included in this analysis. Six percent (6/102) of patients had intra-operative complications, including bleeding, and 41% (42/102) had 30-day postoperative complications, which were associated with pelvic side wall attachment of tumor and intra-op complications. Mortality risk was 12.7% (13/102) in the early postoperative period, and nine patients had a local recurrence within the first year of surgery.

CONCLUSION

There is a high risk of early postoperative morbidity and mortality after intersphincteric resection of the rectum in our setting. The oncological outcomes are favorable in a population that abhors a permanent colostomy.

Molecular and Kinetic Analyses of Circulating Tumor Cells as Predictive Markers of Treatment Response in Locally Advanced Rectal Cancer Patients

Neoadjuvant chemoradiation (NCRT) followed by total mesorectal excision is the standard treatment for locally advanced rectal cancer (LARC). To justify a non-surgical approach, identification of pathologic complete response (pCR) is required. Analysis of circulating tumor cells (CTCs) can be used to evaluate pCR. We hypothesize that monitoring of thymidylate synthase (TYMS) and excision repair protein, RAD23 homolog B (RAD23B), can be used to predict resistance to chemotherapy/radiotherapy. Therefore, the aims of this study were to analyze CTCs from patients with LARC who underwent NCRT plus surgery for expression of TYMS/RAD23B and to evaluate their predictive value. Blood samples from 30 patients were collected prior to NCRT (S1) and prior to surgery (S2). CTCs were isolated and quantified by ISET^®, proteins were analyzed by immunocytochemistry, and TYMS mRNA was detected by chromogenic in situ hybridization. CTC counts decreased between S1 and S2 in patients exhibiting pCR (p = 0.02) or partial response (p = 0.01). Regarding protein expression, TYMS was absent in 100% of CTCs from patients with pCR (p = 0.001) yet was expressed in 83% of non-responders at S2 (p < 0.001). Meanwhile, RAD23B was expressed in CTCs from 75% of non-responders at S1 (p = 0.01) and in 100% of non-responders at S2 (p = 0.001). Surprisingly, 100% of non-responders expressed TYMS mRNA at both timepoints (p = 0.001). In addition, TYMS/RAD23B was not detected in the CTCs of patients exhibiting pCR (p = 0.001). We found 83.3% of sensitivity for TYMS mRNA at S1 (p = 0.001) and 100% for TYMS (p = 0.064) and RAD23B (p = 0.01) protein expression at S2. Thus, TYMS mRNA and/or TYMS/RAD23B expression in CTCs, as well as CTC kinetics, have the potential to predict non-response to NCRT and avoid unnecessary radical surgery for LARC patients with pCR.

Radiologic Evaluation of Clinically Benign Rectal Neoplasms May Not Be Necessary Before Local Excision

BACKGROUND

Local excision may be curative for benign and malignant rectal neoplasms. Because many early rectal cancers are discovered incidentally after local excision of clinically benign lesions, it is unclear whether preoperative imaging with transrectal ultrasound or MRI affects management.

OBJECTIVE

The purpose of this study was to determine the diagnostic characteristics and effect of preoperative imaging on the incidence of malignancy in benign rectal lesions undergoing local excision.

DESIGN

Prospective data from 2 institutions were included. Coarsened exact matching created a balanced cohort comparing imaging and no-imaging groups.

SETTING

The study was conducted at high-volume specialist referral hospitals.

PATIENTS

Adult patients undergoing local excision via transanal endoscopic surgery between 1997 and 2016 for clinically benign rectal neoplasms were included.

INTERVENTION

The study intervention included preoperative imaging with transrectal ultrasound and/or MRI.

MAIN OUTCOME MEASURES

We measured the incidence of malignancy and diagnostic accuracy of preoperative imaging.

RESULTS

A total of 620 patients were included (272 with preoperative imaging and 348 without). There were 250 patients undergoing transrectal ultrasound, and 24 patients undergoing MRI (2 patients underwent both). Transrectal ultrasound and MRI correctly identified malignant polyps in 50% (11/22) and 44% (8/18). Overall agreement for benign versus malignant polyps between preoperative imaging and final pathology was κ = 0.30 (95% CI, 0.18-0.41) for transrectal ultrasound and 0.29 (95% CI, 0.01-0.57) for MRI. In both the overall and unmatched cohorts, the incidence of malignancy, margin involvement, and proportion of patients requiring salvage surgery was similar.

LIMITATIONS

Data were obtained from 2 institutions with different equipment over a long time period.

CONCLUSIONS

Preoperative imaging did not accurately identify malignancy in clinically benign rectal lesions and did not affect the incidence of malignancy, margin involvement, or proportion of patients requiring salvage surgery. Therefore, preoperative imaging may not be necessary for clinically benign lesions undergoing local excision. See Video Abstract at http://links.lww.com/DCR/A695.

