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Background: Neoadjuvant chemoradiotherapy followed by total mesorectal excision is a standard treatment for locally advanced rectal cancer. Mismatch repair-deficient locally advanced rectal cancer (LARC) was highly sensitive to PD-1 blockade. However, most rectal cancers are microsatellite stable (MSS) or mismatch repair-proficient (pMMR) subtypes for which PD-1 blockade is ineffective. Radiation can trigger the activation of CD8 + T cells, further enhancing the responses of MSS/pMMR rectal cancer to PD-1 blockade. Radioimmunotherapy offers a promising therapeutic modality for rectal cancer. Progenitor T exhausted cells are abundant in tumour-draining lymph nodes and play an important role in immunotherapy. Conventional irradiation fields include the mesorectum and regional lymph nodes, which might cause considerable damage to T lymphocytes and radiation-induced fibrosis, ultimately leading to a poor response to immunotherapy and rectal fibrosis. This study investigated whether node-sparing modified short-course irradiation combined with chemotherapy and PD-1 blockade could be effective in patients with MSS/ pMMR LARC., Methods: This was a open-label, single-arm, multicentre, prospective phase II trial. 32 LARC patients with MSS/pMMR will receive node-sparing modified short-course radiotherapy (the irradiated planned target volume only included the primary tumour bed but not the tumour-draining lymph nodes, 25 Gy/5f, 5 Gy/f) followed by CAPOX and tislelizumab. CAPOX and tislelizumab will be started two days after the completion of radiotherapy: oxaliplatin 130 mg/m 2 intravenous infusion, day 1; capecitabine 1000 mg/m 2 oral administration, days 1-14; and tislelizumab 200 mg, intravenous infusion, day 1. There will be four 21-day cycles. TME will be performed at weeks 14-15. We will collect blood, tumour, and lymphoid specimens; perform flow cytometry and in situ multiplexed immunofluorescence detection; and analyse the changes in various lymphocyte subsets. The primary endpoint is the rate of pathological complete response. The organ preservation rate, tumour regression grade, local recurrence rate, disease-free survival, overall survival, adverse effects, and quality of life will also be analysed., Discussion: In our research, node-sparing modified radiotherapy combined with immunotherapy probably increased the responsiveness of immunotherapy for MSS/pMMR rectal cancer patients, reduced the occurrence of postoperative rectal fibrosis, and improved survival and quality of life. This is the first clinical trial to utilize a node-sparing radiation strategy combined with chemotherapy and PD-1 blockade in the neoadjuvant treatment of rectal cancer, which may result in a breakthrough in the treatment of MSS/pMMR rectal cancer., Trial Registration: This study was registered at www., Clinicaltrials: gov ., Trial Registration Number: NCT05972655. Date of registration: 31 July 2023., (© 2024. The Author(s).)

Background: Postoperative bowel dysfunction, also known as low anterior resection syndrome, is common in rectal cancer survivors and significantly impacts quality of life. Although long-term longitudinal follow-up is lacking, improvement of the syndrome is commonly believed to happen only within the first 2 years., Objective: This study aimed to depict the longitudinal evolvement of low anterior resection syndrome beyond 3 years and explore factors associated with changes., Design: Longitudinal long-term follow-ups were performed for the single center with the largest cohort within the multicenter FOWARC randomized controlled trial., Setting: A quaternary referral center., Patients: Individuals diagnosed with rectal cancer who received long-course neoadjuvant chemotherapy or chemoradiotherapy, followed by sphincter-preserving radical proctectomy., Main Outcome Measurements: Change of low anterior resection syndrome score and stoma status., Results: Of the 220 patients responding to the first follow-up at a median of 39 months, 178 (80.9%) responded to the second follow-up after a median of 83 months. During this interval, the mean low anterior resection syndrome score improved from 29.5 (95% CI, 28.3-30.7) to 18.6 (95% CI, 16.6-20.6). Fifty-six (31.5%) patients reported improvement from major to no/minor severity, and 6 (3.4%) patients had new stomas because of severe bowel dysfunction. Neoadjuvant radiotherapy ( p = 0.016) was independently and negatively associated with improvement of the score., Limitations: Loss of follow-up during the long-term follow-ups., Conclusions: Most rectal cancer survivors with low anterior resection syndrome continued to improve beyond 3 years after proctectomy. Neoadjuvant radiotherapy was negatively associated with long-term improvement of low anterior resection syndrome. See Video Abstract ., Cambio a Largo Plazo Del Sndrome De Reseccin Anterior Baja En Supervivientes De Cncer De Recto Seguimiento Longitudinal De Un Ensayo Controlado Aleatorio: ANTECEDENTES:La disfunción intestinal posoperatoria, también conocida como síndrome de resección anterior baja, es común en los sobrevivientes de cáncer de recto y afecta significativamente la calidad de vida. Aunque falta un seguimiento longitudinal a largo plazo, comúnmente se cree que la mejoría del síndrome ocurre sólo dentro de los primeros dos años.OBJETIVO:Este estudio tiene como objetivo representar la evolución longitudinal del síndrome de resección anterior baja más allá de los 3 años y explora los factores asociados con el cambio.DISEÑO:Se realizaron seguimientos longitudinales a largo plazo para el único centro con la cohorte más grande dentro del ensayo controlado aleatorio multicéntrico FOWARC.AJUSTE:Un centro de referencia cuaternario.PACIENTES:Individuos diagnosticados con cáncer de recto que recibieron quimioterapia neoadyuvante de larga duración o quimiorradioterapia, seguida de proctectomía radical con preservación del esfínter.PRINCIPALES MEDICIONES DE RESULTADO:Cambio en la puntuación del síndrome de resección anterior baja y el estado del estoma.RESULTADOS:De los 220 pacientes que respondieron al primer seguimiento con una mediana de 39 meses, 178 (80,9%) respondieron al segundo seguimiento después de una mediana de 83 meses. Durante el intervalo, la puntuación media del síndrome de resección anterior baja mejoró de 29,5 (intervalo de confianza [IC] del 95%: 28,3-30,7) a 18,6 (IC del 95%: 16,6-20,6). 56 (31,5%) pacientes informaron una mejoría de mayor a ninguna gravedad, y 6 (3,4%) pacientes tuvieron un nuevo estoma debido a una disfunción intestinal grave. La radiación neoadyuvante (p = 0,016) se asoció de forma independiente y negativa con la mejora de la puntuación.LIMITACIONES:Pérdida de seguimiento durante los seguimientos a largo plazo.CONCLUSIÓN:La mayoría de los sobrevivientes de cáncer de recto con síndrome de resección anterior baja continuaron mejorando más allá de los 3 años después de la proctectomía. La radiación neoadyuvante se asoció negativamente con la mejora a largo plazo del síndrome de resección anterior baja. (Traducción-Dr Yolanda Colorado )., (Copyright © The ASCRS 2024.)

