National and international guidelines for rectal cancer

Altered dynamic functional connectivity in rectal cancer patients with and without chemotherapy: a resting-state fMRI study

Purpose: Understanding the mechanism of brain functional alterations in rectal cancer (RC) patients is of great significance to improve the prognosis and quality of life of patients. Additionally, the influence of chemotherapy on brain function in RC patients is still unclear. In this study, we aimed to investigate the alterations of brain functional network dynamics in RC patients and explore the effects of chemotherapy on temporal dynamics of dynamic functional connectivity (DFC).

Methods: The group independent component analysis (GICA) and sliding window method were applied to investigate abnormalities of DFC based on resting-state functional magnetic resonance imaging (rs-fMRI) of 18 RC patients without chemotherapy (RC_NC), 21 RC patients with chemotherapy (RC_C) and 33 healthy controls (HC). Then, the Spearman correlation between aberrant properties and clinical measures was calculated.

Results: Two discrete states were identified. Compared to HC, RC_NC exhibited increased mean dwell time (MDT) and fractional windows (FW) in state 2 and decreased transition numbers between the two states. Notably, three temporal properties in RC_C showed an intermediate trend in comparison with RC_NC and HC. Furthermore, RC_C also demonstrated abnormal intra- and inter-network connections, involving the visual (VIS), default mode (DM), and cognitive control (CC) networks, and most connections related to VIS were correlated with the severity of anxiety and depression.

Conclusions: Our study suggested that abnormal DFC patterns could be manifested in RC patients and chemotherapy would further correct abnormalities of network dynamics, which may provide new insights into the brain functional alterations in patients with RC from the time-varying connectivity perspective.

Effect of laparoscopic versus open surgery on postoperative wound complications in patients with low rectal cancer: A meta-analysis

This meta-analysis was conducted to evaluate the effect of microinvasive and open operations on postoperative wound complications in low rectal carcinoma patients. Research on limited English has been conducted systematically in PubMed, Embase, Cochrane Library and Web of Science. The date up to the search was in August 2023. Following review of the classification and exclusion criteria for this research and the evaluation of its quality in the literature, there were a total of 266 related papers, which were reviewed for inclusion in the period from 2004 to 2017. A total of 1774 cases of low rectal cancer were enrolled. Of these 913 cases, the laparoscopic operation was performed on 913 cases, while 861 cases were operated on low rectal carcinoma. The overall sample was between 10 and 482. Five trials described the efficacy of laparoscopy have lower risk than open on postoperative wound infection in patients with low rectal cancer (OR, 0.72;95 % CI, 0.48,1.09 p = 0.12). Three studies results showed that the anastomotic leak was not significantly different between open and laparoscopy (OR, 0.86; 95% CI, 0.58,1.26 p = 0.44). Six surgical trials in low rectal cancer patients reported haemorrhage, and five cases of surgical time were reported, with laparoscopy having fewer bleeding compared with open surgery (MD, -188.89; 95% CI, -341.27, -36.51 p = 0.02). Compared with laparoscopy, the operation time was shorter for the open operation (MD, 33.06; 95% CI, 30.56, 35.57 p < 0.0001). Overall, there is no significant difference between laparoscopy and open surgery in terms of incidence of infection and anastomosis leak. However, the rate of haemorrhage in laparoscopy is lower，and operation time in open surgery is lower.

Watch and Wait, Worth It?

Background The surgery with total mesorectal excision recommended by R. J. Heald in 1982 is the gold standard. Rectal cancer (RC) surgery has a morbidity rate ranging from 6 to 35%, and it can cause functional issues such as sexual, urinary, and bowel dysfunction in the long term. Neoadjuvant chemoradiotherapy (CRT) has been gaining ground in patients with lesions in the middle and lower rectum. The aim of the present study is to present the experience of a reference service in the treatment of RC.

Patients and Methods A retrospective study involving 53 patients diagnosed with RC between January 2017 and December 2019 with follow-up until December 2020. We examined tumor location, disease stage, digital rectal exam findings, carcinoembryonic antigen (CEA), therapeutic modality offered, and follow-up time.

Results A total of 32% of the patients were men and 68% were women, with a mean age of 60 years old. Location: upper rectum in 6 cases, middle rectum in 21 cases, and lower rectum in 26 cases with evolution from 9.8 to 13.5 months. The most frequent complaints were hematochezia and constipation. A total of 36 patients underwent neoadjuvant therapy: 11 complete clinical response (CCR) (30.5%), 20 (55.5%) partial clinical response (PCR), and no response in 5 patients (14%). The follow-up ranged from 12 to 48 months, with a mean of 30.5 months. A total of 25% of the patients had RC that went beyond the mesorectal fascia, and 22.64% had metastases in other parts of the body when they were diagnosed.

Conclusion Neoadjuvant radio and chemotherapy present themselves as an alternative in the treatment of rectal cancer. In 36 patients, 30.5% had a complete clinical response, 55.5% had a partial clinical response, and 14% had no response. It was worth doing the “Watch and Wait” (W&W) to sample. A definitive colostomy was avoided. However, it is necessary to expand the study to a larger follow-up and more patients. Additionally, it is necessary to implement a multicenter study.

How to accurately measure the distance from the anal verge to rectal cancer on MRI: a prospective study using anal verge markers

PURPOSE

To determine an accurate method for localizing rectal cancer using the distance from the anal verge on preoperative MRI.

METHODS

This prospective study included 50 patients scheduled for MRI evaluation of rectal cancer. After rectal filling with gel, MRI was performed with two markers attached at the anal verge. The distance between the tumor and the anal verge on a sagittal T2-weighted image (T2WI) was measured independently by two radiologists using six methods divided into three groups of similar measurement approaches, and compared to those obtained on rigid sigmoidoscopy. The anal verge location relative to the external anal sphincter was assessed on oblique coronal T2WI in reference to the markers. Correlation analysis was performed using the intraclass correlation coefficient (ICC) for verification, and a paired t test was used to evaluate the mean differences.