Critical and Challenging Issues in the Surgical Management of Low-Lying Rectal Cancer

Despite innovative advancements, the management of distally located rectal cancer (RC) remains a formidable endeavor. The critical location of the tumor predisposes it to a circumferential resection margin that tends to involve the sphincters and surrounding organs, pelvic lymph node metastasis, and anastomotic complications. In this regard, colorectal surgeons should be aware of issues beyond the performance of total mesorectal excision (TME). For decades, abdominoperineal resection had been the standard of care for low-lying RC; however, its association with high rates of tumor recurrence, tumor perforation, and poorer survival has stimulated the development of novel surgical techniques and modifications, such as extralevator abdominoperineal excision. Similarly, difficult dissections and poor visualization, especially in obese patients with low-lying tumors, have led to the development of transanal TME or the "bottom-to-up" approach. Additionally, while neoadjuvant chemoradiotherapy has allowed for the execution of more sphincter-saving procedures without oncologic compromise, functional outcomes remain an issue. Nevertheless, neoadjuvant treatment can lead to significant tumor regression and complete pathological response, permitting the utilization of organ-preserving strategies. At present, an East and West dualism pervades the management of lateral lymph node metastasis, thereby calling for a more global and united approach. Moreover, with the increasing importance of quality of life, a tailored, individualized treatment approach is of utmost importance when taking into account oncologic and anticipated functional outcomes.

A Phase I Study Examining the Feasibility and Safety of an Aerobic Exercise Intervention in Patients With Rectal Cancer During and After Neoadjuvant Chemoradiotherapy

PURPOSE/OBJECTIVES

To assess the feasibility and safety of an aerobic exercise intervention in patients with rectal cancer during and after neoadjuvant chemoradiotherapy (NACRT).
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DESIGN

A prospective, single-group design with assessments at pre-NACRT, post-NACRT, and presurgery.
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SETTING

The Cross Cancer Institute and University of Alberta in Edmonton, Canada.
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SAMPLE

18 patients with rectal cancer scheduled to receive long-course NACRT followed by definitive surgery. 
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METHODS

Participants received a supervised moderate-intensity aerobic exercise program three days per week during six weeks of NACRT followed by an unsupervised aerobic exercise program for 150 minutes or more per week for 6-8 weeks prior to surgery.
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MAIN RESEARCH VARIABLES

Eligibility rate, recruitment rate, follow-up rate, exercise adherence, serious adverse events, health-related fitness outcomes, and patient-reported outcomes.
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FINDINGS

Follow-up rates post-NACRT were 83% for health-related fitness outcomes and 94% for patient-reported outcomes. Patients attended a median of 83% of their supervised exercise sessions and completed a mean of 222 minutes per week (SD = 155) of their unsupervised exercise. No serious adverse events were observed or reported. Most health-related fitness outcomes and patient-reported outcomes declined during NACRT and recovered after NACRT. 
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CONCLUSIONS

Aerobic exercise is feasible and safe for patients with rectal cancer during and after NACRT.
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IMPLICATIONS FOR NURSING

Patients with rectal cancer are able to engage in moderate-intensity aerobic exercise during NACRT.

Predictors of adherence to aerobic exercise in rectal cancer patients during and after neoadjuvant chemoradiotherapy

This pilot study explored predictors of adherence to exercise during and after neoadjuvant chemoradiotherapy (NACRT) in rectal cancer patients. Eighteen rectal cancer patients were prescribed three supervised aerobic exercise sessions/week during NACRT followed by ≥150 min/week of unsupervised aerobic exercise after NACRT. Although not statistically significant, adherence to supervised exercise during NACRT was meaningfully better for patients who were women (d = .82; P = .12), younger (d = -.62; P = .30), married (d = .62; P = .42), with better mental health (r = .32; P = .21), fewer diarrhea symptoms (r = .48; P = .052), and higher anticipated enjoyment (r = .31; P = .23), support (r = .32; P = .22), and motivation (r = .31; P = .23). After NACRT, adherence was significantly better for patients who reported worse mental health (r = -.56; P = .046) and meaningfully better for patients who were women (d = .54; P = .38), better educated (d = .77; P = .22), had no comorbidities (d = -.63; P = .17), and exercised at baseline (d = 1.05; P = .12). Demographics, tumor side effects, and motivational variables may predict adherence to exercise during and after NACRT.

Exercise motivation in rectal cancer patients during and after neoadjuvant chemoradiotherapy

PURPOSE

Aerobic exercise is safe and feasible for rectal cancer patients during and after neoadjuvant chemoradiotherapy (NACRT), but their motivation to perform such exercise is unknown. Here, we explore the motivational outcomes, perceived benefits and harms, and perceived barriers to exercise during and after NACRT.

METHODS

Rectal cancer patients (n = 18) participated in supervised aerobic exercise during NACRT followed by unsupervised exercise after NACRT. Using the theory of planned behavior, we assessed perceived benefits, harms, enjoyment, support, difficulty, and barriers for exercise both during and after NACRT.

RESULTS

Patients reported that exercise during NACRT was more enjoyable (p = 0.003) and less difficult (p = 0.037) than initially anticipated. The most common perceived benefits of exercise during NACRT were cardiovascular endurance (75 %), quality of life (75 %), and self-esteem (65 %). After NACRT, the most common perceived benefits were physical functioning (93 %), cardiovascular endurance (86 %), and quality of life (79 %). The most common perceived harms of exercise during NACRT were fatigue (31 %), diarrhea (31 %), and skin irritation (24 %). After NACRT, the most common perceived harms were fatigue (21 %) and hand-foot-syndrome (15 %). Side effects from NACRT were the most common exercise barrier during NACRT (88 %) whereas lack of motivation was the most common barrier after NACRT (79 %).

CONCLUSIONS

Rectal cancer patients reported aerobic exercise during NACRT to be more enjoyable and less difficult than anticipated despite significant barriers. This positive motivational response may facilitate recruitment and adherence in future interventions. Moreover, rectal cancer patients identified potential benefits and harms that should be closely monitored in future interventions.