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The Society of Abdominal Radiology’s Colorectal and Anal Cancer Disease-Focused Panel (DFP) first published a rectal cancer lexicon paper in 2019. Since that time, the DFP has published revised initial staging and restaging reporting templates, and a new SAR user guide to accompany the rectal MRI synoptic report (primary staging). This lexicon update summarizes interval developments, while conforming to the original lexicon 2019 format. Emphasis is placed on primary staging, treatment response, anatomic terminology, nodal staging, and the utility of specific sequences in the MRI protocol. A discussion of primary tumor staging reviews updates on tumor morphology and its clinical significance, T1 and T3 subclassifications and their clinical implications, T4a and T4b imaging findings/definitions, terminology updates on the use of MRF over CRM, and the conundrum of the external sphincter. A parallel section on treatment response reviews the clinical significance of near-complete response and introduces the lexicon of “regrowth” versus “recurrence”. A review of relevant anatomy incorporates updated definitions and expert consensus of anatomic landmarks, including the NCCN’s new definition of rectal upper margin and sigmoid take-off. A detailed review of nodal staging is also included, with attention to tumor location relative to the dentate line and locoregional lymph node designation, a new suggested size threshold for lateral lymph nodes and their indications for use, and imaging criteria used to differentiate tumor deposits from lymph nodes. Finally, new treatment terminologies such as organ preservation, TNT, TAMIS and watch-and-wait management are introduced. This 2023 version aims to serve as a concise set of up-to-date recommendations for radiologists, and discusses terminology, classification systems, MRI and clinical staging, and the evolving concepts in diagnosis and treatment of rectal cancer.

Pelvic exenteration is a complex operation performed for locally advanced and recurrent pelvic cancers. The goal of surgery is to achieve clear margins, therefore identifying adjacent or involved organs, bone, muscle, nerves and/or vascular structures that may need resection. While these extensive resections are potentially curative, they can be associated with substantial morbidity. Recently, there has been a move to centralize care to specialized units, as this facilitates better multidisciplinary care input. Advancements in pelvic oncology and surgical innovation have redefined the boundaries of pelvic exenterative surgery. Combined with improved neoadjuvant therapies, advances in diagnostics, and better reconstructive techniques have provided quicker recovery and better quality of life outcomes, with improved survival This article provides highlights of the current management of advanced pelvic cancers in terms of surgical strategy and potential future developments.

To compare the urinary and sexual outcomes between robot-assisted rectal cancer (RC) surgery (RRCS) and laparoscopic RC surgery (LRCS) using a meta-analysis, searches were conducted of the Embase, PubMed, Cochrane Library, CNKI, and Wanfang databases. The International Prostate Symptom Score (IPSS) was the primary outcome. Eleven studies (790 patients with RRCS and 888 with LRCS) were included. The IPSS scores were significantly lower for RRCS than LRCS from baseline to 3 months (weighted mean difference [WMD] =  − 1.21, 95% confidence interval [CI]: − 1.8,-0.62, I 2  = 89.9%), to 6 months (WMD =  − 1.13, 95% CI: − 1.74, − 0.52, I 2  = 93.3%), and to 12 months (WMD =  − 0.93, 95% CI: − 1.59, − 0.26, I 2  = 93.8%). The International Index of Erectile Function (IIEF) scores were significantly higher for RRCS than LRCS from baseline to 3 months (WMD = 3.36, 95% CI: 1.28, 5.44, I 2  = 92.7%). The female sexual function index (FSFI) scores were significantly higher for RRCS than LRCS from baseline to 3 months (WMD = 1.31, 95% CI: 0.87, 1.76, I 2  = 0), to 6 months (WMD = 2.36, 95% CI: 1.93, 2.79, I 2  = 24.3%), and to 12 months (WMD = 1.67, 95% CI: 0.41, 2.93, I 2  = 90.9%). RRCS also achieved a better recovery of the urological and sexual function than LRCS for patients with RC. Larger-scale prospective randomized control trials are needed to verify these results.