Objective: To determine the morbidity, mortality, and pathologic outcomes of transanal total mesorectal resection (taTME) versus laparoscopic total mesorectal excision (laTME) among patients with rectal cancer with clinical stage I to III rectal cancer below the peritoneal reflection., Background: Studies with sufficient numbers of patients allowing clinical acceptance of taTME for rectal cancer are lacking. Thus, we launched a randomized clinical trial to compare the safety and efficacy of taTME versus laTME., Methods: A randomized, open-label, phase 3, noninferiority trial was performed at 16 different hospitals in 10 Chinese provinces. The primary endpoints were 3-year disease-free survival and 5-year overall survival. The morbidity and mortality within 30 days after surgery, and pathologic outcomes were compared based on a modified intention-to-treat principle; this analysis was preplanned., Results: Between April 13, 2016, and June 1, 2021, 1115 patients were randomized 1:1 to receive taTME or laTME. After exclusion of 26 cases, modified intention-to-treat set of taTME versus laTME groups included 544 versus 545 patients. There were no significant differences between taTME and laTME groups in intraoperative complications [26 (4.8%) vs 33 (6.1%); difference, -1.3%; 95% confidence interval (CI), -4.2% to 1.7%; P =0.42], postoperative morbidity [73 (13.4%) vs 66 (12.1%); difference, 1.2%; 95% CI, -2.8% to 5.2%; P =0.53), or mortality [1 (0.2%) vs 1 (0.2%)]. Successful resection occurred in 538 (98.9%) versus 538 (98.7%) patients in taTME versus laTME groups (difference, 0.2%; 95% CI, -1.9% to 2.2%; P >0.99)., Conclusions: Experienced surgeons can safely perform taTME in selected patients with rectal cancer., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Neoadjuvant radiation has been increasingly associated with postoperative bowel dysfunction, including low anterior resection syndrome (LARS). Although permanent stoma often results from severe bowel dysfunction and significantly impacts quality of life, the presence of stoma paradoxically excludes patients from functional follow-up. Hence, stoma status is rarely reported along with LARS, while assessment of both is essential for the comprehensive evaluation of bowel dysfunction in long-term survivors of rectal cancer., Method: Patients enrolled into the Neoadjuvant FOLFOX6 Chemotherapy with or without Radiation in Rectal Cancer (FOWARC) multicentre randomized clinical trial were randomized to receive long-course neoadjuvant chemoradiotherapy (nCRT) or chemotherapy (nCT) followed by sphincter-saving proctectomy and longitudinal follow-up. The primary outcome of the trial was disease-free survival. LARS score and stoma status were assessed secondarily for postoperative bowel function in the largest single-centre cohort of the trial., Results: Overall, 327 patients with locally advanced rectal cancer were enrolled in the original trial and 203 responded after a median follow-up of 83.4 months, of whom 24 (11.8 per cent) had persistent stoma, and 48 patients (23.6 per cent) reported major LARS. Compared with the nCT group, the nCRT group reported more persistent stomas (16.5 per cent versus 4.9 per cent, P = 0.014), and more major LARS in patients without persistent stoma (34.7 per cent versus 16.7 per cent, P = 0.003). The combined prevalence of persistent stoma and major LARS was significantly higher in the nCRT group (45.5 per cent versus 20.7 per cent, P < 0.001). Long-course neoadjuvant radiation (OR 2.20, 95 per cent c.i. 1.10 to 4.40, P = 0.027), height of anastomosis (OR 0.74, 95 per cent c.i. 0.61 to 0.91, P = 0.004), and anastomotic leak (OR 4.97, 95 per cent c.i. 2.24 to 11.05, P < 0.001) were associated with persistent stoma and major LARS in multivariate analysis., Conclusion: More than one-third of patients receiving sphincter-saving proctectomy reported major LARS or persistent stoma at long-term follow-up. Long-course neoadjuvant radiation, low anastomosis, and postoperative leak are independent risk factors for persistent stoma and major LARS., (© The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd.)

Aim: Bowel dysfunction after sphincter-preserving proctectomy, also known as low anterior resection syndrome (LARS), has significant impact on survivors of rectal cancer. This study aimed to assess the temporal change of LARS beyond 2 years after proctectomy, which has not been fully studied., Methods: We longitudinally enrolled consecutive patients who had received total mesorectal excision in a tertiary academic medical center, with preoperative neoadjuvant therapy if indicated. LARS score was longitudinally assessed by two serial follow-ups, with a fixed interval of 18 months., Results: Overall, 107 patients responded for the first follow-up after a median of q20 months, 96 of whom responded for the second follow-up after a median of 38 months. At the first follow-up, 48 patients (44.9%) reported major LARS, compared with 23 (24.0%) at the second follow-up (p < 0.001). Mean LARS score improved from 27.3 to 18.6, mostly from "urgency" (12.2 vs. 6.2, p < 0.001) and "clustering of stools" (9.7 vs. 7.7, p = 0.001). Anastomosis less than 3 cm from the anal verge was independently associated with LARS improvement., Conclusion: Bowel dysfunction continues to improve 2 years after total mesorectal excision, with most symptom relief in urgency and stool clustering, especially in patients with lower anastomosis., (© 2021 Wiley Periodicals LLC.)

Background: The local recurrence of rectal cancer has been improved by total mesorectal excision following neoadjuvant chemoradiotherapy. However, in patients with low locally advanced rectal cancer, lateral pelvic recurrence remains to be addressed., Objective: This study aimed to determine the efficiency of neoadjuvant radiotherapy in addressing lateral pelvic recurrence and which subgroup of patients might be optimal to receive lateral lymph node dissection., Design: The MRI/CT images were reassessed for lateral lymph node status. The lateral lymph nodes with short axis ≥5 mm and ≥4 mm were considered positive in pretreatment and restaging MRI/CT., Setting: This was a post hoc analysis of a prospective randomized controlled trial (FOWARC, NCT01211210)., Patients: A total of 495 patients with stage II or III rectal adenocarcinoma were included in the original trial. According to the excluding criteria, the finally included population consists of 253 patients; of these, 195 patients received neoadjuvant chemoradiotherapy and 94 received chemotherapy alone., Main Outcomes and Measures: The primary outcome was the 5-year lateral pelvic recurrence rate., Results: Compared with patients receiving chemotherapy alone, patients receiving additional radiotherapy had a marginal significance of lower lateral pelvic recurrence rate (6.6% vs 13.0%; p = 0.051). In the subset with pretreatment positive lateral lymph nodes, patients had a lateral pelvic recurrence rate of 22.6% and 45.1% after neoadjuvant chemoradiotherapy and chemotherapy alone. Of note, 34.9% of the pretreatment positive lateral lymph nodes were persistent after neoadjuvant chemoradiotherapy, culminating in a lateral pelvic recurrence rate of 63.3%., Limitations: This is a post hoc analysis, and only the patients from the leading center were included, which limited the sample size. In addition, the lateral lymph node dissection was not performed in this cohort., Conclusions: The addition of radiotherapy in neoadjuvant regimens could not address lateral pelvic recurrence adequately. Some subgroups of patients might need additional dissection. See Video Abstract at http://links.lww.com/DCR/B613., La Inclusion De La Radioterapia Preoperatoria Es Insuficiiente En El Control Plvico Lateral En Un Subgrupo De Pacientes Con Cncer De Recto Inferior Localmente Avanzado Un Estudio Posthoc Controlado Y Randomizado: ANTECEDENTES:La recurrencia local del cancer de recto ha disminuido al efectuar una excision mesorrectal total seguida de quimioradioterapia neoadyuvante. No obstante, en pacientes con cancer de tercio inferior de recto avanzado localmente, aún está por controlarse la recurrencia pélvicaOBJETIVOS:Determinar la eficacia de la radioterapia neoadyuvante en el control de la recurrencia pélvica lateral y en que subgrupo de pacientes sería conveniente efecutar una excisión lateral de las cadenas ganglionares.DISEÑO:Se reevaluaron las imágenes tomográficas y de resonancia magnética del status de las cadenas ganglionares linfáticas laterales. Los ganglios linfáticos laterales con un eje-corto > 5 mm y ≥ 4 mm se consideraron como positivos previo al tratamiento y reestadificados con RM y TAC respectivamente.ESCENARIO:Es un análisis post hoc de un studio prospectivo randomizado controlado (FOWARC, NCT01211210).PACIENTESSe incluyeron un total de 495 pacientes en estdio II o III con adenomcarcinoma rectal en el estudio original. De acuerdo a los criterios de exclusión, la población final incluida consistió en 253 pacientes; de estos, 195 recibieron quimioradioterapia neoadyuvante y 94 quimioterapia sola.EVALUACION DE LOS RESULTADOS PRINCIPALES:El parámetro mas importante fue la tasa de recurrencia pélvica lateral a cinco años.RESULTADOS:En comparación con los pacientes que recibieron quimioterapia sola, aquellos que además fueron sometidos a radioterapia adicional presentaron un margen significativo de menor tasa de recurrencia pélvica lateral (6.6% vs. 13.0%; p=0.051). En el grupo de pacientes con ganglios linfáticos laterales positivos, los enfermos presentaron una tasa de recurrencia pélvica lateral de 22.6% y 45.1% después de quimioradiaterapia neoadyuvante en comparación con quimioterapia sola respectivamente. Cabe mencionar que el 34.9% de los pacientes con ganglios linfáticos laterales positivos antes del tratamiento persistieron después de la quimioradioterapia neoadyuvante, reportándose finalmente una recurrencia pélvica lateral de un 63.3%.LIMITACIONES:Se trata de un análisis posthoc y solo los pacientes del hospital fueron incluidos, lo que limita el tamaño de la muestra. Además, no se efectuó la disección de los ganglios linfáticos laterales en este grupo.CONCLUSIONES:La radioterapia en los esquemas de neoadyuvancia no logran controlar la recurrencia pélvica lateral en forma adecuada. Algunos subgrupos de pacientes podría requerir de disección adicional. Consulte Video Resumen en http://links.lww.com/DCR/B613., (Copyright © The ASCRS 2021.)