RESULTS

The highest correlation (ICC 0.797-0.815) and the least mean difference (0.74-0.85 cm) with rigid sigmoidoscopy, and the least standard deviation (3.12-3.17 cm) were obtained in the direct methods group using a straight line from the anal verge to the tumor. The anal verge was localized within a range of - 1.4 to 1.5 cm (mean - 0.31 cm and - 0.22 cm) from the lower end of the external anal sphincter.

CONCLUSION

The direct methods group provided the most accurate tumor distance among the groups. Among the direct methods, we recommend the direct mass method for its simplicity. Despite minor differences in location, the lower end of the external anal sphincter was a reliable anatomical landmark for the anal verge.

A Diagnostic Biopsy-Adapted Immunoscore Predicts Response to Neoadjuvant Treatment and Selects Patients with Rectal Cancer Eligible for a Watch-and-Wait Strategy

PURPOSE

No biomarker to personalize treatment in locally advanced rectal cancer (LARC) is currently available. We assessed in LARC whether a diagnostic biopsy-adapted immunoscore (IS_B) could predict response to neoadjuvant treatment (nT) and better define patients eligible to an organ preservation strategy ("Watch-and-Wait").

EXPERIMENTAL DESIGN

Biopsies from two independent cohorts (n ₁ = 131, n ₂ = 118) of patients with LARC treated with nT followed by radical surgery were immunostained for CD3⁺ and CD8⁺ T cells and quantified by digital pathology to determine IS_B. The expression of immune-related genes post-nT was investigated (n = 64 patients). Results were correlated with response to nT and disease-free survival (DFS). The IS_B prognostic performance was further assessed in a multicentric cohort (n = 73 patients) treated by Watch-and-Wait.

RESULTS

IS_B positively correlated with the degree of histologic response (P < 0.001) and gene expression levels for Th1 orientation and cytotoxic immune response, post-nT (P = 0.006). IS_B high identified patients at lower risk of relapse or death compared with IS_B low [HR, 0.21; 95% confidence interval (CI), 0.06-0.78; P = 0.009]. Prognostic performance of IS_B for DFS was confirmed in a validation cohort. IS_B was an independent parameter, more informative than pre- (P < 0.001) and post-nT (P < 0.05) imaging to predict DFS. IS_B combined with imaging post-nT discriminated very good responders that could benefit from organ preservation strategy. In the "Watch-and-Wait" cohort (n = 73), no relapse was observed in patients with IS_B high (23.3%).

CONCLUSIONS

IS_B predicts response to nT and survival in patients with LARC treated by surgery. Its usefulness in the selection of patients eligible for a Watch-and-Wait strategy is strongly suggested.

Value of intra-tumor heterogeneity evaluated by diffusion-weighted MRI for predicting pathological stages and therapeutic responses to chemoradiotherapy in lower rectal cancer

Aim: Diffusion-weighted MRI (DWI) has the potential to reveal intra-tumor structural heterogeneity consisting of stroma through an evaluation of uniformity on DWI. In present study, we examined the diagnostic value of intra-tumor heterogeneity evaluated by DWI in lower rectal cancer (LRC).

Patients and Methods: A total of 172 LRC patients underwent radical surgery between 2009 and 2017. T1 tumors and cases without pre-operative MRI were excluded. Twenty-nine primary resection cases (PR) and 37 pre-operative chemoradiotherapy followed by radical surgery cases (pCRT) were targeted. Intra-tumor heterogeneity on DWI was quantified using a specific formula (HSD). Structural heterogeneity was objectively quantified by an image analysis of resected specimens using a digital microscope (HSP). The relationships between HSD and HSP, pathological factors, and tumor regression grades (TRG) of pCRT were evaluated.

Results: The relationship between HSD and HSP was analyzed by a linear regression model in PR cases, revealing a positive correlation (R²=0.43). PR cases were divided into HSD-high and HSD-low according to the median. There were more pT3 or N(+) cases in HSD-high (p=0.038, 0.095). HSD before pCRT correlated with TRG (grade 1 versus 2/3) in pCRT cases (p=0.001). The diagnostic accuracy of HSD for predicting T and N stages and therapeutic grades was evaluated by cut-off values calculated using a ROC curve and revealed that each factor may be accurately diagnosed.

Conclusion: Intra-tumor heterogeneity on DWI corresponded with stromal pathological heterogeneity. It is useful for predicting T3 or deeper tumor invasion, pathological N(+), and the therapeutic effects of pCRT.

Totally robotic vs hybrid abdominoperineal resection: A retrospective multicenter analysis

INTRODUCTION

Laparoscopic abdominoperineal resection (APR) for low rectal cancers is technically demanding. Robotic assistance may be of help and can be hybrid (HAPR) or totally robotic (RAPR). The present study describes outcomes of robotic APR and compares both approaches.

MATERIAL AND METHODS

A multicentric retrospective analysis of rectal cancer patients undergoing either HAPR or RAPR was conducted. Patients' demographics, surgeons' experience, oncologic results, and intraoperative and postoperative outcomes were collected.

RESULTS

One hundred twenty-five patients were included, 48 in HAPR group and 77 in RAPR group. Demographics and comorbidities were comparable. Operative time was reduced in RAPR group (266.9 ± 107.8 min vs 318.9 ± 75.1 min, P = .001). RAPR patients were discharged home more frequently (91.18% vs 66.67%, P = .001), and experienced fewer parastomal hernias (3.71% vs 9.86%, P = .001).

CONCLUSION

RAPR is safe and feasible with appropriate oncologic outcomes. Totally robotic approach reduces operative time and may improve functional outcomes.

