Comparing robotic with laparoscopic beyond total mesorectal excision for advanced rectal cancer-a propensity-matched analysis.

AIM: Robotic surgery is increasingly being used for rectal resection, with short-term benefits such as reduced hospital stay, faster bowel recovery and fewer complications. However, its utility for advanced rectal cancers requiring beyond total mesorectal excision has not been adequately evaluated. The aim of this study was to compare robotic and laparoscopic approaches for extended rectal resection, with postoperative and short-term oncological outcomes as endpoints. METHOD: A retrospective, single-centre study of patients with advanced rectal cancer requiring extended rectal resection between January 2017 and December 2022 was carried out. Beyond total mesorectal excisions included pelvic exenteration, en bloc soft tissue or partial organ resection with the rectum, and lateral pelvic node dissection. Propensity score matching in a 4:1 ratio of laparoscopic to robotic was performed with age, sex, comorbidities, body mass index, organs involved, clinical T stage and colonoscopic obstruction. RESULTS: A total of 425 beyond total mesorectal excisions were performed by minimally invasive approaches during the study period, and after propensity matching 228 laparoscopic operations were compared with 57 robotic resections. All baseline characteristics were balanced. No difference in blood loss, postoperative complications, length of hospital stay, positive resection margin or nodal yield was found, but there was a somewhat longer operating duration in robotics. The 2-year disease-free and overall survival were also similar. CONCLUSIONS: No differences in postoperative or short-term oncological outcomes were found between robotic and laparoscopic beyond total mesorectal excisions for advanced tumours when performed by teams experienced in both robotics and laparoscopy.

Perineal wound complications after vertical rectus abdominis myocutaneous flap and mesh closure following abdominoperineal surgery and pelvic exenteration of anal and rectal cancers: A meta-analysis.

A meta-analysis research was implemented to appraise the perineal wound complications (PWCs) after vertical rectus abdominis myocutaneous (VRAM) flap and mesh closure (MC) following abdominoperineal surgery (AS) and pelvic exenteration (PE) of anal and rectal cancers. Inclusive literature research till April 2023 was done and 2008 interconnected researches were revised. Of the 20 picked researches, enclosed 2972 AS and PE of anal and rectal cancers persons were in the utilized researchers' starting point, 1216 of them were utilizing VRAM flap, and 1756 were primary closure (PC). Odds ratio (OR) and 95% confidence intervals (CIs) were utilized to appraise the consequence of VRAM flap in treating AS and PE of anal and rectal cancers by the dichotomous approach and a fixed or random model. VRAM flap had significantly lower PWCs (OR, 0.64; 95% CI, 0.42-0.98, p < 0.001), and major PWCs (OR, 0.50; 95% CI, 0.32-0.80, p = 0.004) compared to PC in AS and PE of anal and rectal cancers persons. However, VRAM flap and PC had no significant difference in minor PWCs (OR, 1; 95% CI, 0.54-1.85, p = 1.00) in AS and PE of anal and rectal cancer persons. VRAM flap had significantly lower PWCs, and major PWCs, however, no significant difference was found in minor PWCs compared to PC in AS and PE of anal and rectal cancers persons. However, caution needs to be taken when interacting with its values since there was a low sample size of most of the chosen research found for the comparisons in the meta-analysis.

The quality of lymph node harvests in extralevator abdominoperineal excisions.