Background: For patients with locally advanced rectal cancer (LARC), it is unclear whether neoadjuvant chemoradiotherapy-induced pathologic complete response (pCR) individuals would further benefit from adjuvant chemotherapy (ACT)., Methods: The pCR individuals who received different ACT cycles were paired by propensity score matching. Overall survival (OS), disease-free survival (DFS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) were calculated by Kaplan-Meier and log-rank test., Results: In total, 1041 pCR individuals were identified from 5567 LARC cases. Specifically, 303 pCR cases had no ACT treatment, and 738 pCR patients received fluoropyrimidine-based ACT (median, 4 cycles) treatment. After 1:3 propensity score matching, 297 cases without ACT treatment were matched to 712 cases who received ACT treatment. Kaplan-Meier analysis showed that pCR individuals treated with or without ACT had the similar 3-year outcome (OS, DFS, LRFS and DMFS) (all P > 0.05). Moreover, the pCR patients received different ACT cycle(s) (0 vs. 1-4 cycles, 0 vs. ≥5 cycles) had comparable 3-year OS, DFS, LRFS and DMFS (all P > 0.05). In stratified analysis, ACT treatment did not improve 3-year survival (OS, DFS, LRFS and DMFS) for the baseline high-risk (cT3-4/cN1-2) subgroup patients (all P > 0.05)., Conclusion: ACT, which did not improve survival, is unnecessary to neoadjuvant treatment-induced pCR LARC patients., Trial Registration: 2019ZSLYEC-136 (24-6-2019).

Introduction: Although neoadjuvant chemo-radiotherapy (CRT) achieves low local recurrence rates in locally advanced rectal cancer (LARC), it raises a lot of concerns about long-term anal and sexual functions. We explored the efficacy of preoperative chemotherapy with mFOLFOXIRI (folinic acid, 5-fluorouracil, oxaliplatin, and irinotecan) in patients with LARC., Patients and Methods: Patients with LARC evaluated by pelvic magnetic resonance imaging (MRI) were enrolled in this trial. All received 4 to 6 cycles of mFOLFOXIRI. MRI was performed to assess clinical response after chemotherapy. Patients with mesorectal fascia-positive or ycT4a/b after re-evaluation would receive radiation before surgery, whereas responders would have immediate total mesorectal excision (TME). Adjuvant chemotherapy with mFOLFOX6 (folinic acid, 5-fluorouracil, and oxaliplatin) was recommended. The primary endpoint was the proportion of tumor downstaging to ypT 0-2 N 0 M 0 . The secondary endpoints were pathologic complete response rate (pCR), 3-year disease-free survival rate, and safety., Results: Overall, 106 patients were enrolled and received neoadjuvant mFOLFOXIRI chemotherapy. A total of 103 participants underwent TME surgery. Among 103 patients who completed at least 4 cycles of preoperative chemotherapy, 2 received short-term radiation before TME, and 12 underwent long-term CRT after MRI evaluation. The pCR rate was 20.4%, and the tumor downstaging rate was 42.7%. Among patients without preoperative long-term radiotherapy, the pCR rate and tumor downstaging rate were 17.4% and 41.3%, respectively. Among the per-protocol population, the tumor downstaging rate was 48.1%, and the pCR rate was 20.3%. The chemotherapy-related toxicity was well-tolerated., Conclusion: Neoadjuvant chemotherapy with mFOLFOXIRI and selective radiation does not seem to compromise outcomes in LARC. It could be a reasonable alternative to CRT in previously untreated patients with LARC., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: In the multicenter, open-label, phase III FOWARC trial, modified infusional fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) plus radiotherapy resulted in a higher pathologic complete response rate than fluorouracil plus radiotherapy in Chinese patients with locally advanced rectal cancer. Here, we report the final results., Methods: Adults ages 18 to 75 years with stage II/III rectal cancer were randomly assigned (1:1:1) to five cycles of infusional fluorouracil (leucovorin 400 mg/m 2 , fluorouracil 400 mg/m 2 , and fluorouracil 2.4 g/m 2 over 48 hours) plus radiotherapy (46.0 to 50.4 Gy delivered in 23 to 25 fractions during cycles 2 to 4) followed by surgery and seven cycles of infusional fluorouracil, the same treatment plus intravenous oxaliplatin 85 mg/m 2 on day 1 of each cycle (mFOLFOX6), or four to six cycles of mFOLFOX6 followed by surgery and six to eight cycles of mFOLFOX6. The primary end point was 3-year disease-free survival (DFS)., Results: In total, 495 patients were randomly assigned to treatment. After a median follow-up of 45.2 months, DFS events were reported in 46, 39, and 46 patients in the fluorouracil plus radiotherapy, mFOLFOX6 plus radiotherapy, and mFOLFOX6 arms. In each arm, the probability of 3-year DFS was 72.9%, 77.2%, and 73.5% ( P = .709 by the log-rank test), the 3-year probability of local recurrence after R0/1 resection was 8.0%, 7.0%, and 8.3% ( P = .873 by the log-rank test), and the 3-year overall survival rate was 91.3%, 89.1%, and 90.7% ( P = .971 by log-rank test), respectively., Conclusion: mFOLFOX6, with or without radiation, did not significantly improve 3-year DFS versus fluorouracil with radiation in patients with locally advanced rectal cancer. No significant difference in outcomes was found between mFOLFOX6 without radiotherapy and fluorouracil with radiotherapy, which requires additional investigation of the role of radiotherapy in these regimens.

