Recent advances in the management of rectal cancer: No surgery, minimal surgery or minimally invasive surgery

Abstract

Over the last decade, with the acceptance of the need for improvements in the outcome of patients affected with rectal cancer, there has been a significant increase in the literature regarding treatment options available to patients affected by this disease. That treatment related decisions should be made at a high volume multidisciplinary tumor board, after pre-operative rectal magnetic resonance imaging and the importance of total mesorectal excision (TME) are accepted standard of care. More controversial is the emerging role for watchful waiting rather than radical surgery in complete pathologic responders, which may be appropriate in 20% of patients. Patients with early T1 rectal cancers and favorable pathologic features can be cured with local excision only, with transanal minimal invasive surgery (TAMIS) because of its versatility and almost universal availability of the necessary equipment and skillset in the average laparoscopic surgeon, emerging as the leading option. Recent trials have raised concerns about the oncologic outcomes of the standard “top-down” TME hence transanal TME (TaTME “bottom-up”) approach has gained popularity as an alternative. The challenges are many, with a dearth of evidence of the oncologic superiority in the long-term for any given option. However, this review highlights recent advances in the role of chemoradiation only for complete pathologic responders, TAMIS for highly selected early rectal cancer patients and TaTME as options to improve cure rates whilst maintaining quality of life in these patients, while we await the results of further definitive trials being currently conducted.

Stability of radiomic features of apparent diffusion coefficient (ADC) maps for locally advanced rectal cancer in response to image pre-processing

“…One common observer (author AT) delineated on both THUNDER and CLINIC cohorts. Observers (median experience, 4 years; range [1][2][3][4][5][6][7][8][9][10] were trained by a resident radiation oncologist to identify relevant normal and abnormal anatomical structures within the ADC maps. In addition, original CT scans with annotated lesions for all the patients were available to the observers, so that they could be guided in the delineations in the ADC maps.…”

“…Neo-adjuvant chemoradiotherapy (NACRT) followed by total mesorectal excision (TME) is the accepted standard of care for locally advanced rectal cancer (LARC) due to conclusive evidence of superior clinical outcome [1][2][3][4][5]. However, TME is a highly invasive procedure leading to bowel and bladder complications, and its added value for "good responders" is currently being debated [6,7].…”

Management of rectal cancer in Canada: an evidence-based comparison of clinical practice guidelines

“…1 The detection, staging and management of rectal cancer has evolved dramatically over the last 30 years, with improved surgical techniques, involvement of multidisciplinary cancer disease site groups, and the utilization of a multimodal approach to treatment. [2][3][4] During this time, there has been an improvement of outcomes in locoregional control and overall survival. 5,6 However, with the volume and pace of evidence being generated, there remains some uncertainty and controversy regarding several elements of care, including the optimal neoadjuvant protocol, use of local excision and utility of adjuvant systemic therapy.…”

Robotic transanal microsurgery for high early rectal neoplasia (T0-T1, N0 lesions), case series of 10 patients

“…Multiple studies have demonstrated that increased distance from the anal verge, anterior, and lateral rectal wall locations are associated with an increased risk for peritoneal violation during TEM and TaTME. 17,[19][20][21][22] In these retrospective reviews, peritoneal violation was not associated with increased risk for short-term or long-term complications, or increased rate of local recurrence. 20 One study, which looked at 28 cases with peritoneal perforation during TEM for T1 to T2 cancers and noted two occurrences of local recurrence, despite nonradical resection in 21% of cases.…”

“…However, due to the infancy of TAMIS, the literature on complication rates specific for robotic TAMIS is still very limited. Multiple studies have demonstrated that increased distance from the anal verge, anterior, and lateral rectal wall locations are associated with an increased risk for peritoneal violation during TEM and TaTME . In these retrospective reviews, peritoneal violation was not associated with increased risk for short‐term or long‐term complications, or increased rate of local recurrence .…”