Population-based assessment of the National Comprehensive Cancer Network recommendations for baseline imaging of rectal cancer

Aim: To examine the performance characteristics of alternative criteria for baseline staging, in a cohort of contemporary rectal cancer patients from the Surveillance, Epidemiology and End Results (SEER) database. Methods: The SEER database (2010-2015) was accessed and patients with rectal cancer plus complete information on clinical T and N stages as well as metastatic sites were evaluated. We examined various performance characteristics of baseline imaging, including specificity, sensitivity, number needed to investigate (NNI), positive predictive value (PPV), negative predictive value and accuracy. Results: A total of 15,836 rectal cancer patients were included. Based on current guidelines that suggest cross-sectional chest and abdominal imaging for all cases of invasive rectal cancer, these recommendations would yield a PPV of 11.9% for the detection of liver metastases and 6.2% for the detection of lung metastases. This would translate to an NNI of 8.4 for liver metastases and an NNI of 16.1 for lung metastases. When patients with T1N0 were excluded from routine imaging, this resulted in a PPV of 6.4% and an NNI of 15.6 to identify one case of lung metastasis. Likewise, this resulted in a PPV of 12.3% and an NNI of 8.0 to detect one case of liver metastasis. Similarly, when patients with either T1N0 or T2N0 were excluded from routine imaging, the PPV and NNI for lung metastases improved to 6.6% and 15.1, respectively, and the PPV and NNI for liver metastases improved to 12.6 and 7.9%, respectively. Conclusion: Our study suggests that the specificity of the current imaging approach for rectal cancer staging is limited and that the omission of chest and abdominal imaging among selected early stage asymptomatic cases may be reasonable to consider.

Treatment Options in Oncology

Multiple treatment strategies exist for many oncologic problems. In this review, we provide a summary of various reasons for the existence of multiple treatment options in oncology, including factors that concern the treating physician (eg, treatment preferences), environmental factors (eg, financial, regulatory, and scientific aspects), and individual patient-specific factors (eg, medical condition, preferences). We demonstrate the vital role of available treatment options and their origins for clinical decision making and patient communication. These aspects are particularly helpful in the process of shared decision making, which is increasingly favored in situations where there are multiple medically reasonable options.

Determining the use of preoperative (chemo)radiotherapy in primary rectal cancer according to national and international guidelines

BACKGROUND

Pre-operative radiotherapy (RT) or chemoradiotherapy (CRT) is frequently used prior to rectal cancer surgery to improve local control and survival. The treatment is administered according to guidelines, but these recommendations vary significantly between countries. Based on the stage distribution and risk factors of rectal cancers as determined by magnetic resonance imaging (MRI) in an unselected Swedish population, the use of RT/CRT according to 15 selected guidelines is described.

MATERIALS AND METHODS

Selected guidelines from different countries and regions were applied to a well-characterized unselected population-based material of 686 primary non-metastatic rectal cancers staged by MRI. The fraction of patients assigned to surgery alone or surgery following pre-treatment with (C)RT was determined according to the respective guideline. RT/CRT administered to rectal cancer patients for other reasons, for example, for organ preservation or palliation, was not considered.

RESULTS

The fraction of patients with a clear recommendation for pre-treatment with (C)RT varied between 38% and 77% according to the different guidelines. In most guidelines, CRT was recommended to all patients who were not operated directly, and, in others, short-course RT was also recommended to patients with intermediate risk tumours. If only non-resectable or difficult to resect tumours were recommended pre-treatment, as stated in many Japanese publications, 9% would receive CRT followed by a delay to surgery.

CONCLUSIONS

According to most guidelines, well over 50% of primary non-metastatic rectal cancer patients from a general population, in which screening for colorectal cancer is not practised, are recommended treatment with pre-operative/neo-adjuvant therapy.

The adipofasciocutaneous gluteal fold perforator flap a versatile alternative choice for covering perineal defects

AIM

Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects.

METHODS

We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal.

RESULTS

Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes.

CONCLUSIONS

The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.

Determination of Tumor Location in Rectosigmoid Carcinomas: Difficulties in Preoperative Diagnostics

Differentiation between rectal and sigmoid carcinomas is a diagnostic challenge with important implications for further treatment. Depending on the tumor stage, treatment for rectal carcinoma consists of preoperative (chemo)radiotherapy and surgery. Sigmoid carcinomas are treated with surgery alone. We established the diagnostic accuracy of flexible endoscopy, MRI and/or CT scan, and both modalities combined as reflected by the conclusion of our multidisciplinary team (MDT). Furthermore, we assessed the treatment consequences of misdiagnosis. Consecutive patients were included who underwent surgery from January 2012 to January 2017 for colorectal carcinoma located ≤20 cm from the anal verge as determined by flexible colonoscopy. Diagnostic accuracy of MRI/CT, flexible endoscopy and the final MDT conclusion were analyzed as index test. The location of the tumor during surgery and the type of surgery was the reference standard. We included 293 patients. Flexible endoscopy had a diagnostic accuracy of 90% and for MRI/CT scanning this was 86–87%. Combination of both modalities improved diagnostic accuracy to 96%. Due to misdiagnosis during initial staging, three patients (1%) erroneously underwent neoadjuvant treatment and in two patients neoadjuvant treatment was potentially erroneously omitted. In conclusion, the combination of both flexible endoscopy and MRI/CT (the MDT conclusion) improves diagnostic accuracy. Erroneous clinical diagnosis can lead to under- and overtreatment.

Impact of Long-Course Neoadjuvant Radiation on Postoperative Low Anterior Resection Syndrome and Quality of Life in Rectal Cancer: Post Hoc Analysis of a Randomized Controlled Trial

BACKGROUND

Neoadjuvant radiation is recommended for locally advanced rectal cancer, with proven benefit in local control but not in disease-free survival. However, the impact of long-course radiation on postoperative bowel function and quality of life (QOL) remains controversial. This study aimed to investigate the impact of long-course neoadjuvant radiation on bowel function and QOL, and to identify risk factors for severe bowel dysfunction.