Background: We demonstrated previously that radiation proctitis induced by preoperative radiotherapy is a predisposing factor for clinical anastomotic leakage in patients undergoing rectal cancer resection. Quantitative measurement of radiation proctitis is needed., Objective: This study aimed to quantitate the changes of anatomic features caused by preoperative radiotherapy for rectal cancer and evaluate its ability to predict leakage., Design: It was a secondary analysis of a randomized controlled trial (NCT01211210). MRI variables were retrospectively assessed., Settings: The study was conducted in the leading center of the trial, which is a tertiary GI hospital., Patients: Patients undergoing preoperative chemoradiation with sphincter-preserving surgery were included., Main Outcome Measures: Anatomic features were measured by preradiotherapy and postradiotherapy MRI. Univariate analyses were used to identify prognostic factors. Receiver operating characteristic curves were constructed to determine the cutoff value of the changes of MRI variables in predicting leakage., Results: Eighteen (14.4%) of the 125 included patients developed clinical anastomotic leakage. Baseline characteristics were comparable between leakage group and nonleakage group. Relative increments of width of presacral space, thickness of rectal wall, and distal end of sigmoid colon discriminate between the 2 groups better than random chance. Relative increments of width of presacral space was the best performing predictor, with area under the curve of 0.722, sensitivity of 66.7%, specificity of 72.0%, and positive and negative predictive value of 28.6% and 92.8%., Limitations: The study was limited by its small sample size and retrospective design., Conclusions: Increments of the width of the presacral space, thickness of rectal wall, and distal part of the sigmoid colon helps to identify individuals not at risk for clinical anastomotic leakage after rectal cancer resection. The first variable is the strongest predictor. Changes of these variables should be taken into consideration when evaluating the application of defunctioning stoma. See Video Abstract at http://links.lww.com/DCR/B23., Clinical Trials Identifier: NCT1211210. LAS FUGAS ANASTOMÓTICAS CLÍNICAS DESPUÉS DE LA RESECCIÓN DEL CÁNCER DEL RECTO PUEDEN PREDECIRSE POR LAS CARACTERÍSTICAS ANATÓMICAS PÉLVICAS EN LAS IMAGENES DE RESONANCIA MAGNÉTICA PREOPERATORIA: UN ANÁLISIS SECUNDARIO DE UN ESTUDIO CONTROLADO ALEATORIZADO:: Anteriormente demostramos que la proctitis inducida por la radiación de radioterapia preoperatoria es un factor predisponente para la fuga anastomótica clínica en pacientes sometidos a resección de cáncer rectal. Es necesaria la medición cuantitativa de la proctitis por radiación.Este estudio tuvo como objetivo cuantificar los cambios en las características anatómicas causados por la radioterapia preoperatoria para el cáncer de recto y evaluar su capacidad para predecir las fugas anastomoticas.Fue un análisis secundario de un estudio controlado aleatorio (NCT01211210). Los variables de imagines de resonancia magnetica se evaluaron retrospectivamente.Se llevó a cabo en el centro principal del estudio, que es un hospital gastrointestinal terciario.Se incluyeron pacientes sometidos a quimiorradiación preoperatoria con cirugía conservadora del esfínter.Las características anatómicas se midieron mediante imagines de resonancia magnetica previa y posterior a la radioterapia. Se utilizaron análisis univariados para identificar los factores pronósticos. Las curvas de características operativas del receptor se construyeron para determinar el valor de corte de los cambios de los variables de resonancia magnetica en la predicción de fugas.Dieciocho (14.4%) de los 125 pacientes incluidos desarrollaron fugas anastomóticas clínicas. Las características basales fueron comparables entre el grupo de fugas y el grupo de no fugas. Los incrementos relativos del ancho del espacio presacro, el grosor de la pared rectal y distal del colon sigmoide discriminan entre los dos grupos mejor que la posibilidad aleatoria. Los incrementos relativos del ancho del espacio presacro fueron el mejor pronóstico con un AUC de 0.722, sensibilidad del 66.7%, especificidad del 72.0%, valor predictivo positivo y negativo del 28.6% y 92.8%.Estaba limitado por el tamaño de muestra pequeño y el diseño retrospectivo.Los incrementos en el ancho del espacio presacro, el grosor de la pared rectal y la parte distal del colon sigmoide ayudan a identificar a las personas que no tienen riesgo de fuga anastomótica clínica después de la resección del cáncer rectal. La primera variable es el predictor más fuerte. Los cambios de estos variables deben tenerse en cuenta al evaluar la aplicación del estoma para desvio. Vea el Resumen del Video en http://links.lww.com/DCR/B23.

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.

Background: The clinical factors that accurately predict the response to preoperative treatment in rectal cancer were yet unknown. The carcinoembryonic antigen (CEA) clearance pattern during neoadjuvant treatment has been developed and the predictive value explored in rectal cancer patients with elevated CEA levels (> 5 ng/mL)., Methods: The training cohort was derived from the FOWARC prospective phase III trial, and 71/483 eligible patients were included. The validation cohort consisted of 75/587 consecutive rectal cancer patients from Xiangya Hospital between 2014 and 2015. The kinetic changes in serum CEA were measured at different time points during the neoadjuvant treatment. An exponential trend line was drawn using the CEA values. The patients were categorized into two groups based on the R 2 value of the trend line, which indicates the correlation coefficient between the exponential graph and measured CEA values: exponential decrease group (0.9 < R 2  ≤ 1.0) and non-exponential decrease group (R 2  ≤ 0.9)., Results: In multivariate analysis, the patients in the CEA exponential decrease group had significantly high adequate rate of downstaging (ypT0-2N0M0), and pathologic complete response (pCR) rates after neoadjuvant treatment in the training cohort. The predictive values of the CEA clearance pattern for tumor downstaging and pCR were further confirmed in an independent validation cohort., Conclusions: The CEA clearance pattern was an independent predictor of tumor response to neoadjuvant treatment in patients with rectal cancer. It might serve as an adjunct in the assessment of complete clinical response and guide individualized treatment strategies., Trial Registration: NCT01211210.

Rectal cancer is one of the most common malignancies in China. Total mesorectal excision (TME) plus neoadjuvant therapy is the standard treatment for locally advanced rectal cancer. After a development of over 20 years, neoadjuvant synchronous chemoradiotherapy has become the standard treatment and cornerstone of neoadjuvant therapy for rectal cancer. However, radiotherapy does not really increase the overall survival and is associated with long-term impact on the functions of anus, sex, urinary system and fertility, so the application of simple neoadjuvant chemotherapy rises gradually and becomes a potentially better treatment option. This paper elaborates the reason, present research status and future trend of the rising neoadjuvant chemotherapy.

Background and Objective: With the increase in sphincter preserving rate of rectal cancer (RC) cancer, postoperative quality-of-life, such as genital dysfunction, has become a major issue in the patient management. In this study, we proposed a measurement, namely, the sphincter preserving length (SPL), and investigated the relationship between SPL and postoperative genital function and survival in RC patients., Methods: A total of 536 male patients who had a diagnosis of RC and underwent sphincter preserving rectal resection in the Sixth Affiliated Hospital of Sun Yat-sen University and the First Affiliated Hospital of Sun Yat-sen University between October 1997 and December 2013 were included in our study. SPL was defined as the distance between the lowest edge of the tumor to dentate line. Postoperative genital function was evaluated by erection function and ejaculation function. Five-year survival status was extracted from the hospital database., Results: Larger SPL was significantly associated with poorer postoperative erection and ejaculation function. For a SPL of 7.25 cm, the sensitivity and specificity of the diagnosis of erection dysfunction was 68.6% and 68.8%, respectively. The corresponding sensitivity and specificity for the diagnosis of ejaculation dysfunction was 70.9% and 75.7%, respectively. SPL was also negatively associated with survival rate. Compared with lower anterior resection, patients with lower RC who underwent local resection or draw-out colon-anal anastomosis had better postoperative genital function., Conclusions: SPL might be a useful measurement to assess the risk of postoperative genital dysfunction and survival status and an indicator for initiation of early preventative treatment in patients with RC.

