Search Results (84)

Intraoperative radiotherapy (IORT) is a radiation technique that allows for the delivery of a high radiation dose to the target while preserving the surrounding structures, which can be displaced during the surgical procedure. An important limitation of this technique is the lack of real-time image guidance, which is one of the main achievements of modern radiation therapy because it allows for treatment optimization. IORT can be delivered by low-energy X-rays or by accelerated electrons. The present review describes the most relevant clinical applications for IORT and discusses the potential advantages of using artificial intelligence (AI) to overcome some of the current limitations of IORT. In recent decades, IORT has proven to be an effective treatment in several cancer types. In breast cancer, IORT can be used to deliver a single dose of radiation (partial breast irradiation) or as a boost in high-risk patients. In locally advanced rectal cancer, a single dose to the tumor bed can improve local control and prevent pelvic relapse in primary and recurrent tumors. In sarcomas, IORT enables the delivery of high doses, achieving good functional outcomes with low toxicity in tumors located in the retroperitoneum and extremities. In pancreatic cancer, IORT shows promising results in borderline resectable and unresectable cases. Ongoing technological advances are addressing current challenges in imaging and radiation planning, paving the way for personalized, image-guided IORT. Recent innovations such as CT- and MRI-equipped hybrid operating theaters allow for real-time imaging, which could be used for AI-assisted segmentation and planning. Moreover, the implementation of AI in terms of machine learning, deep learning, and radiomics can improve the interpretation of imaging, predict treatment outcomes, and optimize workflow efficiency. Full article

Introduction: Total pelvic exenteration (TPE) is a radical procedure for advanced pelvic malignancies involving adjacent organs. The Hugo™ RAS System is a novel robotic platform, but its application in TPE has not previously been reported. We describe the first case of robotic-assisted TPE using Hugo™ RAS in a patient with locally advanced rectal cancer invading the prostate. Methods: A 69-year-old male with mucous and bloody stools was diagnosed with cT4b (prostate, levator ani muscle) N0M0 rectal cancer. After short-course radiotherapy (25 Gy/5 fractions), robotic-assisted TPE was performed. Port placement was planned to coincide with future colostomy and urostomy sites to minimize abdominal wall trauma. En bloc resection was achieved, followed by pelvic reconstruction with a gluteus maximus musculocutaneous flap and fascia lata autograft. Urinary diversion was completed with a robotic intracorporeal Wallace-type ileal conduit. Results: The operation lasted 17 h 56 min, with 175 mL blood loss. Postoperatively, Clavien–Dindo grade IIIa paralytic ileus occurred but was managed conservatively. Pathology revealed pT4b (prostate) N1a M0 disease with negative circumferential margin (11 mm). No recurrence was observed at 9 months. Conclusions: This case highlights the technical feasibility and safety of Hugo™ RAS-assisted TPE. Further clinical experience is needed to confirm reproducibility and oncologic safety. Full article

Introduction: Recurrence after pelvic exenteration remains a significant concern in patients with locally advanced rectal cancer (LARC). Therefore, there is a need for improved non-invasive predictive tools to aid in patient selection. Radiomics, which extracts quantitative imaging features, may help identify patients at greater risk of recurrence. This study aimed to develop and validate a radiomics-based nomogram using pre-treatment MRI to predict postoperative recurrence risk in LARC. Methods: The largest multicenter retrospective radiomics analysis of 191 patients with pathologically confirmed LARC treated at fourteen centres (2016–2018) was performed. All patients received neoadjuvant chemoradiotherapy followed by curative-intent exenterative surgery. Manual tumour segmentation was performed on pre-treatment T2-weighted MRI. Feature selection employed LASSO regression with 5-fold cross-validation across 1000 bootstrap samples. The most frequently selected features were used to construct a logistic regression model via stepwise backward selection. Model performance was assessed using ROC analysis, calibration plots, decision curve analysis, and internal validation with 1000 bootstraps. A nomogram was generated to enable individualized recurrence risk estimation. Results: Postoperative recurrence occurred in 51% (n = 98) of cases. Five radiomic features reflecting tumour heterogeneity, morphology, and texture were included in the final model. In multivariable analysis, all selected features were significantly associated with recurrence, with odds ratios ranging from 0.63 to 1.64. The model achieved an optimism-adjusted AUC of 0.70, indicating fair discrimination. Calibration plots showed good agreement between predicted and observed recurrence probabilities. Decision curve analysis confirmed clinical utility across relevant thresholds. A clinically interpretable nomogram was developed based on the final model. Conclusions: A radiomics-based model using preoperative MRI can predict recurrence in LARC. The derived nomogram provides a practical tool for preoperative risk assessment. Prospective validation is necessary. Full article