METHODS

Patients who underwent long-course neoadjuvant chemoradiotherapy (nCRT) or chemotherapy (nCT) followed by radical low anterior resection for locally advanced rectal cancer were recruited from the FOWARC randomized controlled trial. Low anterior resection syndrome (LARS) score and European Organisation for Research and Treatment of Cancer (EORTC) C30/CR29 questionnaires were used to assess bowel function and QOL, respectively.

RESULTS

Overall, 220 patients responded after a median follow-up of 40.2 months, of whom 119 (54.1%) reported major LARS, 74 (33.6%) reported minor LARS, and 27 (12.3%) reported no LARS. Compared with the nCT group, the nCRT group reported more major LARS (64.4% vs. 38.6%, p < 0.001) and worse QOL. Long-course neoadjuvant radiation (OR 2.20, 95% CI 1.24-3.91; p = 0.007), height of anastomosis (OR 0.74, 95% CI 0.63-0.88; p < 0.001), and diverting ileostomy (OR 2.59, 95% CI 1.27-5.30; p = 0.009) were independent risk factors for major LARS.

CONCLUSIONS

Long-course neoadjuvant radiation, along with low anastomosis, are likely independent risk factors for postoperative bowel function and QOL. Our findings might have implications for alleviating LARS and improving QOL by informing selection of neoadjuvant treatment.

Stage distribution utilizing magnetic resonance imaging in an unselected population of primary rectal cancers

BACKGROUND

Pre-operative radiotherapy (RT) or chemo-radiotherapy (CRT) are sometimes recommended prior to rectal cancer surgery, but guideline recommendations vary. The aim was to describe stage distribution and other important characteristics required for the treatment decision of patients with primary rectal cancers utilizing magnetic resonance imaging (MRI) in an unselected population.

PATIENTS AND METHODS

All 796 histopathologically verified rectal adenocarcinomas diagnosed 2010-2015 in two counties in Sweden (population 630,000 in 2015) were identified. Staging with pelvic MRI unless contraindications were present, treatment and pathology followed Swedish guidelines.

RESULTS

Twenty-three % of cases (n = 186) had distant metastases at diagnosis, demonstrating more advanced tumor and nodal stages when compared with non-metastatic patients (p < 0.001), and they more often displayed MRI-identified mucinous features and extramural vascular invasion (EMVI) than non-metastatic tumors (p < 0.001 for both). In non-metastatic patients, 8% displayed clinical stage T1 (cT1), 21% cT2, and 53% cT3; one-third of the latter threatened or involved the mesorectal fascia (MRF+). Almost 20% had stage cT4 (4% cT4a, 14% cT4b) of which 50% were considered "non-resectable". EMVI was seen in 33% of cT3M0 tumors and in 48% of cT4M0 tumors.

CONCLUSIONS

In an unselected population, approximately 80% of primary rectal cancers are referred to as "locally advanced" (stage II-III, or cT3-4 or N+), meaning that they, according to many international guidelines, are recommended neo-adjuvant treatment. This study provides a detailed description of the clinical stages and presence of characteristics identifiable on MRI which are of importance when assessing the needs for RT/CRT, when using different guidelines.

The prognostic value of combining the CD8 + lymphocyte density and the circulating lymphocyte ratio in circumferential resection margin biopsy in rectal cancer

BACKGROUND

A positive circumferential resection margin (CRM) may result in local recurrence (LR), but the significance remains controversial. We attempted to utilize the lymphocyte ratio (LYMR), neutrophil-lymphocyte ratio (NLR), tumor-infiltrating lymphocyte (TIL) count, and their combinations (TIL-LYMR/TIL-NLR) in predicting LR after rectal resection.

METHODS

Patients with rectal cancer who underwent curative resection between January 2016 and December 2018 were enrolled. Biopsy samples and data from the blood tests of 124 patients with rectal cancer who underwent curative resection were retrospectively obtained. Patients were divided into 2 groups: LR group and non-local recurrence (nLR) group. CD8 + TILs were immunostained using an antibody against CD8. The density of TILs was defined as the number of positive CD8 lymphocytes per square millimeter and was then graded as either high or low (cutoff = 80/mm). The count of LYMR and NLR was also graded as either high or low. The associations between TILs, LYMR, NLR, and their combinations (TIL-LYMR/TIL-NLR) were evaluated.

RESULTS

With a median follow-up of 24.4 months, TIL-LYMR showed a positive correlation with LR (P = .001), but not with the CD8 + TIL count (P = .215) or TIL-NLR count (P = .638). Among inflammatory and immune markers variables, univariate analysis revealed that gender, CD8 + TIL count, and TIL-NLR count were associated with anastomotic leakage (P = .001, P = .014, and P = .036, respectively). In multivariate analysis, TIL-LYMR remained an independent predictor of LR (OR = 8.918, CI = 1.124-70.747, P = .038). We also showed that gender associated with anastomotic leakage in rectal cancer (OR 5.429; 95% CI 1.885-15.637; P = .002).

CONCLUSION

In this study, our data indicate that absence of CD8 + T-cell infiltration in CRM may influence LR. These parameters may help identify LR provide additional information for therapeutic decision-making.

Surgical Quality in Rectal Cancer Management: What Can Be Achieved by a Voluntary Observational Study?

Purpose

Countries with nationwide quality programmes in colorectal cancer report an improved outcome. In Germany, a self-organized and self-financed observational quality assurance project exists, based on voluntary participation. The object of the present study was to ascertain whether this nationwide project also improves the outcome of colorectal cancer.

Methods

The German Quality Assurance in Colorectal Cancer Project started in 2000 and by 2012 contained 85,000 patients. Inclusion criteria for the study were participation for the entire period of 13 years and treatment of rectal cancer. The following parameters were analysed: (1) patient related: age, gender, ASA classification, T-stage, and N-stage, (2) system related: frequency of preoperative CT and MRI, and (3) outcome related: CRM status, complications, and hospital mortality.