Background Impact of rectal tumour location on risk of lymph node metastases (LNM) and recurrence in early RC is poorly studied and elusive. Tumour location as a prognostic factor may contribute to optimise management of early RC in the future. The aim of this study was to investigate rectal tumour location as an independent predictor of oncologic outcome in early rectal cancer (RC). Methods Retrospective multicentre national cohort study on prospectively collected data on all patients with T1-T2 RC, undergoing surgical resection between 2009 and 2021. Tumour location was categorised as distal (0–5 cm), mid (5–10 cm), and proximal (10–16 cm), measured from the anal verge. Results Incidence of LNM in the 2424 included T1–T2 RC patients was 18.2%, 17.3% and 21.6% for distal, mid and proximal tumours, respectively. Recurrence was detected in 130 (7.6%) out of 1705 patients available for recurrence analyses (60-month median follow-up). Incidence of recurrence was twice as high in distal (11.4%) compared to proximal (5.6%) tumours and was 8.3% in mid located tumours. Distal (HR 2.051, CI 1.248–3.371, P  < 0.05) and mid (HR 1.592, CI 1.061–2.388, P  < 0.05) tumour location were significant risk factors of recurrence in uni- and multivariate Cox regression analyses. Conclusions This study shows that tumour location significantly affects incidence of recurrence in early RC, with an increasing risk for mid and especially distal location, found to be a predominant risk factor of recurrence. Our findings stress the need for an increased awareness on differences in oncologic outcome related to tumour location in early RC.

The therapeutic landscape in locally advanced rectal cancer (LARC) has undergone a significant paradigm shift in recent years with the rising adoption of total neoadjuvant treatment (TNT). This comprehensive approach entails administering chemotherapy and radiation therapy before surgery, followed by optional adjuvant chemotherapy. To establish and deliver the optimal tailored treatment regimen to the patient, it is crucial to foster collaboration among a multidisciplinary team comprising healthcare professionals from various specialties, including medical oncology, radiation oncology, surgical oncology, radiology, and pathology. This review aims to provide insights into the current state of TNT for LARC and new emerging strategies to identify potential directions for future research and clinical practice, such as circulating tumor-DNA, immunotherapy in mismatch-repair-deficient tumors, and nonoperative management.

PurposeTo establish and validate two predictive radiomics models for preoperative prediction of lymph node metastases (LNMs) and tumor deposits (TDs) respectively in rectal cancer (RC) patients.MethodsA total of 139 RC patients (98 in the training cohort and 41 in the validation cohort) were enrolled in the present study. High-resolution magnetic resonance images (HRMRI) were retrieved for tumor segmentation and feature extraction. HRMRI findings of RC were assessed by three experienced radiologists. Two radiomics nomograms were established by integrating the clinical risk factors, HRMRI findings and radiomics signature.ResultsThe predictive nomogram of LNMs showed good predictive performance (area under the curve [AUC], 0.90; 95% confidence interval [CI] 0.83–0.96) which was better than clinico-radiological (AUC, 0.83; 95% CI 0.74–0.93; Delong test, p = 0.017) or radiomics signature-only model (AUC, 0.77; 95% CI 0.67–0.86; Delong test, p = 0.003) in training cohort. Application of the nomogram in the validation cohort still exhibited good performance (AUC, 0.87; 95% CI 0.76–0.98). The accuracy, sensitivity and specificity of the combined model in predicting LNMs was 0.86,0.79 and 0.91 in training cohort and 0.83,0.85 and 0.82 in validation cohort. As for TDs, the predictive efficacy of the nomogram (AUC, 0.82; 95% CI 0.71–0.93) was not significantly higher than radiomics signature-only model (AUC, 0.80; 95% CI 0.69–0.92; Delong test, p = 0.71). Radiomics signature-only model was adopted to predict TDs with accuracy=0.76, sensitivity=0.72 and specificity=0.94 in training cohort and 0.68, 0.62 and 0.97 in validation cohort.ConclusionHRMRI-based radiomics models could be helpful for the prediction of LNMs and TDs preoperatively in RC patients.

The response to neoadjuvant chemoradiation (nCRT) is a critical step in the management of locally advanced rectal cancer (LARC) patients. Only a minority of LARC patients responds completely to neoadjuvant treatments, thus avoiding invasive radical surgical resection. Moreover, toxic side effects can adversely affect patients’ survival. The difficulty in separating in advances responder from non-responder patients affected by LARC highlights the need for valid biomarkers that guide clinical decision-making. In this context, microRNAs (miRNAs) seem to be promising candidates for predicting LARC prognosis and/or therapy response, particularly due to their stability, facile detection, and disease-specific expression in human tissues, blood, serum, or urine. Although a considerable number of studies involving potential miRNA predictors to nCRT have been conducted over the years, to date, the identification of the perfect miRNA signatures or single miRNA, as well as their use in the clinical practice, is still representing a challenge for the management of LARC patients. In this review, we will first introduce LARC and its difficult management. Then, we will trace the scientific history and the key obstacles for the identification of specific miRNAs that predict responsiveness to nCRT. There is a high potential to identify non-invasive biomarkers that circulate in the human bloodstream and that might indicate the LARC patients who benefit from the watch-and-wait approach. For this, we will critically evaluate recent advances dealing with cell-free nucleic acids including miRNAs and circulating tumor cells as prognostic or predictive biomarkers.