Introduction: Pelvic exenteration (PEx) was first described in the 1940s as a palliative procedure in managing cervical cancer. Since then, advancements in perioperative care have transformed the options available to patients. This highly morbid procedure now offers a “cure” in a select cohort of patients with locally advanced and recurrent pelvic cancers. The large volume of literature in this field has resulted in a heterogeneity of data reporting, making comparative analysis extremely difficult. As such, we set out to examine the current literature and identify currently reported outcomes to guide development of a core information set (CIS) for data reporting for PEx in non-rectal cancers. Methods: A systematic review was carried out. Studies reporting on outcomes following PEx for advanced and recurrent gynecological, urological, and other non-rectal malignancies were included. Standardized outcomes were extracted and mapped to pre-determined domains. Results: Forty-four studies were found to meet our inclusion criteria. A total of 1735 data elements (DEs) were extracted verbatim, and these were assimilated into 111 standard DEs across nine domains. A wide range of reporting frequencies was observed, with the pathological domain containing the highest overall frequencies of DE reporting. Conversely, patient-reported and functional outcomes were noted to be the domain with the lowest frequency. Conclusions: This review highlights recent trends of increased reporting in the field of PEx and how this had invariably resulted in heterogeneous data reporting. We aim to guide the development of a CIS for reporting in non-rectal pelvic malignancies to help standardize future reporting. Full article

Rectal cancer remains a significant clinical challenge due to its complex anatomy and the critical need to balance oncological radicality with functional preservation. Multimodal treatment strategies, including neoadjuvant therapy, advanced endoscopic techniques, and precise surgical approaches, have evolved to optimize patient outcomes. Neoadjuvant chemoradiotherapy improves resectability and local control in locally advanced tumors, while endoscopic treatment offers organ-preserving options for carefully selected early-stage cancers. Surgical resection, primarily through total mesorectal excision (TME), remains the cornerstone of curative therapy, with minimally invasive and transanal approaches enhancing precision and recovery. In advanced and recurrent cases, extended procedures such as pelvic exenteration provide potential for cure despite substantial morbidity. This review summarizes current evidence on the indications, techniques, and outcomes of neoadjuvant, endoscopic, and surgical treatments for rectal cancer, emphasizing individualized treatment planning to achieve optimal oncological and functional results. Full article

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. Full article

Introduction/Background: Patients with locally advanced rectal cancer (LARC) with pathological complete response (pCR) after neoadjuvant chemo-radiotherapy (NCRT) are a privileged group because of the favorable progression of their disease. However, their follow-up patterns after surgery are similar to those of other groups with worse prognosis, with the consequent psychological and economic impact. Methods: This is a retrospective observational multicenter study with data obtained from the Spanish Rectal Cancer Project. Patients with LARC who underwent surgery with curative intent after NCRT and achieved pCR were selected. The last follow-up update was conducted in December 2021. A conditional survival model was used to analyze oncological outcomes during follow-up. Recurrence-free survival (RFS) was analyzed for the entire cohort of patients and for those who survived at one, two, and three years. Results: A total of 815 patients from 32 hospitals were included. Their mean age was 65.1 years, and 36.1% of them were women. Of the 815 patients, 35 died or experienced recurrence (local or systemic) in the first postoperative year, and 780 were included in the conditional survival analysis one year after surgery. The probability of RFS at 5 years was 86.5% in the whole cohort and 89.4%, 92.9%, and 95.2% for survivors at one, two, and three years, respectively. The probability of recurrence in these same groups was 6.5%, 4.3%, 1.8%, and 0.6%. Conclusions: Follow-up of patients with LARC and pCR after NCRT followed by surgery could be adapted based on conditional survival data showing that the probability of RFS increases as patients remain recurrence-free, and recurrences more than 3 years after treatment are exceptional. Full article