Results

Forty-one of the 345 hospitals treating 11,597 patients fulfilled the inclusion criteria. The median age increased from 67 to 69 years (p = 0.002). ASA stages III and IV increased from 32.0% to 37.6% (p = 0.005) and from 2.0% to 3.3% (p = 0.022), respectively. The use of CT rose from 67.2% to 88.8% (p < 0.001) and that of MRI from 5.0% to 35.2% (p < 0.001). The proportion of patients suffering from complications decreased from 7.9% to 5.3% (p < 0.001) for intraoperative and from 28.0% to 18.6% (p < 0.001) for postoperative surgical complications, but general postoperative complications increased from 25.8% to 29.5% (p = 0.006). The distribution of histopathological stage, anastomotic leakage, and in-hospital mortality did not change significantly.

Conclusion

Participation in a quality assurance project improves compliance with treatment standards, especially for diagnostic procedures. An improvement of surgical results will require further investment in training.

Session 4: Shaping radiotherapy for rectal cancer: should this be personalized?

Preoperative radiotherapy continues to be widely used in patients with operable rectal cancer. However, the indications and goals for such treatment are evolving. Professor Marijnen reviews the historic and current evidence base for the use of preoperative neoadjuvant radiotherapy and the future challenges in tailoring the therapy according to the patients' needs and tumour stage.

Intravoxel Incoherent Motion Diffusion-Weighted Imaging of Primary Rectal Carcinoma: Correlation with Histopathology

Background

Comprehensive and precise assessment of rectal carcinoma is crucial before surgery to plan an individual treatment strategy. New functional techniques, such as intravoxel incoherent motion (IVIM), have emerged and could lead to more detailed information. The aim of this study was to evaluate the difference between the rectal tumor parenchyma and normal wall by IVIM and to explore the correlations of IVIM parameters and histopathology.

Material/Methods

We prospectively enrolled 128 patients with pathologically proven rectal non-mucinous carcinoma with differentiation degree and 16 patients with mucinous carcinoma. All patients underwent routine MR examination and IVIM sequence. The IVIM maps were automatically generated and 3 ROIs were drawn on the maximal rectal tumor parenchyma and normal rectal wall. The Wilcoxon signed rank test, t test, Mann-Whitney U test, and Spearman’s rank correlation test were performed.

Results

All IVIM parameters demonstrated the difference between rectal tumor parenchyma and normal wall (P_D<0.001; P_D*=0.014; P_f<0.001). Poorly differentiated carcinoma had a significantly lower f value (P_f=0.049) than well/moderately-differentiated carcinoma. In addition, mucinous carcinoma had a higher D (P_D=0.001) and a lower D* value (P_D*=0.001) than non-mucinous carcinoma. Correlation analysis between IVIM parameters and histopathology showed that D (|r|=0.538, P_D=0.000) and D* (|r|=0.267, P_D*=0.001) had statistically significant correlations with histological type and f (|r|=0.175, P_f=0.048) was significantly correlated with differentiation degree.

Conclusions

The IVIM parameters of rectal tumor parenchyma and normal wall were significantly different. D appears to be a valid and promising parameter to indicate histological features of rectal carcinoma.

Development and external validation of a nomogram and online tool to predict bowel dysfunction following restorative rectal cancer resection: the POLARS score

OBJECTIVE

Bowel dysfunction is common following a restorative rectal cancer resection, but symptom severity and the degree of quality of life impairment is highly variable. An internationally validated patient-reported outcome measure, Low Anterior Resection Syndrome (LARS) score, now enables these symptoms to be measured. The study purpose was: (1) to develop a model that predicts postoperative bowel function; (2) externally validate the model and (3) incorporate these findings into a nomogram and online tool in order to individualise patient counselling and aid preoperative consent.

DESIGN

Patients more than 1 year after curative restorative anterior resection (UK, median 54 months; Denmark (DK), 56 months since surgery) were invited to complete The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30 version3 (EORTC QLQ-C30 v3), LARS and Wexner incontinence scores. Demographics, tumour characteristics, preoperative/postoperative treatment and surgical procedures were recorded. Using transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines, risk factors for bowel dysfunction were independently assessed by advanced linear regression shrinkage techniques for each dataset (UK:DK).

RESULTS

Patients in the development (UK, n=463) and validation (DK, n=938) datasets reported mean (SD) LARS scores of 26 (11) and 24 (11), respectively. Key predictive factors for LARS were: age (at surgery); tumour height, total versus partial mesorectal excision, stoma and preoperative radiotherapy, with satisfactory model calibration and a Mallow's Cp of 7.5 and 5.5, respectively.

CONCLUSIONS

The Pre-Operative LARS score (POLARS) is the first nomogram and online tool to predict bowel dysfunction severity prior to anterior resection. Colorectal surgeons, gastroenterologist and nurse specialists may use POLARS to help patients understand their risk of bowel dysfunction and to preoperatively highlight patients who may require additional postoperative support.

How Should Imaging Direct/Orient Management of Rectal Cancer?

Modern rectal cancer management is dependent on preoperative staging, and radiological assessment is a crucial part of this process. Imaging must provide sufficient information to guide preoperative decision-making that is reliable and reproducible. Different methods have been used for local staging; however, magnetic resonance imaging (MRI) has shown to be the most reliable tool for this purpose. MRI offers prognostic information about the patients and guides the decision between neoadjuvant treatment and total mesorectal excision alone. Also, not only the initial staging but also restaging by MRI can provide significant information regarding tumor response that is essential when considering alternative approaches.