BACKGROUND: Lymph node (LN) harvest in colorectal cancer resections is a well-recognised prognostic factor for disease staging and determining survival, particularly for node-negative (N0) diseases. Extralevator abdominoperineal excisions (ELAPE) aim to prevent "waisting" that occurs during conventional abdominoperineal resections (APR) for low rectal cancers, and reducing circumferential resection margin (CRM) infiltration rate. Our study investigates whether ELAPE may also improve the quality of LN harvests, addressing gaps in the literature. METHODS: This retrospective observational study reviewed 2 sets of 30 consecutive APRs before and after the adoption of ELAPE in our unit. The primary outcomes are the total LN counts and rates of meeting the standard of 12-minimum, particularly for those with node-negative disease. The secondary outcomes are the CRM involvement rates. Baseline characteristics including age, sex, laparoscopic or open surgery and the use of neoadjuvant chemoradiotherapy were accounted for in our analyses. RESULTS: Median LN counts were slightly higher in the ELAPE group (16.5 vs. 15). Specimens failing the minimum 12-LN requirements were almost significantly fewer in the ELAPE group (OR 0.456, P = 0.085). Among node-negative rectal cancers, significantly fewer resections failed the 12-LN standard in the ELAPE group than APR group (OR 0.211, P = 0.044). ELAPE led to a near-significant decrease in CRM involvement (OR 0.365, P = 0.088). These improvements were persistently observed after taking into account baselines and potential confounders in regression analyses. CONCLUSION: ELAPE provides higher quality of LN harvests that meet the 12-minimal requirements than conventional APR, particularly in node-negative rectal cancers. The superiority is independent of potential confounding factors, and may implicate better clinical outcomes.

Over-Expression of CHD4 Is an Independent Biomarker of Poor Prognosis in Patients with Rectal Cancers Receiving Concurrent Chemoradiotherapy.

Neoadjuvant concurrent chemoradiotherapy (CCRT), followed by radical proctectomy, is the standard treatment for locally advanced rectal cancer. However, a poor response and therapeutic resistance continue to occur despite this treatment. In this study, we analyzed the microarray datasets (GSE68204) of rectal cancer from the Gene Expression Omnibus database, and identified CHD4 as one of the most significantly up-regulated genes among all subunits of the nucleosome remodeling and histone deacetylation (NuRD) complex, in non-responders to CCRT, among locally advanced rectal cancer (LARC) patients. We confirmed the predictive and prognostic significance of CHD4 expression in CCRT treatment, and its correlation with other clinicopathological features, such as tumor regression grade (TRG), therapeutic response, and patient survival. This was carried out by immunohistochemical studies on endoscopic biopsy tissues from 172 rectal cancer patients, receiving neoadjuvant concurrent chemoradiotherapy (CCRT). A high expression of CHD4 was significantly associated with pre-treatment tumor status (p < 0.001) and lymph node metastasis (p < 0.001), post-treatment tumor status (p < 0.001), and lymph node metastasis (p < 0.001), vascular invasion (p = 0.042), and tumor regression grade (p = 0.001). A high expression of CHD4 could also predict poor disease-specific survival and metastasis-free survival (log-rank test, p = 0.0373 and p < 0.0001, respectively). In multivariate Cox proportional-hazards regression analysis, CHD4 overexpression was an independent factor of poor prognosis for metastasis-free survival (HR, 4.575; 95% CI, 1.717-12.192; p = 0.002). By in vitro studies, based on cell line models, we also demonstrated that, the overexpression of CHD4 induced radio-resistance in microsatellite instability-high (MSI-H) colorectal cells (CRCs). On the contrary, the knockdown of CHD4 enhanced radiosensitivity in microsatellite stable (MSS) CRCs. Altogether, we have identified CHD4 as an important regulator of radio-resistance in both MSI-H and MSS CRC cell lines.

Comparative proteogenomic analysis of right-sided colon cancer, left-sided colon cancer and rectal cancer reveals distinct mutational profiles.

Right-sided colon cancer (RCC) has worse prognosis compared to left-sided colon cancer (LCC) and rectal cancer. The reason for this difference in outcomes is not well understood. We performed comparative somatic and proteomic analyses of RCC, LCC and rectal cancers to understand the unique molecular features of each tumor sub-types. Utilizing a novel in silico clonal evolution algorithm, we identified common tumor-initiating events involving APC, KRAS and TP53 genes in RCC, LCC and rectal cancers. However, the individual role-played by each event, their order in tumor development and selection of downstream somatic alterations were distinct in all three anatomical locations. Some similarities were noted between LCC and rectal cancer. Hotspot mutation analysis identified a nonsense mutation, APC R1450* specific to RCC. In addition, we discovered new significantly mutated genes at each tumor location, Further in silico proteomic analysis, developed by our group, found distinct central or hub proteins with unique interactomes among each location. Our study revealed significant differences between RCC, LCC and rectal cancers not only at somatic but also at proteomic level that may have therapeutic relevance in these highly complex and heterogeneous tumors.