Objective: To explore the feasibility and clinical significance of precision low inferior mesenteric artery (IMA) ligation with the left colonic artery (LCA) preservation and root lymph node dissection in laparoscopic radical resection for rectal cancer, according to the inferior mesenteric artery (IMA) types., Methods: One Hundred and fore cases of rectal cancer patients who underwent laparoscopic resection in The Sixth Affiliated Hospital of Sun Yat-sen University from October 2015 to June 2016 were selected and divided into study group and control group according to different surgical methods. The study group (52 cases) accepted precision low IMA ligation with the LCA preservation and root lymph node (No.253) dissection, according to the IMA types and length examined by preoperative computed tomography angiography (CTA) reconstruction. The control group (52 cases) accepted the traditional high IMA ligation. The perioperative efficacy indexes and postoperative recovery situation of the two groups were compared., Results: The IMA types, IMA length and preoperative clinical stages were not significantly different between the two groups (all P>0.05). The surgery was completed smoothly for patients in both groups, with no conversion to open surgery. But two patients in the study group underwent left colonic artery ligation for intra-operative need. There were no significant differences in the operative time, intra-operative blood lose, the rate of protective ileostomy and post-operative pathological stages between the two groups (all P>0.05). More total lymph nodes [(24.9±5.7) vs. (16.9±4.2), P=0.001] and No.253 lymph nodes [(2.4±1.1) vs. (1.5±0.8), P=0.001] were harvested in study group as compared to control group. However, the positive rate of total harvested lymph nodes and No.253 lymph nodes between the two groups were not significantly different (P>0.05). There were no significant differences between the two groups in postoperative first anal exhaust time, postoperative hospital stay, total volume of postoperative intraperitoneal drainage, postoperative abdominal drainage tube retention time, postoperative anal drainage tube retention time and postoperative catheter retention time (All P>0.05). There were 2 cases of postoperative dysuria and 1 case of anastomotic bleeding in study group. There were 3 cases of postoperative dysuria and 2 cases of anastomotic leak in control group. Less postoperative complications (5.8% vs. 9.6%, P<0.05) in study group as compared to control group. There was no rehospitalization or death case in two groups within 30 days after operation., Conclusions: In the laparoscopic radical resection of rectal cancer, preserving LCA and cleaning the root lymph nodes according to IMA types, which could increase the number of harvested lymph nodes and reduce the postoperative complications was safe and effective.

Radical surgeries and(neo) adjuvant therapies have significantly prolonged survival of patients with colorectal cancer. Microinvasive surgery and function preservation become more important with the prerequisite of R0 resection. As for colorectal cancer, long term survival after laparoscopic curative surgery is proved non-inferior to its open counterpart. The new transanal approach of total mesorectal excision, while avoiding abdominal incision for extraction, may as well improve surgical quality. Local excision and the "watch and wait" strategy, though attractive for organ-preservation, are undermined by suboptimal clinical and radiographic assessment of lymph node and treatment response, respectively. Meanwhile, fresh changes are challenging long-established perioperative regiments. Shortening of adjuvant chemotherapy to 3 months reduces adverse events without compromising survival. Moving part of, or all, adjuvant courses to before surgery may improve response, thereby omitting protectomy or radiotherapy. To summarize, function preservation and quality of life has, together with survival, increasingly become the ultimate aim of colorectal cancer treatment, a field of constant evolvement.

Background: Neoadjuvant therapy plays a vital role in the treatment of locally advanced rectal cancer but impairs bowel function after restorative surgery. Optimal decision making requires adequate information of functional outcomes., Objective: This study aimed to assess postoperative bowel function and to identify predictors for severe dysfunction., Design: The study included a cross-sectional cohort and retrospective assessments of pelvic anatomic features., Settings: The study was conducted at a tertiary GI hospital in China., Patients: Included patients underwent neoadjuvant chemoradiotherapy or chemotherapy without radiation and curative low anterior resection for rectal cancer between 2012 and 2014., Main Outcome Measures: Bowel function was assessed using the validated low anterior resection syndrome score. The thicknesses of the rectal wall, obturator internus, and levator ani were measured by preoperative MRI., Results: A total of 151 eligible patients were identified, and 142 patients (94.0%) participated after a median of 19 months from surgery. Bowel dysfunction was observed in 71.1% (101/142) of patients, with 44.4% (63/142) reporting severe dysfunction. Symptoms of urgency and clustering were found to be major disturbances. Regression analysis identified preoperative long-course radiotherapy (p < 0.001) and a lower-third tumor (p = 0.002) independently associated with severe bowel dysfunction. Irradiated patients with a lower-third tumor (OR = 14.06; p < 0.001) or thickening of the rectal wall (OR = 11.09; p < 0.001) had a markedly increased risk of developing severe dysfunction., Limitations: The study was based on a limited cohort of patients and moderate follow-up after the primary surgery., Conclusions: Bowel function deteriorates frequently after low anterior resection for rectal cancer. Severe bowel dysfunction is significantly associated with preoperative long-course radiotherapy and a lower-third tumor, and the thickening of rectal wall after radiation is a strong predictor. Treatment decisions and patient consent should be implemented with raising awareness of bowel symptom burdens. See Video Abstract at http://links.lww.com/DCR/A317.

Objective: To investigate the expression of hypoxia-inducible factor 1α (HIF-1α) and CD133 in predicting pathologic remission and survival of patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy. Methods: One hundred and fourteen patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy from January 2010 to December 2015 in Jinhua Municipal Central Hospital were enrolled in the study. RT-PCR and immunohistochemistry methods were used to detect the mRNA and protein expression of HIF-1α and CD133 before and after chemoradiotherapy. Spearman rank correlation was used to analyze the correlation between HIF-1α and CD133 mRNA expression. Univariate and logistic multivariate analyses were used to determine the factors related to pathological complete response (pCR). Logistic regression analysis and Cox's proportional hazard model were used to determine factors related to overall survival and recurrence-free survival. Results: The expression of HIF-1α and CD133 mRNA was correlated with pT, ypTNM, pCR, recurrence and metastasis of rectal cancer, while not correlated with sex, age and BMI of patients. HIF-1α mRNA expression was positively correlated with CD133 mRNA expression ( α =0.579, P =0.000). Immunohistochemistry analysis showed that residual cancer cells strongly expressing HIF-1α also expressed CD133 strongly. Univariate analysis showed that HIF-1α mRNA and CD133 mRNA were significantly correlated with pCR ( P =0.001, P =0.022, respectively). Multivariate analysis showed that HIF-1α and CD133 mRNA expression were independent prognostic factors of pCR ( P =0.012, P =0.047, respectively). Cox regression analysis showed that the expression of HIF-1α mRNA and CD133 mRNA were independent predictors of recurrence-free survival and overall survival ( P =0.025, P =0.033, respectively). Conclusion: The study indicates that HIF-1α and CD133 can predict pathological complete remission and survival of patients with locally advanced rectal cancer.