Cell-free DNA levels and correlation to stage and outcome following treatment of locally advanced rectal cancer

Accurate staging of rectal cancer remains essential for optimal patient selection for combined modality treatment, including radiotherapy, chemotherapy and surgery. We aimed at examining the correlation of cell free DNA with the pathologic stage and subsequent risk of recurrence for patients with locally advanced rectal cancer undergoing preoperative chemoradiation. We examined 75 patients with locally advanced rectal cancer receiving preoperative chemoradiation. Blood samples for translational use were drawn prior to rectal surgery. The level of cell free DNA was quantified by digital droplet PCR and expressed as copy number of beta 2 microglobulin. We found a median level of cell free DNA in the AJCC stages I-III of 3100, 8300, and 10,700 copies/mL respectively. For patients with 12 sampled lymph nodes or above, the median level of cell free DNA were 2400 copies/mL and 4400 copies/mL (p = 0.04) for node negative and node positive disease respectively. The median follow-up was 39 months and 11 recurrences were detected (15%). The median level for patients with recurrent disease was 13,000 copies/mL compared to 5200 copies/mL for non-recurrent patients (p = 0.08). We have demonstrated a correlation between the level of total cell free DNA and the pathologic stage and nodal involvement. Furthermore, we have found a trend towards a correlation with the risk of recurrence following resection of localized rectal cancer.

Clinical and Prognostic Significance of Pathological and Inflammatory Markers in Mucinous Rectal Cancer Patients Receiving Neoadjuvant Chemoradiotherapy and Curative Surgery

Background

The aim of this study was to investigate the clinical and prognostic significance of pathological and inflammatory marker in mucinous rectal cancer patients receiving neoadjuvant chemoradiotherapy and curative surgery.

Material/Methods

We retrospectively evaluated the patient records of mucinous rectal cancer patients receiving neoadjuvant chemoradiotherapy and curative surgery at Liaoning Cancer Hospital and Institute from January 2006 to December 2013. The relationship between overall survival (OS) and clinicopathologic variables, pretreatment neutrophil-to-lymphocyte ratio (NLR), pretreatment platelet-to-lymphocyte ratio (PLR), pretreatment lymphocyte-to-monocyte ratio (LMR), and other biomarkers were analyzed by using Kaplan-Meier analysis and log-rank testing. Subsequently a Cox proportional hazard model was used to calculate hazard ratios for the risk of death.

Results

A total of 100 mucinous rectal cancer patients were included for analysis during the study period. The median age at presentation was 60.5 years (range, 26–81 years). The median overall survival (OS) for the whole group was 94 months. On univariate analysis, time interval from CCRT to operation (HR 0.37, p=0.03), lymphovascular invasion (HR 3.23, p=0.009), pretreatment NLR (HR 3.87, p=0.012), and LMR (HR 0.31, p=0.002) were significant prognostic factors for OS. In a multivariate analysis, pretreatment LMR was found to be an independent prognostic factor for overall survival (HR, 0.43; 95%CI, 0.18 to 1.00, p=0.045).

Conclusions

Pretreatment lymphocyte-to-monocyte ratio is a useful prognostic marker of OS in patients with mucinous rectal carcinoma treated with neoadjuvant chemoradiotherapy and curative surgery.

A rectal cancer feasibility study with an embedded phase III trial design assessing magnetic resonance tumour regression grade (mrTRG) as a novel biomarker to stratify management by good and poor response to chemoradiotherapy (TRIGGER): study protocol for a randomised controlled trial

BACKGROUND

Pre-operative chemoradiotherapy (CRT) for MRI-defined, locally advanced rectal cancer is primarily intended to reduce local recurrence rates by downstaging tumours, enabling an improved likelihood of curative resection. However, in a subset of patients complete tumour regression occurs implying that no viable tumour is present within the surgical specimen. This raises the possibility that surgery may have been avoided. It is also recognised that response to CRT is a key determinant of prognosis. Recent radiological advances enable this response to be assessed pre-operatively using the MRI tumour regression grade (mrTRG). Potentially, this allows modification of the baseline MRI-derived treatment strategy. Hence, in a 'good' mrTRG responder, with little or no evidence of tumour, surgery may be deferred. Conversely, a 'poor response' identifies an adverse prognostic group which may benefit from additional pre-operative therapy.

METHODS/DESIGN

TRIGGER is a multicentre, open, interventional, randomised control feasibility study with an embedded phase III design. Patients with MRI-defined, locally advanced rectal adenocarcinoma deemed to require CRT will be eligible for recruitment. During CRT, patients will be randomised (1:2) between conventional management, according to baseline MRI, versus mrTRG-directed management. The primary endpoint of the feasibility phase is to assess the rate of patient recruitment and randomisation. Secondary endpoints include the rate of unit recruitment, acute drug toxicity, reproducibility of mrTRG reporting, surgical morbidity, pathological circumferential resection margin involvement, pathology regression grade, residual tumour cell density and surgical/specimen quality rates. The phase III trial will focus on long-term safety, regrowth rates, oncological survival analysis, quality of life and health economics analysis.

DISCUSSION

The TRIGGER trial aims to determine whether patients with locally advanced rectal cancer can be recruited and subsequently randomised into a control trial that offers MRI-directed patient management according to radiological response to CRT (mrTRG). The feasibility study will inform a phase III trial design investigating stratified treatment of good and poor responders according to 3-year disease-free survival, colostomy-free survival as well as an increase in cases managed without a major resection.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02704520 . Registered on 5 February 2016.

Evolution of Surgical Treatment for Rectal Cancer: a Review

Surgery that produces an optimal total mesorectal excision (TME) resection specimen remains the cornerstone of curative rectal cancer management. In the modern era, despite the results of recent randomised trials, laparoscopic TME is a crucial technique in the TME surgery armamentarium. Laparoscopic surgery offers the benefit of magnified views that aid sharp and precise dissection. However operating in the confines of a narrow pelvis, particularly when the mesorectum is bulky, requires significant technical skill. This is compounded by limited angulation of laparoscopic instruments and staplers. The final challenge is to preserve the integrity of the mesorectum during delivery of the specimen. The principles of TME surgery, on which Bill Heald founded the Basingstoke Colorectal unit, can equally be applied to laparoscopic, transanal and robotic TME, but great care must be taken to preserve the key principle-that no steps are taken that have the potential to shed tumour cells or compromise the quality of the mesorectal specimen.