Fecal Volume after Laparoscopic Low Anterior Resection Predicts Anastomotic Leakage.

BACKGROUND/AIM: Anastomotic leakage (AL) is a major complication after laparoscopic low anterior resection (Lap-LAR). Many surgeons encounter AL following severe postoperative diarrhea. However, little is known about the relationship between postoperative fecal volume and AL. This study determined whether postoperative fecal volume can predict AL. METHODS: A retrospective assessment was performed with data from 176 patients with rectal cancers who underwent Lap-LAR between April 2011 and August 2015. A transanal tube was routinely placed in all cases. The fecal volume from the transanal tube was measured daily. The total fecal volume for 3 days after surgery was compared between the AL and non-AL groups. RESULTS: AL occurred in 11 patients. There were 3 patients with a fecal volume ≥1,000 mL for 3 days after surgery. AL occurred in these 3 patients. In patients with a fecal volume <1,000 mL, the total fecal volume was significantly greater in the AL group than that in the non-AL group (p = 0.0003). The cut-off value of the total fecal volume in AL was 118 mL. CONCLUSIONS: The volume of fecal discharge for 3 days after surgery is associated with the incidence of AL, and a fecal volume ≥118 mL may be a reliable predictor for AL.

Necessary circumferential resection margins to prevent rectal cancer relapse after abdomino-peranal (intersphincteric) resection.

PURPOSE: The purpose of this study was to determine the adequate circumferential resection margin (CRM) for abdomino-peranal (intersphincteric) resection (ISR) that would prevent the relapse of rectal cancers. METHODS: The records of 41 cases that underwent curative ISR for rectal cancer were retrospectively reviewed. The relapse-free survival rates and overall survival rates were evaluated and correlated with the maximum depth of the inner muscularis layer reached during ISR (i.e., the radial margin [RM] and distal margin [DM]). Cases were divided into three groups based on the sizes of the RM and DM: (1) group A (RM >2 mm and DM >1.5 cm), (2) group B (RM >2 mm or DM >1.5 cm but not both), and (3) group C (RM <2 mm and DM <1.5 cm). RESULTS: The relapse-free survival rates of the cases in group C were lower than those in the cases of group A or group B (p = 0.002 and 0.037, respectively). The resection margins required to prevent rectal cancer relapse were >2 mm for the RM and >1.5 cm for the DM. For these margins, the intersphincteric space had to be entered (i.e., between the internal and external anal sphincters). CONCLUSION: It is critical to enter the intersphincteric space to ensure an adequate CRM (RM >2 mm and DM >1.5 cm) for preventing rectal cancer recurrence after ISR.

Influence of the contrast agents on treatment planning dose calculations of prostate and rectal cancers.

AIM: The aim of the present study is to quantify differences in dose calculations caused by using CA and determine if the resulting differences are clinically significant. BACKGROUND: The influence of contrast agents (CA) on radiation dose calculations must be taken into account in treatment planning. MATERIALS AND METHODS: Eleven patients with pelvic cancers were included in this study and two sets of CTs were taken for each patient (without and with CA) in the same position and coordinates. Both sets of images were transferred to the DosiSoft ISOgray treatment planning system for contouring and calculating the dose distribution and monitor units (MUs) with Collapsed Cone and Superposition algorithms, respectively. All plans were generated on pre-contrast CT and subsequently copied to the post-contrast CT. Radiation dose calculations from the two sets of CTs were compared using a paired sample t-test. RESULTS: The results showed a statistically insignificant difference between pre- and post-contrast CT treatment plans for target volume and OARs (p > 0.05), except bladder organ in the prostate region (p < 0.05) but the relative mean dose and MU differences were less than 2% in any patient for 18 MV photon beam. CONCLUSIONS: Treatment planning on contrasted images generally showed a lower radiation dose to both target volume and OARs than plans on non-contrasted images. The results of this research showed that the small radiation dose differences between the plans for the CT scans with and without CA seem to be clinically insignificant; therefore, contrast-enhanced CT can be used for both target delineation and treatment planning of prostate and rectal cancers.