Locally advanced rectal cancer (LARC) remains a major clinical challenge due to its high risk of local recurrence and distant metastasis. Although total mesorectal excision (TME) has been established as the gold standard surgical approach, high recurrence rates associated with surgery alone have driven the development of multimodal preoperative strategies, such as radiotherapy and chemoradiotherapy. More recently, total neoadjuvant therapy (TNT)—which integrates systemic chemotherapy and radiotherapy prior to surgery—and non-operative management (NOM) for patients who achieve a clinical complete response (cCR) have further expanded treatment options. These advances aim not only to improve oncologic outcomes but also to enhance quality of life (QOL) by reducing long-term morbidity and preserving organ function. However, several unresolved issues persist, including the optimal sequencing of therapies, precise risk stratification, accurate evaluation of treatment response, and effective surveillance protocols for NOM. The advent of molecular biomarkers, next-generation sequencing, and artificial intelligence (AI) presents new opportunities for individualized treatment and more accurate prognostication. This narrative review provides a comprehensive overview of the current status of preoperative treatment for LARC, critically examines emerging strategies and their supporting evidence, and discusses future directions to optimize both oncological and patient-centered outcomes. By integrating clinical, molecular, and technological advances, the management of rectal cancer is moving toward truly personalized medicine. Full article

Background: Total neoadjuvant therapy (TNT) has emerged as a promising strategy for locally advanced rectal cancer (LARC). By administering both chemoradiotherapy (CRT) and systemic chemotherapy (CHT) pre-surgery, TNT is associated with improved disease-free survival (DFS), reduced distant metastases, and higher pathological complete response (pCR) rates. Materials and Methods: This study included patients with LARC who received various TNT schedules: induction chemotherapy (iCHT), consolidation chemotherapy (cCHT), or a combination of both (sandwichCHT). We analyzed treatment adherence, toxicity, and pathological response. Local and distant disease recurrence, as well as survival outcomes, were also evaluated. Results: Between May 2021 and January 2025, 70 patients received TNT. Treatment included iCHT (41%), sandwichCHT (49%), and cCHT (10%). Most patients (94%) received long-course radiotherapy (LCRT). Overall, TNT was well tolerated, with grade 2 gastrointestinal toxicity during CRT being the most common frequent adverse event (33%). Disease progression during TNT was noted in five patients (7%); three of these patients were receiving chemotherapy, while two underwent surgical resection of the primary tumor. A watch-and-wait strategy was adopted for five patients (7%) following TNT. Surgical procedures performed included anterior resection (92%), abdominoperineal resection (7%), and local excision (1%). Pathological assessment revealed an overall pCR rate of 30%. With a median follow-up of 17 months, no patients experienced local recurrence. Post-surgery, 10 patients (17%) developed disease progression. The median DFS was 14.7 months. Five patients (7%) died during the follow-up period, with only one death attributed to causes other than disease progression. Conclusions: In this cohort of LARC patients, TNT demonstrated favorable tolerability and encouraging short-term efficacy. Full article