Objective: To evaluate the influences of inferior mesenteric artery (IMA) types and Riolan artery arcade absence on the incidence of anastomotic leakage(AL) after laparoscopic resection of rectal cancer., Methods: Clinical data of 116 local advanced rectal cancer patients who underwent laparoscopic resection in The Sixth Affiliated Hospital of Sun Yat-sen University from January 2012 to December 2014 were analyzed retrospectively. IMA and Riolan artery arcade were examined by preoperative computed tomography angiography (CTA) reconstruction. The influences of IMA type, Riolan artery arcade absence and ligation site (high or low) on AL were analyzed by Logistic regression., Results: The proportion of IMA types(I(-IIII() was 57.8%(67/116), 10.3%(12/116), 31.0%(36/116) and 0.9%(1/116), respectively. Riolan artery arcade absence was found in 60.3%(70/116). Eight (6.9%) patients suffered from AL. IMA type III( had significantly higher AL incidence as compared to other IMA types [19.4%(7/36) vs. 1.2%(1/80), P=0.001]. Meanwhile, patients with Riolan artery arcade absence also had significantly higher AL incidence[11.4%(8/70) vs. 0.0%(0/46), P=0.030]. However, the difference in AL incidence between high and Low IMA ligation was not statistically significant [8.0%(7/87) vs. 3.4%(1/29), P=0.531]. Seven of these 8 AL patients were found in IMA type III( with Riolan artery arcade absence and high ligation. Multivariate analysis showed that IMA type III( (P=0.001) and Riolan artery arcade absence (P=0.002) were independent risk factors of AL., Conclusions: IMA type III( with Riolan artery arcade absence increases AL incidence significantly in laparoscopic resection of rectal cancer. IMA type and Riolan aretry arcade absence or not contribute to the selection of IMA ligation site in the operation. For the colorectal cancer patients with IMA type III( and Riolan artery arcade absence, selective low IMA ligation with root lymph node dissection should be recommended.

Background: Evidence regarding the effect of preoperative radiotherapy on anastomotic integrity remains conflicting in rectal cancer surgery. Prospective comparisons with appropriate controls are needed., Objective: This study aimed to assess the impact of preoperative radiotherapy on anastomotic leakage and stenosis after rectal cancer resection., Design: This was a post hoc analysis of a randomized controlled trial (NCT01211210)., Settings: Data were retrieved from the leading center of the trial, which is a tertiary hospital., Patients: The full analysis population of 318 patients was included., Interventions: Patients were randomly assigned to receive preoperative radiation (50 Gy per 25 fractions) and 5-fluorouracil infusion, alone (arm A) or combined with oxaliplatin (arm B), or preoperative chemotherapy with 5-fluorouracil and oxaliplatin without radiation (arm C)., Main Outcome Measures: The rates of anastomotic leakage and stenosis were calculated for each treatment arm. Multivariate analysis was used to verify the effect of preoperative radiotherapy., Results: The treatment arms were comparable in terms of most baseline characteristics, but more diversions were used in the chemoradiotherapy arms. Anastomotic leakage occurred in 20.2% of patients in arm A, 23.6% of patients in arm B, and 8.5% of patients in arm C (p = 0.007). The corresponding rates of stenosis were 17.0%, 18.9%, and 6.8% (p = 0.02). Multivariate analysis confirmed the correlation between preoperative radiotherapy and clinical leakage (p = 0.02), which was associated with delayed stenosis (p < 0.001). For patients undergoing chemoradiotherapy, radiation proctitis was identified as an independent risk factor for clinical leakage (p = 0.01) and stenosis (p < 0.001)., Limitations: The main limitations were discrepancies in stoma creation and chemotherapy regimen among the treatment arms., Conclusions: Preoperative radiotherapy increases the risk of anastomotic leakage and stenosis after rectal cancer resection. Clinical leakage independently contributes to the development of stenosis.

Purpose: Total mesorectal excision with fluorouracil-based preoperative chemoradiotherapy and postoperative chemotherapy is a standard treatment of locally advanced rectal cancer. This study investigated the addition of oxaliplatin with and without preoperative radiotherapy., Methods: In this multicenter, open-label, phase III trial, we randomly assigned (1:1:1) Chinese adults (age 18 to 75 years) with locally advanced stage II/III rectal cancer to three treatments: five 2-week cycles of infusional fluorouracil (leucovorin 400 mg/m(2), fluorouracil 400 mg/m(2), and fluorouracil 2.4 g/m(2) over 48 h) plus radiotherapy (46.0 to 50.4 Gy delivered in 23 to 25 fractions during cycles 2 through 4) followed by surgery and seven cycles of infusional fluorouracil, the same treatment plus intravenous oxaliplatin 85 mg/m(2) on day 1 of each cycle (modified FOLFOX6 [mFOLFOX6]), or four to six cycles of mFOLFOX6 followed by surgery and six to eight cycles of mFOLFOX6. Random assignment was performed by using computer-generated block randomization codes. The primary end point was 3-year disease-free survival. Secondary end points of histopathologic response and toxicity are reported., Results: A total of 495 patients were enrolled from June 2010 to February 2015; 475 were evaluable (fluorouracil-radiotherapy, n = 155; mFOLFOX6-radiotherapy, n = 157; mFOLFOX6, n = 163). In the fluorouracil-radiotherapy, mFOLFOX6-radiotherapy, and mFOLFOX6 groups, the rate of pathologic complete response (pCR) was 14.0%, 27.5%, and 6.6%, and downstaging (ypStage 0 to 1) was achieved by 37.1%, 56.4%, and 35.5% of patients, respectively. Higher toxicity and more postoperative complications were observed in patients who received radiotherapy., Conclusion: mFOLFOX6-based preoperative chemoradiotherapy results in a higher pCR rate than fluorouracil-based treatment. Perioperative mFOLFOX6 alone had inferior results and a lower pCR rate than chemoradiotherapy but led to a similar downstaging rate as fluorouracil-radiotherapy, with less toxicity and fewer postoperative complications., (© 2016 by American Society of Clinical Oncology.)

Since the characteristics of metastasis and invasion of rectal cancer are confirmed gradually, the aim of surgical treatment in rectal cancer is to protect anal and reproductive function, and to minimize the damage of patients. With prominent advantages of identified lower tumor resection margin, enough circumference resection margin, more minimally invasive procedure and faster recovery, transanal total mesorectal excision(taTME) integrated with natural canal theory, transanal minimally invasive technique and TME can effectively solve the difficulties of transabdominal procedure and becomes the research hotspot in rectal cancer surgery worldwide. Though taTME is still at the initial stage and has certain problems, such as the definition of operational procedure, careful performance of standard operation, further summary of operational detail and skill, observation of long-term efficacy and optimization design of operational instruments, it will be supported by high-level evidence based on increasing cases, maturation of procedure, and clinical multicenter cohort researches. TaTME has a good application prospect and may become one of the main procedures of colorectal surgery to treat the middle or low rectal cancer.

Objective: To explore the learning curve of transanal total mesorectal excision (taTME) for rectal cancer., Methods: Clinical data of 60 rectal cancer patients undergoing taTME from July 2014 to April 2016 were retrospectively analyzed. According to the sequence of operation date, 60 patients were divided into four groups (A, B, C, D) with 15 cases in each group. General information and perioperative, especially the operative indexes were compared among four groups., Results: There were no significant differences in age, sex, preoperative staging, BMI, tumor size among four groups (all P>0.05). The distance from tumor to anal verge in A group was(6.7±2.5) cm, which was significantly different with B group (4.6±1.2) cm, C group (4.5±1.0) cm and D group (4.0±1.0) cm (P=0.000, P=0.000, P=0.001). Ratio of receiving neoadjuvant therapy was 0, 60.0%(9 cases), 26.7%(4 cases) and 26.7%(4 cases) in A, B, C, D groups respectively with significant difference (P=0.004). Ratio of receiving complete taTME was 73.3%(11/15) in A group, 26.7%(4/15) in B group, 13.3%(2/15) in C group and 26.7%(4/15) in D group, while other patients underwent laparoscopy-assisted procedures. This ratio of A group was significantly higher as compared to B, C, D groups (P=0.003). The operation time was significantly different among four groups [A group (223.0±105.2) minutes, B group (299.0±131.0) minutes, C group(278.0±44.8) minutes, D group (246.0±34.0) min, P=0.035]. Fluctuation of operation time was more common in A and B groups, which became stable in C and D groups. Though intra-operative blood loss was not significantly different among four groups [A group (249.0±559.6) ml, B group (288.0±568.1) ml, C group (87.0±43.3) ml, D group (69.0±64.5) ml, P=0.225], but it presented a decline trend in C and D groups. Number of harvested lymph node from postoperative pathological specimen was 10.9±5.9 in A group, 9.6±2.7 in B group, 15.8±4.8 in C group, and 14.2±5.1 in D group, with significant difference among groups (P=0.008; A group vs. C group, P=0.010; B group vs. C group, P=0.002; B group vs. D group, P=0.021). There were no significant differences in specimen length, postoperative complication rate, distal margin distance and hospital stay., Conclusion: A well-skilled laparoscopic colorectal surgeon, by following the standard surgical procedures, are likely to overcome the learning curve smoothly after performing approximately 30 cases of taTME for rectal cancer.