Concurrent rectal perforation and obstruction following neoadjuvant chemoradiation for locally advanced rectal cancer: A case report.

INTRODUCTION: Locally advanced rectal cancer (LARC) is commonly managed with neoadjuvant chemoradiation (neoCRT) followed by surgery, though not without complications. The anatomical exposure of the colon and rectum and pelvic radiotherapy poses risk, with rectal perforation and bowel obstruction, though rare, carrying life-threatening potential. PRESENTATION OF CASE: This case highlights an exceptionally rare occurrence of concurrent rectal perforation and rectal obstruction in a 77-year-old male with LARC, just two months post neoCRT. Initial symptoms included rectal bleeding, and diagnostic procedures confirmed rectal T1N3adenocarcinoma with no metastasis. Emergency admission, prompted by complete bowel obstruction symptoms, led to discovery of rectal perforation during laparotomy, sealed by the bladder. Pathological analysis attributed the cause to radiation proctitis, reporting complete response to neoCRT with no residual tumor. DISCUSSION: The rarity of both bowel obstruction and perforation as neoCRT complications, particularly in the acute phase of radiation proctitis, is noteworthy in this case. The absence of tumoral cells at the affected sites emphasizes the exceptional nature of this case. CONCLUSION: This case underscores the importance of recognizing acute post neoCRT injuries as potentially life-threatening complications, emphasizing the need for heightened awareness and consideration in clinical management.

Prospective evaluation of dose-escalated preoperative concurrent chemo-radiation with image guided-IMRT in locally advanced rectal cancers.

Purpose: To analyse the safety and efficacy of neoadjuvant chemoradiation (NACRT) with dose-escalated image-guided intensity modulated radiation therapy (IG-IMRT) in locally advanced (T3/4; T1-4N1-2) rectal cancers (LARCs). Materials and methods: Twenty patients with the diagnosis of LARC were recruited in this prospective interventional single-arm study treated by IG-IMRT with 45 Gray (Gy) in 25 fractions to elective nodal volumes and 55 Gy in 25 fractions to the gross primary and nodal disease with concurrent capecitabine 825 mg/m2 twice daily on radiotherapy days. Patients underwent total mesorectal excision 6-8 weeks post completion of NACRT followed by adjuvant chemotherapy (Capecitabine and oxaliplatin every 3 weekly for 6-8 cycles). Primary end point was acute toxicity assessment and secondary end points were pathological complete response (pCR) and loco-regional control (LRC). Results: Clinical T stage was T3:T4 in 19:1 and clinical N0:N1: N2 in 2:7:11 patients, respectively. With a median follow up of 21.2 months (13.8-25.6 months), 18 of 20 (90%) patients received the full course of treatment. Tumour and nodal downstaging was achieved in 78% and 84% of patients, respectively. pCR and overall complete response (defined as pCR and near CR) was achieved in 22.2% and 44.4% of patients, respectively. 2 (10%) patients completed NACRT, and achieved complete clinical response but refused surgery. Adjuvant chemotherapy course was completed by 17/18 (94.5%) patients. Grade 3 toxicities were observed in 2 (10%) patients during NACRT. All patients were disease-free at the time of the last follow up. Conclusion: Dose-escalation of NACRT therapy with IG-IMRT in LARC patients offers decent rates of pCR and overall response with excellent LRC and acceptable toxicities.

Immunophenotypic profiles and prognosis for colorectal mucinous adenocarcinomas are dependent on anatomic location.