Trends with neoadjuvant radiotherapy and clinical staging for those with rectal malignancies

AIM

To see how patterns of care changed over time, and how institution type effected these decisions.

METHODS

A retrospective analysis was performed using the National Cancer Database, looking at all patients that were diagnosed with rectal cancer from 1998 to 2011. We tested differences in rates of treatment and stage migration using χ² tests and logistic regression models.

RESULTS

A review of ninety thousand five hundred and ninety four subjects underwent multimodality therapy for cancer of the rectum. Staging and response to treatment varied greatly between centers. Forty-six percent of the time staging was missing in academic practices, vs fifty-four percent of the time in community centers (P < 0.001). As a result, twenty-percent were down-staged and eight percent up-staged in academia, whereas only fifteen percent were down-staged and 8% up-staged in community practices (P < 0.001). Forty-two percent of individuals underwent radiation before surgery in 1998. Within two years this increased to fifty-three percent. This increased to eighty-six percent by 2011 (P < 0.001). Institution specific treatment varied greatly. Fifty-one percent received therapy before surgery in academic centers in 1998. Thirty-nine percent followed this pattern in the same year in the community (P < 0.001). By 2011, ninety-one percent received radiation before their procedure in academic centers, vs eighty-four percent in the community (P < 0.001). Rates of adoption were better in academia, although an increase was seen in both center types.

CONCLUSION

From the study dates of 1998 to 2011, preoperative treatment with radiation has been on the rise. There is certainly an increased rate of use of radiation in academia, however, this trend is also seen in the community. Practice patterns have evolved over time, although rates of assigning clinical stage are grossly underreported prior to initiation of preoperative therapy.

Pre-operative staging of rectal cancer: a review of imaging techniques

INTRODUCTION

The treatment of rectal cancer has diversified in recent years, presenting the clinician and patient with increasingly challenging management decisions. At the heart of this decision-making process are two competing interests; more radical but more morbid treatments which optimize oncological outcome, and less radical treatments which preserve organs and function but may pose a greater risk of disease recurrence.

AREAS COVERED

Imaging plays a vital role informing this decision-making process, both by providing prognostic details about the cancer before the start of treatment and by updating this picture as the cancer responds or fails to respond to treatment. There is a range of available imaging modalities, each with its strengths and weaknesses. Optimizing rectal cancer treatment requires a clear understanding of the important questions that imaging needs to answer and the optimum imaging strategy. Expert Commentary: This article provides an evidence-based review of the available imaging techniques and an expert commentary on the best imaging strategy.

Prospective and Longitudinal Study of Urogenital Dysfunction After Proctectomy for Rectal Cancer

BACKGROUND

Urogenital dysfunctions after rectal cancer treatment are well recognized, although incidence and evolution over time are less well known.

OBJECTIVE

We aimed to assess the evolution of urogenital functions over time after the treatment for rectal cancer.

DESIGN

This is a prospective, longitudinal cohort study.

SETTINGS

This study was conducted at a quaternary referral center for colorectal surgery.

PATIENTS

A total of 250 consecutive patients treated for rectal cancer were prospectively enrolled for urogenital assessment.

MAIN OUTCOME MEASURES

End points were the International Prostatic Symptom Score, the International Index of Erectile Function, and the Female Sexual Index obtained by questionnaires before (baseline status) and after preoperative radiotherapy and 3, 6, and 12 months after surgery.

RESULTS

Overall, 169 patients (68%) responded to the questionnaires. The urinary function decreased temporary after irradiation in men (International Prostatic Symptom Score: 7.8 vs 4.9; p < 0.001). Sexual activity decreased significantly in women after radiotherapy (p = 0.02), and in all patients after surgery (p < 0.001). At 12 months, sexual activity in women declined from 59% before treatment to 36% (p = 0.02). In men, sexual activity (82% vs 57%), erectile function (71% vs 24%), and ejaculatory function (78% vs 32%) decreased from baseline (p < 0.001). Stage T3T4 tumors (OR = 5.72 (95% CI, 1.24-26.36)) and low rectal tumors (OR = 17.86 (95% CI, 1.58-20.00)) were independent factors of worse sexual function.

LIMITATIONS

This study was limited by the proportion of uncompleted questionnaires, especially in women, and by its monocentric feature.

CONCLUSIONS

Most patients experienced sexual dysfunction at 12 months after surgery for rectal cancer, and predictive factors for this dysfunction were related to characteristics of the tumor.

Prognostic significance of neutrophil-to-lymphocyte ratio in rectal cancer: a meta-analysis

Background

Inflammatory responses play decisive roles in tumor development, immune surveillance, and responses to therapy. High neutrophil-to-lymphocyte ratio (NLR), as an inflammation index, has been reported to be a predictor for poor prognosis of various cancers. The purpose of this meta-analysis was to evaluate the prognostic value of NLR in patients with rectal cancer.

Methods

A comprehensive search of the literature was conducted through PubMed and EMBASE. Pooled hazard ratio (HR) with 95% confidence interval (CI) was used to evaluate the association between NLR and three outcomes: overall survival, disease-free survival, and recurrence-free survival.

Results

Seven cohorts involving 959 patients were included in this meta-analysis. Our pooled results demonstrated that elevated NLR was associated with poor overall survival (HR: 13.41, 95% CI: 4.90–36.72), disease-free survival (HR: 4.37, 95% CI: 2.33–8.19), and recurrence-free survival (HR: 3.64, 95% CI: 1.88–7.05).

Conclusion

An elevated NLR is a valuable and easily available prognostic marker for rectal cancer. It is associated with unfavorable overall survival, disease-free survival, and recurrence-free survival. NLR could be a useful candidate factor for making treatment decisions for individual patients with rectal cancer.