Objective: The aim was to evaluate erectile and urinary function of male patients with rectal cancer treated by neoadjuvant (NA) chemoradiotherapy (CRT) or NA chemotherapy only., Methods: In this prospective randomized trial (ClinicalTrials.gov NCT01211210; "FOWARC"), we included 102 men who received NA therapy for stage II-III rectal cancer between January 2011 and June 2013. Before surgery, patients received either NA mFOLFOX6 chemotherapy with radiation (RCS group, n = 54) or NA mFOLFOX6 chemotherapy alone (CS group, n = 48). Erectile and urinary dysfunctions were assessed with the five-item International Index of Erectile Function (IIEF-5) scale and the International Prostatic Symptom Score (IPSS), respectively. Questionnaires were completed at baseline and at 3, 6, and 12 months (t0-t3, respectively) after surgery., Results: At t3, mean IIEF-5 score was significant higher in the CS group (15.3 ± 5.5) than in the RCS group (12.6 ± 5.7; P < 0.05). And score difference was statistically higher in RCS group compared with CS group at t2 and t3, especially t3 (9.3 ± 5.5 vs. 6.1 ± 5.1, P < 0.01). Univariate analysis of the RCS group's IIEF-5 scores associated age, stoma, location, and tumor size to erectile dysfunction. However, mean IPSS scores did not differ between the two groups at any point., Conclusions: Compared with the CS group, erectile and urinary functions were significantly affected by NA CRT. Age, stoma, tumor location, and tumor size were also correlated with erectile dysfunction in the RCS group.

Background: To retrospectively evaluate postoperative genital function, local recurrence rate and survival rate after total mesorectal excision (TME) combined with or without pelvic autonomic nerve preservation (PANP) in male patients with rectal cancer., Methods: A total of 953 male patients with rectal cancer after TME (518 patients received TME combined with PANP [PANP group] and 434patients received TME alone [TME group]) were included. Assessments of postoperative genital function, local recurrence rate, and 5 year survival rate were collected., Results: Rate of erection dysfunction in PANP group (41.9%) was significantly lower than that in TME group (76.7%, P < 0.05). Rate of ejaculation dysfunction in PANP group (42.5%) was also significantly lower than that in TME group (67.3%, P < 0.05). Local recurrence rate (P = 0.66) and survival rate (P = 0.26) did not differ between the two groups. For patients with preoperative obstruction, local recurrence rate was significantly higher (P = 0.01) and survival rate significantly lower (P = 0.03) in PANP group., Conclusions: PANP surgery has significant advantage with respect to preservation of genital function and should be recommended as surgical treatment for rectal cancer patients. However, PANP surgery should be considered with caution in patients with preoperative obstruction in view of the poorer long-term outcomes in these patients.

Objective: To establish the classification of colorectal cancer recurrence patterns based on their relations to prognosis and recurrence., Methods: A total of 463 patients with recurrent rectal cancer (Stage I-III) following curative resection in our hospital from June 2002 to June 2012 were included consecutively. Recurrence status, time, location, survival time after relapse, curability, symptoms and CEA level were recorded. The correlation between each recurrent pattern and recurrent survival (RS) rate were analyzed retrospectively. The survival curve was drawn by Kaplan-Meier method. The Log-rank test was used to test the significance. Univariate analysis was performed by using Cox proportional hazard model., Results: Patients with recurrence within one year, multiple metastases, symptomatic disease, elevated CEA level and unresectable recurrence had significantly lower RS rate than patients with recurrence after one year, solitary metastasis, asymptomatic manifestation, normal CEA level and resectable recurrence respectively. The hazard ratio were 1.34 (95%CI 1.02-1.76, P= 0.033), 1.41 (95%CI 1.04-1.91, P= 0.026), 1.74 (95%CI 1.05-2.88, P= 0.032), 4.06 (95%CI 2.11-7.85, P<0.001) and 1.99 (95%CI 1.34-2.97, P= 0.001) respectively., Conclusion: Early recurrence (<12 months), multiple metastases, symptomatic, unresectable recurrence and elevated CEA indicate poor prognosis after relapse. This study provides a systematic basis for the classification of recurrence in colorectal cancer after radical resection.

Objective: To develop an accurate model with pre-treatment parameters to predict tumor regression and down-staging in locally advanced rectal cancer patients, basing the cohort of preoperative chemotherapy alone in FOWARC study., Patients and Methods: From Jan 2011 to Feb 2015, complete data was available for 137 out of 165 patients who received preoperative chemotherapy alone. All pre-treatment clinical parameters were collected. Tumor regression grade (TRG) 0-1 was defined as good regression, and pathological TNM stage (ypTNM) 0-I after neoadjuvant treatment was defined as good down-staging. Nomogram was established to predict tumor regression and down-staging. The predictive performance of the model was assessed with concordance index and calibration plots., Results: Of the 137 patients, 10 had TRG 0 (complete regression); 32 patients, TRG 1; and 95 patients, TRG 2 and 3 (poor regression); 56 (40.9%) patients were classified as good down-staging with ypTNM stage 0-I. The predictive nomograms were developed to predict the probability of TRG 0-1 and good down-staging with a C-index of 0.72 (95% CI: 0.604-0.797) and 0.76 (95% CI: 0.681-0.844). Calibration plots showed good statistical performance on internal validation. Predictive factors in the models included tumor length, tumor circumferential extent, age, and ApoA1., Conclusions: The model based on available clinical parameters could accurately predict early efficacy with neoadjuvant mFOLFOX6 chemotherapy alone, which might help in patient selection for optimized treatment.

Objective: To study the impact of neoadjuvant radiochemotherapy on erectile and urinary functions in mid-low rectal cancer patients., Methods: Seventy mid-low rectal cancer patients from January 2012 to May 2013 in The Sixth Affiliated Hospital, Sun Yat-sen University were prospectively enrolled. According to tumor staging and patient decision, patients received neoadjuvant radiochemotherapy(50 Grays administered over a six-week period and four cycles of concomitant mFOLFOX6 chemotherapy followed by operation (study group) or surgery alone(control group). Dropouts, loss to follow up and relapse during follow-up were removed from the analysis. A total of 30 patients stayed in study group and 29 patients in control group. To assess erectile and urination functions, the five-item version of the international index of erectile function (IIEF-5) and the international prostate symptom score (IPSS) questionnaires were used before therapy and 12 months after surgery., Results: In both study and control groups, total IIEF-5 score was decreased significantly at postoperative 12-month compared to initial assessment(P<0.01). Compared with control group, IIEF-5 score change was significantly higher in study group (9.6 ± 6.1 vs. 5.3 ± 5.3; P<0.01). Total IPSS score in both groups was increased significantly at postoperative 12-month compared to initial assessment(P<0.05). No significant difference was found in IPSS score change between the two groups (3.0 ± 3.4 vs. 1.5 ± 3.0, P>0.05). Univariate analysis on study group showed that age, tumor location and maximal diameter were associated with erectile dysfunction. Age was associated with urination dysfunction (all P<0.05)., Conclusion: Neoadjuvant radiochemotherapy has significant impact on erectile dysfunction after surgery in mid-low rectal cancer patients.