BACKGROUND: The prognostic value of mucinous adenocarcinomas (MCAs, exhibiting >50% extracellular mucin) of the colorectum, in relation to their anatomic location is not well studied. MATERIALS AND METHODS: We compared MCAs (n = 175) with non-MCAs (NMCAs, n = 1015) and the cancer-specific survival rates were evaluated, based on their anatomic site, by univariate Kaplan-Meier and multivariate Cox methods. Subsets of these tumors were immunostained for MUC1, MUC2, Bcl-2, and p53. RESULTS: MCAs were more commonly found in the right colon, were of high-grade, and were more prevalent in younger patients (<40 years). They exhibited strong expression of MUC2 and Bcl-2 and showed less p53 nuclear staining. In contrast, most NMCAs were low-grade with high expression of MUC1. MCAs of the rectum were associated with poorer outcomes relative to NMCAs (HR 1.85, CI 95% 1.15-2.97), even though the distributions of advanced-stage tumors were similar. CONCLUSION: Late-stage disease and age were poor independent prognostic indicators of cancer-specific deaths across all tumor locations. In summary, rectal MCAs have a poor prognosis.

Impact of consolidation chemotherapy in poor responders to neoadjuvant radiation therapy: magnetic resonance imaging-based clinical-radiological correlation in high-risk rectal cancers.

PURPOSE: The current study was conducted to examine the role of consolidation chemotherapy after neoadjuvant radiation therapy (NART) in decreasing the involvement of the mesorectal fascia (MRF) in high-risk locally advanced rectal cancers (LARCs). METHODS: In total, 46 patients who received consolidation chemotherapy after NART due to persistent MRF involvement were identified from a database. A team of 2 radiologists, blinded to the clinical data, studied sequential magnetic resonance imaging (MRI) scans to assess the tumor response and then predict a surgical plan. This prediction was then correlated with the actual procedure conducted as well as histopathological details to assess the impact of consolidation chemotherapy. RESULTS: The comparison of MRI-based parameters of sequential images showed significant downstaging of T2 signal intensity, tumor height, MRF involvement, diffusion restriction, and N category between sequential MRIs (P < 0.05). However, clinically relevant downstaging (standardized mean difference, > 0.3) was observed for only T2 signal intensity and diffusion restriction on diffusion-weighted imaging. No clinically relevant changes occurred in the remaining parameters; thus, no change was noted in the extent of surgery predicted by MRI. Weak agreement (Cohen κ coefficient, 0.375) and correlation (Spearman rank coefficient, 0.231) were found between MRI-predicted surgery and the actual procedure performed. The comparison of MRI-based and pathological tumor response grading also showed a poor correlation. CONCLUSION: Evidence is lacking regarding the use of consolidation chemotherapy in reducing MRF involvement in LARCs. The benefit of additional chemotherapy after NART in decreasing the extent of planned surgery by reducing margin involvement requires prospective research.

MRI Evaluation of Complete and Near-Complete Response after Neoadjuvant Therapy in Patients with Locally Advanced Rectal Cancer.

Purpose To evaluate MRI performance in restaging locally advanced rectal cancers (LARC) after neoadjuvant chemoradiotherapy (nCRT) and interobserver agreement in identifying complete response (CR) and near-complete response (nCR). Methods 40 patients with CR and nCR on restaging MRI, surgery and/or endoscopy were enrolled. Two radiologists independently scored the restaging MRI and reported the presence of split scar sign (SSS) and MRI tumor regression grade (mrTRG). Diagnostic accuracy and ROC curves were calculated for single and combined sequences, with inter-reader agreement. Results Diagnostic performance was good for detecting CR and weaker for nCR. T2WI had the highest AUCs among individual sequences. There was a significant positive correlation between SSS and CR, with high Sp (89.5%/73.7%) and PPV (90%/79.2%) for both Readers. Similar accuracy rates were observed for the combination of sequences, with AUCs of 0.828-0.847 for CR and 0.690-0.762 for nCR. Interobserver agreement was strong for SSS, moderate for T2WI, weak for the combination of sequences. Conclusions Restaging MRI had good diagnostic performance in identifying CR and nCR. SSS had high Sp and PPV in diagnosing CR, with a strong level of interobserver agreement. T2WI with DWI was the optimal combination of sequences for selecting good responders.