Predicting the Risk of Bowel-Related Quality-of-Life Impairment After Restorative Resection for Rectal Cancer: A Multicenter Cross-Sectional Study

BACKGROUND

Restorative anterior resection is considered the optimal procedure for most patients with rectal cancer and is frequently preceded by radiotherapy. Both surgery and preoperative radiotherapy impair bowel function, which adversely affects quality of life.

OBJECTIVE

This study aimed to report symptoms associated with and key predictors for bowel-related quality-of-life impairment.

DESIGN

The study included a cross-sectional cohort.

SETTINGS

This was a multicenter study from 12 United Kingdom centers.

PATIENTS

A total of 578 patients with rectal cancer underwent curative restorative anterior resection between 2001 and 2012 (median, 5.25 years postsurgery).

MAIN OUTCOME MEASURES

Patients completed outcome measures that assessed bowel dysfunction (low anterior resection syndrome score), incontinence (Wexner score), and quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30), plus an anchor question: "Overall how does bowel function affect your quality of life?"

RESULTS

The response rate was 80% (462/578). Overall, 85% (391/462) of patients reported bowel-related quality-of-life impairment, with 40% (187/462) reporting major impairment. A large difference in global quality of life (22 points; p < 0.001) was reported for "none" versus "major" impairment, with greatest symptom severity being diarrhea (25 points; p < 0.001), insomnia (24 points; p < 0.001), and fatigue (20 points; p < 0.001). Regression analysis identified major impairment in 60% and 45% of patients with low rectal cancer treated with and without preoperative radiotherapy compared with 47% and 33% of middle/upper rectal cancers with and without preoperative radiotherapy.

LIMITATIONS

Advances in radiotherapy delivery and improvements in posttreatment symptom control, although currently of limited efficacy, imply that the content of this consent aid should be re-evaluated in 5 to 10 years.

CONCLUSIONS

Before a restorative anterior resection, patients with rectal cancer should be informed that bowel-related quality-of-life impairment is common. The key risk factors are neoadjuvant therapy and a low tumor height. This study presents quality-of-life and functional outcome data, along with a consent aid, that will enhance this preoperative patient discussion.

The Log Odds of Positive Lymph Nodes Stratifies and Predicts Survival of High-Risk Individuals Among Stage III Rectal Cancer Patients

INTRODUCTION

The log odds of positive lymph nodes (LODDS) is an empiric transform formula that incorporates positive and negative lymph node data into a single ratio for prognostic utility. We sought to determine the value of the log odds ratio as a prognostic indicator compared with established lymph node indices in advanced-stage rectal cancer patients who have undergone curative resection.

METHODS

Retrospective analysis of rectal cancer operations from 1995 to 2013 identified all stage III cancer patients who underwent curative resection. Patients were stratified into three groups according to calculated lymph node ratios (LNRs) and log odds ratios (LODDS). The relationship between LNR, LODDS, and 5-year overall survival (OS) were assessed.

RESULTS

OS for all patients was 81.4%. Both LNR and LODDS stratifications identified differences in 5-year OS. LODDS stratification was significantly associated with OS (p = .04). Additional significant clinicopathologic demographic variables included sex (p = .02), venous invasion (p = .02), tumor location (p < .001), and receipt of adjuvant chemotherapy (p = .047). LODDS separated survival among patients in the low LNR group (LNR1).

CONCLUSION

This study confirms that the measure of lymph node involvement transformed by the log odds ratio is a suitable predictor of 5-year overall survival in stage III rectal cancer. LODDS may be applied to stratify high-risk patients in the management of adjuvant therapy.

IMPLICATIONS FOR PRACTICE

Traditionally, clinicians have relied solely on the total number of positive lymph nodes affected when determining patient prognosis in rectal cancer. However, the current staging strategy does not account for "high-risk," biologically aggressive tumors that fall into the same risk categories as less clinically aggressive tumors. The log odds of positive lymph nodes is a logistic transform formula that uses pathologic lymph node data to stratify survival differences among patients within a single stage of disease. This formula allows clinicians to identify whether patients with clinically aggressive tumors fall into higher-risk groups, providing additional insight into how to better counsel patients and manage postoperative therapies.

Feasibility and response of helical tomotherapy in patients with metastatic colorectal cancer

Purpose

To investigate the treatment outcome and the toxicity of helical tomotherapy (HT) in patients with metastatic colorectal cancer (mCRC).

Materials and Methods

We retrospectively reviewed 18 patients with 31 lesions from mCRC treated with HT between 2009 and 2013. The liver (9 lesions) and lymph nodes (9 lesions) were the most frequent sites. The planning target volume (PTV) ranged from 12 to 1,110 mL (median, 114 mL). The total doses ranged from 30 to 70 Gy in 10-30 fractions. When the α/β value for the tumor was assumed to be 10 Gy for the biologically equivalent dose (BED), the total doses ranged from 39 to 119 Gy₁₀ (median, 55 Gy₁₀). Nineteen lesions were treated with concurrent chemotherapy (CCRT).

Results

With a median follow-up time of 16 months, the median overall survival for 18 patients was 33 months. Eight lesions (26%) achieved complete response. The 1- and 3-year local progression free survival (LPFS) rates for 31 lesions were 45% and 34%, respectively. On univariate analysis, significant parameters influencing LPFS rates were chemotherapy response before HT, aim of HT, CCRT, PTV, BED, and adjuvant chemotherapy. On multivariate analysis, PTV ≤113 mL and BED >48 Gy₁₀ were associated with a statistically significant improvement in LFPS. During HT, four patients experienced grade 3 hematologic toxicities, each of whom had also received CCRT.

Conclusion

The current study demonstrates the efficacy and tolerability of HT for mCRC. To define optimal RT dose according to tumor size of mCRC, further study should be needed.