Purpose: To evaluate retrospectively the postoperative genital function, the local recurrence, and the survival rate impacted by laparoscopic or open surgery for rectal cancer (RC) in male patients., Methods: A total of 398 male RC patients after laparoscopic or open total mesorectal excision (TME) of rectomy (205 patients in the TME with laparoscopy group, and 193 patients in the control group) were included in our study, between October 1997 and December 2013. Postoperative genital function, local recurrence, and the 5-year survival rate were analyzed, retrospectively., Results: The rate of erection dysfunction was lower in the laparoscopic group (60.0%) than in the open group (82.4%, P<0.05); the rate of ejaculation dysfunction in the laparoscopic group (56.6%) was also lower than in the open group (82.4%, P<0.05). No significant difference was found regarding the local recurrence (P=0.87) and the survival rate (P=0.17). Interestingly, for patients with preoperative obstruction, the survival rate was lower in the laparoscopy group compared with the control group (P=0.002)., Conclusions: Laparoscopic surgery should be recommended for mid-RC or low-RC patients to preserve the postoperative genital function. However, for patients with preoperative obstruction, laparoscopy surgery was not recommended.

This study aimed to assess the association between postoperative body temperature and prognosis in patients with rectal cancer. Five hundred and seven patients with stage I to III rectal cancers were enrolled in the current study. Basal body temperature (BBT, measured at 6 am) and maximal body temperature (MBT) on each day after surgery were analyzed retrospectively. Patients were divided into two equal groups according to the median of BBT and MBT at each day. The primary end points were disease-free survival (DFS) and overall survival (OS). The univariate and multivariate analyses showed that patients with low D0-MBT (<37.4 °C) had lower 3-year DFS [adjusted hazard ratio (HR) 1.56 (95 % CI 1.08-2.24, P = 0.017)] as well as OS [adjusted HR 1.72 (95 % CI 1.05-2.82, P = 0.032)] rate as compared to those with high D0-MBT (>37.4 °C). In the subset of 318 patients with T3 stage tumor and the subgroup of 458 patients without blood transfusion as well, low D0-MBT continues to be an independent predictor of DFS/OS with an adjusted HR equal to 1.48 (95 % CI 1.02-2.24, P = 0.046)/1.68 (95 % CI 1.04-2.99, P = 0.048) and 1.45 (95 % CI 1.02-2.13, P = 0.048)/1.59 (95 % CI 1.01-2.74, P = 0.049), respectively. In addition, we found that patients have higher risk of 1-year recurrence if those were exhibiting low preoperative BBT (<36.6 °C) (17 vs. 10 %, P = 0.034). Low body temperature (D0-MBT < 37.4 °C) after surgery was an independent predictor of poor survival outcomes in patients with rectal cancer.

Purpose: Current neoadjuvant chemoradiotherapy had limited impact on distal metastasis and survival in locally advanced rectal cancer. Here, we investigated a new sandwich-like neoadjuvant regimen with bevacizumab., Methods: This was a single-arm, open-labeled, phase II trial. Patients with locally advanced rectal cancer received sandwich-like neoadjuvant therapy with bevacizumab (induction therapy with bevacizumab and FOLFOX, concurrent chemoradiotherapy with bevacizumab and consolidation chemotherapy with FOLFOX). Surgery was performed 4-6 weeks later. The primary endpoint of this study was pathologic complete response., Results: Twenty-five eligible patients were included. All completed the neoadjuvant therapy protocol. During the course of neoadjuvant therapy, 3 patients (12 %) had grade 4 hematological toxicity events and 12 (48 %) had grade 3 non-hematological toxicity events. According to RECIST criteria, 18 patients (72 %) achieved partial response and the rest seven patients (28 %) remained stable disease. Two patients (8 %) refused the subsequent surgical therapy for personal reasons, and 23 patients (92 %) underwent operations finally. Nine (39.1 %, 95 % CI 18.0-57.5 %) of them achieved pathologic complete response. Five of them (21.7 %) had postoperative complications. After a median follow-up period of 25.3 (14.4-40.9) months, four patients developed disease progression and two died of cancer. The 3-year overall survival rate was 95 % (95 % CI 69.5-99.3 %), and the 3-year disease-free survival rate was 72.5 % (95 % CI 33.7-90.9 %)., Conclusions: Sandwich-like neoadjuvant therapy with bevacizumab is safe and effective for locally advanced rectal cancer.

Objective: To evaluate the erectile function of male patients treated by neoadjuvant radiochemotherapy and neoadjuvant chemotherapy alone for mid-low rectal cancer., Methods: The clinical data of 66 patients with rectal cancer from March 2011 to March 2013 were prospectively analyzed. Of all the patients, 56 cases were finally included in the study and were randomly allocated to two groups. Thirty patients were treated by neoadjuvant radiochemotherapy followed by surgery (RCS group), and 26 were treated by neoadjuvant chemotherapy followed by surgery (NCS group). The five-item version of the international index of erectile function (IIEF-5) questionnaire were used to determine erectile function before therapy and at least 12 months after surgery. The impacts of age, location, size of tumor, and body mass index on erectile function were analyzed., Results: Total score was decreased significantly at follow-up compared to initial assessment in both RCS and NCS groups (23.4 ± 1.30 vs. 11.7 ± 5.8, t = 10.748, P < 0.01; 23.1 ± 1.3 vs. 15.2 ± 6.7, t = 5.910, P < 0.01, respectively). Score difference was statistically higher in RCS group compared with NCS group (11.7 ± 5.6 vs. 8.0 ± 6.0, t = 2.394, P = 0.020). In terms of tumor location for RCS group, difference was statistically higher in the patients with low rectal cancer compared with those with middle rectal cancer (14.5 ± 3.5 vs. 9.5 ± 6.0, t = 2.894, P = 0.008)., Conclusions: The erectile functions of patients treated by neoadjuvant radiochemotherapy followed by surgery are more affected than that of patients treated by neoadjuvant chemotherapy followed by surgery in mid-low rectal cancer. Also low rectal cancer are significantly associated with erectile dysfunction in the patients treated by neoadjuvant radiochemotherapy followed by surgery.

Objective: To evaluate the effect of colonic J-pouch coloanal anastomosis after low anterior resection for mid or low rectal cancer on improving defecation and anorectal physiology., Methods: To make a meta-analysis, prospective randomized controlled trial of with or without colonic J-pouch after low anterior resection for mid or low rectal cancer was conducted. The key words included rectal cancer, J-pouch (or J-pouch) and those randomized from selected reports. The data on bowel function and physiological function of the anal canal and (neo) rectum were meta-analyzed using fixed effect model and random effect model., Results: Eight randomized trails including 378 patients entered this study. After one year follow-up, the functional results showed that there were significant differences in stool frequency per day, urgency and use of medication between colonic J-pouch group and straight coloanal anastomosis group. On physiological function of the anal canal and (neo) rectum, there was significant difference only in rectal compliance between the two groups. But there was no significant difference in other 4 items., Conclusions: The functional improvement gained from colonic J-pouch coloanal anastomosis continues to benefit the patient with mid or low rectal cancer for at least 12 months. It is necessary to further study about the effect of colonic J-pouch coloanal anastomosis on physiological function of the anal canal and (neo) rectum.