Baseline MR Staging of Rectal Cancer: A Practical Approach.

As therapeutic options to treat rectal cancers have advanced over the last several decades, MRI has become the standard of care for baseline local tumor and nodal staging of rectal cancers. An understanding of the technique, anatomy, tumor appearance, and elements of staging on MRI is essential to provide prognostic information and to guide neoadjuvant chemoradiation and surgical treatment. We provide a framework for imaging the rectum on MRI followed by a practical case-based approach to interpretation of pre-treatment MRI of the rectum in evaluation of rectal cancers, with examples and illustrations of the range of local tumor (T) stage and nodal (N) disease involvement. This approach can be paired with standardized reporting templates to support clear, accurate and clinically relevant imaging assessment of rectal cancers.

BMI1-KLF4 axis deficiency improves responses to neoadjuvant concurrent chemoradiotherapy in patients with rectal cancer.

PURPOSE: Neoadjuvant concurrent chemoradiotherapy (CCRT) is a gold standard treatment for patients with stage II/III rectal cancer. B-cell-specific Moloney murine leukemia virus insertion site 1 (BMI1) is a member of the polycomb group of proteins that are involved in regulating gene expression. High levels of BMI1 have been demonstrated to contribute to the malignant phenotypes of several cancers; however, its relevance in rectal cancer treated with CCRT is largely unknown. METHODS AND MATERIALS: We used two patient cohorts to address the clinical relevance of BMI1 in human cancers. In addition, HT-29 and HCT-116 cells were chosen as our in vitro models to verify the role of BMI1 in cell response to ionizing radiation. Stemness-related proteins were analyzed by western blotting and cell survival was determined using clonogenic assays. RESULTS: BMI1 overexpression was found to significantly correlate with advanced pre-treatment nodal status (N1-N2; p < 0.001), post-treatment tumor stage (T1-T2; p = 0.015), inferior tumor regression grade (p = 0.001), and also an independent prognosis factor in 172 rectal cancer patients receiving CCRT. Serial cell-based functional examination indicated that BMI1 deficiency sensitized cells to radiation treatment by modulating the gene expression of Kruppel-like factor 4 (KLF4) and enhanced radiosensitivity in microsatellite stable (MSS) colorectal cancers. Overexpression of KLF4 partially overcame BMI1-deficiency-mediated γ-H2AX expression after ionizing radiation exposure. Consistent with in vitro data, an analysis of an additional 30 rectal cancer tissue specimens revealed a positive correlation between BMI1 and KLF4 (p = 0.02). CONCLUSION: Higher levels of BMI1 are associated with poor therapeutic response and adverse outcomes in rectal cancer patients receiving CCRT.

Biomarker Discovery for the Carcinogenic Heterogeneity Between Colon and Rectal Cancers Based on lncRNA-Associated ceRNA Network Analysis.

