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PURPOSE: The aim of this work was to determine whether locally advanced rectal cancer (LARC) with negative mesorectal fascia (MRF) predicted by magnetic resonance imaging (MRI) can be excluded from preoperative radiation therapy treatment. METHODS AND MATERIALS: This multicenter, open-label, non-inferiority, randomized clinical trial enrolled patients with LARC within 6 to 12 cm from the anal verge and with negative MRI-predicted MRF. Participants were randomized to the intervention group (primary surgery, in which the patients with positive pathologic [CRM] circumferential margins were subjected to chemoradiotherapy [CRT] and those with negative CRM underwent adjuvant chemotherapy according to pathologic staging) or the control group (preoperative CRT, in which all patients underwent subsequent surgery and adjuvant chemotherapy). The primary endpoint was 3-year disease-free survival (DFS). RESULTS: A total of 275 patients were randomly assigned to the intervention (n = 140) and control (n = 135) groups, in which 33.57% and 28.15% patients were at clinical T4 stage and 85.92% and 80.45% patients were at "bad" or "ugly" risk in the intervention and control groups, respectively. There were 2 patients (1.52%) and 1 patient (0.77%) with positive CRM in the intervention and control groups, respectively (P > .05). The non-adherence rates for the intervention and control groups were 3.6% and 23.7%, respectively. After a median follow-up of 34.6 months (IQR, 18.2-45.7), 43 patients had positive events (28 patients and 15 patients in the intervention and control groups, respectively). There were 6 patients (4.4%) with local recurrence in the intervention group and none in the control group, which led to the termination of the trial. The 3-year DFS rate was 81.82% in the intervention group (95% CI, 78.18%-85.46%) and 85.37% in the control group (95% CI, 81.75%-88.99%), with a difference of -3.55% (95% CI, -3.71% to -3.39%; hazard ratio, 1.76; 95% CI, 0.94-3.30). In the per-protocol data set, the difference between 3-year DFS rates was -5.44% (95% CI, -5.63% to -5.25%; hazard ratio, 2.02; 95% CI, 1.01-4.06). CONCLUSIONS: Based on the outcomes of this trial, in patients with LARC and MRI-negative MRF, primary surgery could negatively influence their DFS rates. Therefore, primary surgery was an inferior strategy compared with preoperative CRT followed by surgery and cannot be recommended for patients with LARC.
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OBJECTIVE: To explore the application value of multi-slice spiral CT angiography (MSCTA) for the preoperative evaluation of laparoscopic right hemicolectomy. METHODS: Abdominal CT slice images of 160 patients(group A) were collected for 3-dimensional reconstruction using volume rendering technique. Interpretation and anatomical classification of the major branches and course of the superior mesenteric artery(SMA) in the reconstructed images of the arterial phase were carried out. Forty-five patients(group B) undergoing laparoscopic right hemicolectomy were evaluated with MSCT combining images obtained from the arterial phase and portal venous phase. The relationship between ileocolic artery and ileocolic vein was analyzed. The preoperative imaging findings were compared to that revealed during the procedure. RESULTS: In group A, 70(43.8%) out of 160 patents showed anatomical variations of the superior mesenteric artery, of whom 51(31.9%) had two right colic arteries, and 14(8.8%) had two middle colic arteries. Preoperative MSCTA showed that in group B ileocolic artery was running ventrally to ileocolic vein in 13(28.9%) out of 45 patients, while running dorsally in 32(71.1%). Compared to the skeletonized vessels during the procedure, the consistency rate was 100%. CONCLUSION: Anatomical variations of superior mesenteric artery are common, therefore, multi-slice spiral CT scan is vital for preoperation evaluation.