Background The evaluation of lymph nodes in rectal cancer dictates treatment. The goals of this study are to characterize the contemporary rate of lymph node metastasis in early stage rectal cancer and to re-investigate histologic factors that predict positive lymph nodes. Materials and Methods Using the National Cancer Database, we identified patients with clinical stage I rectal adenocarcinoma. Multivariable logistic regression was used to determine risk factors for lymph node positivity. Results 12.2% of patients with T1 tumors and 18.0% of patients with T2 tumors had positive lymph nodes. For T1 tumors, positive lymph nodes were present in 9.3% with neither poor differentiation nor lymphovascular invasion (LVI), 17.3% with poor differentiation alone, 34.7% with LVI alone, and 45.0% with both poor differentiation and LVI. For T2 tumors, positive lymph nodes were present in 11.7% with neither poor differentiation nor LVI, 25.3% with poor differentiation alone, 47.3% with LVI alone, and 41.5% with both poor differentiation and LVI. LVI was an independent predictor of positive lymph nodes (OR;4.75,95%CI;3.17–7.11, p  < 0.001) for T1 and (OR;6.20,95%CI;4.53–8.51, p  < 0.001) T2 tumors. Conclusions T1/T2 tumors have higher rates of positive lymph nodes when poor differentiation and LVI are present. These results should be taken into consideration prior to surgical treatment.

Introduction: Pelvic exenteration (PEx) is a radical procedure used in the treatment of locally advanced (LARC) and locally recurrent rectal cancer (LRRC). With recent advancements in perioperative treatment regimens, there has been renewed interest in this procedure as it offers the opportunity for complete tumour resection in a select cohort. This has resulted in large heterogeneity in outcome reporting, making comparing and conducting a meta-analysis of published results challenging. Standardising outcome reporting will ensure meaningful data reporting and allow the cross-centre comparison of data. Aims: To conduct a systematic review of the current literature, to identify the various outcomes reported for PEx in rectal cancer, and to develop a standard outcome reporting set. Methods: A systematic review was carried out following the PRISMA guidelines. Relevant domains were identified first. Data elements (DEs) were extracted verbatim prior to standardisation and mapping to relevant domains. Results: There has been a noticeable trend of increased literature on PEx in the last decade. Forty-nine papers were identified. A total of 1549 DEs were extracted verbatim. These were standardised to 119 unique DEs mapped to ten distinct domains capturing the patient care journey. There was large variation in the frequency of reporting, with some key outcomes reported in a limited number of studies. Conclusions: There is considerable heterogeneity at present in data reporting for PEx in LARC and LRRC. Standardisation of outcomes is the first step in guiding the development of a core information set to overcome heterogeneity and guide future research development.

Pelvic exenteration (PE) is now the standard of care for locally advanced (LARC) and locally recurrent (LRRC) rectal cancer. Reports of the significant short-term morbidity and survival advantage conferred by R0 resection are well established. However, longer-term outcomes are rarely addressed. This systematic review focuses on long-term oncosurgical and quality of life (QoL) outcomes following PE for rectal cancer. A systematic review of the PubMed , Cochrane Library, MEDLINE and Embase databases was conducted, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Studies were included if they reported long-term outcomes following PE for LARC or LRRC. Studies with fewer than 20 patients were excluded. A total of 25 papers reported outcomes for 5,489 patients. Of these, 4,744 underwent PE for LARC (57.5%) or LRRC (42.5%). R0 resection rates ranged from 23.2% to 98.4% and from 14.9% to 77.8% respectively. The overall morbidity rates were 17.8-87.0%. The median survival ranged from 12.5 to 140.0 months. None of these studies reported functional outcomes and only four studies reported QoL outcomes. Numerous different metrics and timepoints were utilised, with QoL scores frequently returning to baseline by 12 months. This review demonstrates that PE is safe, with a good prospect of R0 resection and acceptable mortality rates in selected patients. Morbidity rates remain high, highlighting the importance of shared decision making with patients. Longer-term oncological outcomes as well as QoL and functional outcomes need to be addressed in future studies. Development of a core outcomes set would facilitate better reporting in this complex and challenging patient group.