BACKGROUND: Colorectal cancer (CRC) is one of the leading causes of cancer death worldwide. Emerging evidence has revealed that risk factors and metastatic patterns differ greatly between colon and rectal cancers. However, the molecular mechanism underlying their pathogenic differences remains unclear. Therefore, we here aimed to identify non-coding RNA biomarkers based on lncRNA-associated ceRNA network (LceNET) to elucidate the carcinogenic heterogeneity between colon and rectal cancers. METHODS: A global LceNET in human was constructed by employing experimental evidence-based miRNA-mRNA and miRNA-lncRNA interactions. Then, four context-specific ceRNA networks related to cancer initiation and metastasis were extracted by mapping differentially expressed lncRNAs, miRNAs and mRNAs to the global LceNET. Notably, a novel network-based bioinformatics model was proposed and applied to identify lncRNA/miRNA biomarkers and critical ceRNA triplets for understanding the carcinogenic heterogeneity between colon and rectal cancers. Moreover, the identified biomarkers were further validated by their diagnostic/prognostic performance, expression pattern and correlation analysis. RESULTS: Based on network modeling, lncRNA KCNQ1OT1 (AUC>0.85) and SNHG1 (AUC>0.94) were unveiled as common diagnostic biomarkers for the initiation and metastasis of colon and rectal cancers. qRT-PCR analysis uncovered that these lncRNAs had significantly higher expression level in CRC cell lines with high metastatic potential. In particular, KCNQ1OT1 and SNHG1 function in colon and rectal cancers via different ceRNA mechanisms. For example, KCNQ1OT1/miR-484/ANKRD36 axis was involved in the initiation of colon cancer, while KCNQ1OT1/miR-181a-5p/PCGF2 axis was implicated in the metastasis of rectal cancer; the SNHG1/miR-484/ORC6 axis played a role in colon cancer, while SNHG1/miR-423-5p/EZH2 and SNHG1/let-7b-5p/ATP6V1F axes participated in the initiation and metastasis of rectal cancer, respectively. In these ceRNA triplets, miR-484, miR-181a-5p, miR-423-5p and let-7b-5p were identified as miRNA biomarkers with excellent distinguishing ability between normal and tumor tissues, and ANKRD36, PCGF2, EZH2 and ATP6V1F were closely related to the prognosis of corresponding cancer. CONCLUSION: The landscape of lncRNA-associated ceRNA network not only facilitates the exploration of non-coding RNA biomarkers, but also provides deep insights into the oncogenetic heterogeneity between colon and rectal cancers, thereby contributing to the optimization of diagnostic and therapeutic strategies of CRC.

Outcomes of Definitive Treatment of Signet Ring Cell Carcinoma of the Rectum: Is Minimal Invasive Surgery Detrimental in Signet Ring Rectal Cancers?

The outcome of surgery for signet ring adenocarcinoma of rectum is suboptimal with high predilection for locoregional and peritoneal metastases. Lack of intercellular adhesion due to focal loss of epithelial cell adhesion molecule (EpCAM) may account for this. In such patients, whether minimal invasive surgery carries a high risk of dissemination by pneumoperitoneum and tumor implantation remains uncertain. The aim of this study was to compare the outcomes of patients undergoing minimally invasive surgery (MIS) versus open surgery in patients with signet ring cell adenocarcinoma of rectum. A retrospective study was conducted at a tertiary care center over 3 years on 39 patients undergoing open surgery and 40 patients undergoing MIS diagnosed with signet ring cell carcinoma (SRCC) identified from our surgical database. Patient characteristics in terms of demographics, clinicoradiological staging, neoadjuvant therapy, and type of surgery with morbidity were compared in the two groups. Data on patients undergoing adjuvant therapy and 3 years disease-free survival (DFS) and overall survival (OS) were analyzed. Recurrence patterns in both groups were separately identified as locoregional, peritoneal, or systemic. The number of patients undergoing surgery in the two arms was 40 (MIS) and 39 (open). In the MIS arm, mean DFS was 29 months whereas in the open arm, it was 25.8 months. The mean OS was 33.65 months for the MIS arm and that for the open arm was 36.34 months. This retrospective study reveals no significant difference in outcomes of surgery for signet ring cell rectal cancers with either MIS or open approach.

Synchronous primary carcinomas of the prostate, thyroid and rectum: case report and review of the literature.

We report a case of rectal cancer with an initial symptom of rectal bleeding. The clinical, morphological, immunohistochemical, and imaging findings supported a diagnosis of synchronous primary carcinoma of the prostate, rectal adenocarcinoma, and papillary thyroid tumor. The patient, whose poor cardiac function contraindicated surgery, underwent long-course chemoradiotherapy and hormonal therapy. The patient is currently asymptomatic, with stable disease and an improved quality of life. To our knowledge, synchronous primary carcinomas of the prostate, thyroid, and rectum are extremely rare in the literature. There are few published reports addressing parallel treatment and outcomes when such a synchronous diagnosis is made; we share here our experience in formulating a treatment plan.

Systemic chemotherapy and short-course radiation in metastatic rectal cancers: A feasible paradigm in unresectable and potentially resectable cancers.

BACKGROUND: The optimal use and sequencing of short-course radiotherapy (SCRT) in metastatic rectal cancers (mRCs) are not well established. MATERIALS AND METHODS: We retrospectively reviewed the records of mRC patients receiving SCRT followed by palliative chemotherapy between January 1, 2013, and December 31, 2016, in Tata Memorial Hospital. Patients were classified as having "potentially resectable" disease (local and metastatic) or "unresectable" disease at baseline based on prespecified criteria. RESULTS: A total of 105 consecutive patients were available for analysis. The median age of patients was 48 years (range: 16-62 years), and 57.1% were male patients. Signet ring histology was seen in 13.3% of patients. The most common site of metastases was liver limited (29.5%), nonloco-regional nodes (12.4%), and lung limited metastases (9.5%). Chemotherapeutic regimens administered were capecitabine-oxaliplatin (70.5%), modified 5 fluorouracil (5 FU)-leucovorin-irinotecan-oxaliplatin (10.5%), and modified 5 FU-leucovorin-irinotecan (8.6%). Targeted therapy accompanying chemotherapy was administered in 27.6% of patients. About 42.1% of patients with potentially resectable disease and 11.1% with the unresectable disease at baseline underwent curative-intent resection of the primary and address of metastatic sites. With a median follow-up 18.2 months, median overall survival (OS) was 15.7 months (95% confidence interval: 10.42-20.99). Patients classified as potentially resectable had a median OS of 32.62 months while patients initially classified as unresectable had a median OS of 13.04 months (P = 0.016). The presence of signet ring morphology predicted for inferior mOS (P = 0.021). CONCLUSIONS: SCRT followed by systemic therapy in mRC is a feasible, efficacious paradigm for maximizing palliation, and achieving objective responses. The classification of patients based on resectability was predictive of actual resection rates as well as outcomes. Signet ring mRC show inferior outcomes in this cohort of patients.

Assessment of bowel and anal sphincter function after neoadjuvant chemoradiotherapy in locally advanced rectal cancer.

PURPOSE: To report long-term effects on anorectal function and bowel disorders and late toxicity rate of preoperative chemoradiotherapy in patients with locally advanced rectal cancer. METHODS: Between 2000 and 2016, 201 patients treated with different neoadjuvant schedules of chemotherapy and radiotherapy doses were retrospectively analyzed. The Memorial Sloan-Kettering Cancer Center score was used for the evaluation of anal sphincter function. RESULTS: The median follow-up time was 68 months (interquartile range 35-113 months). Radical resection was performed in 188 (93.5%) patients with a pathologic complete response rate of 26.4%. Overall sphincter function resulted excellent in 105 (52.2%) patients, good in 13 (6.5%), fair in 10 (5.0%), and poor (incontinence) in 40 (19.9%), with a persistent stoma rate of 16.4%. A further evaluation on 194 patients showed an improvement of sphincter function after 2 years in 11.9% of them. Seventy-three patients presenting stoma or poor sphincter function were re-evaluated for quality of life (QoL) indexes. Twenty-one (29%), 19 (26%), and 24 (33%) of them declared some variations concerning well-being, fatigue, and ability to perform daily activities. The 5-year overall survival, disease-free survival, and local recurrence rates were 88.0% ± 2.6%, 86.3% ± 2.5%, and 94.6% ± 1.9%, respectively. CONCLUSIONS: In our study, neoadjuvant chemoradiotherapy was associated with good results in terms of sphincter function, late toxicities, and QoL indexes. A routine use of assessment scales could contribute to a better selection of patients with increased risk of developing functional disorders who could benefit from neoadjuvant therapy.