Background: Systemic inflammatory markers have emerged as accessible and reproducible tools for oncologic risk stratification, yet their prognostic value in rectal cancer remains incompletely defined, particularly in acute surgical settings. This study aimed to assess six inflammation-based indices—NLR, PLR, MLR, SII, SIRI, and AISI—in relation to tumor stage, recurrence, and outcomes among patients undergoing emergency versus elective resection for rectal cancer. Methods: We retrospectively evaluated 174 patients treated between 2018 and 2024. Pre-treatment blood counts were used to calculate inflammatory indices. Clinical and pathological parameters were correlated with biomarker levels using univariate and multivariate analyses. Results: Pre-treatment inflammation markers were significantly elevated in patients requiring emergency surgery (e.g., NLR: 3.34 vs. 2.4, p = 0.001; PLR: 204.1 vs. 137.8, p < 0.001; SII: 1008 vs. 693, p = 0.007), reflecting advanced tumor biology and immune activation. Notably, these patients also had higher rates of stage IV disease (p = 0.029) and permanent stoma (p = 0.002). Post-treatment, recurrence was paradoxically associated with significantly lower levels of SII (p = 0.021), AISI (p = 0.036), and PLR (p = 0.003), suggesting a potential role for immune exhaustion rather than hyperinflammation in early relapse. Conclusions: Inflammatory indices provide valuable insights into both tumor local invasion and host immune status in rectal cancer. Their integration into perioperative assessment could improve prognostication, particularly in emergency presentations. Post-treatment suppression of these markers may identify patients at high risk for recurrence despite initial curative intent. Full article

Traditionally, the therapeutic approach to rectal cancer has involved neoadjuvant chemoradiotherapy followed by surgical resection, and, in some cases, adjuvant chemotherapy. This study aims to present current advances and ongoing controversies in the management of patients with locally advanced rectal cancer (LARC), with a particular focus on clarifying the role of total neoadjuvant therapy (TNT) in contemporary treatment strategies. Methods: We conducted a systematic literature review in Medline/PubMed using various keyword combinations, including “rectal cancer/neoplasia” and“therapy” or “neoadjuvant therapy” or “TNT”, and included articles published between 2015 and 2025. Results: The association of neoadjuvant radiochemotherapy with preoperative systemic chemotherapy has led to the current concept of total neoadjuvant therapy. The advantages of preoperative chemotherapy include better patient compliance, a decrease in the rate of local recurrence and distant metastases via the early destruction of infra-clinical micrometastases, and higher rates of pathological complete response. All of these have led to the inclusion of this strategy in treatment guidelines for patients with locally advanced rectal cancer. Conclusions: However, the selection of patients with advanced rectal tumors for optimal therapy requires comprehensive imaging assessments, molecular and genetic testing, and a multidisciplinary team to determine the most appropriate total neoadjuvant therapy approach. Full article

Rectal cancer management necessitates a rigorous multidisciplinary strategy, emphasizing precise staging and detailed risk stratification to inform optimal therapeutic decision-making. Obtaining an accurate histological diagnosis before initiating treatment is essential. Comprehensive staging integrates clinical evaluation, thorough medical history analysis, assessment of carcinoembryonic antigen (CEA) levels, and computed tomography (CT) imaging of the abdomen and thorax. High-resolution pelvic magnetic resonance imaging (MRI), utilizing dedicated rectal protocols, is critical for identifying recurrence risks and delineating precise anatomical relationships. Endoscopic ultrasound further refines staging accuracy by determining the tumor infiltration depth in early-stage cancers, while preoperative colonoscopy effectively identifies synchronous colorectal lesions. In early-stage rectal cancers (T1–T2, N0, and M0), radical surgical resection remains the standard of care, although transanal local excision can be selectively indicated for certain T1N0 tumors. In contrast, locally advanced rectal cancers (T3, T4, and N+) characterized by microsatellite stability or proficient mismatch repair are optimally managed with total neoadjuvant therapy (TNT), which combines chemoradiotherapy with oxaliplatin-based systemic chemotherapy. Additionally, tumors exhibiting high microsatellite instability or mismatch repair deficiency respond favorably to immune checkpoint inhibitors (ICIs). The evaluation of tumor response following neoadjuvant therapy, utilizing MRI and endoscopic assessments, facilitates individualized treatment planning, including non-operative approaches for patients with confirmed complete clinical responses who comply with rigorous follow-up. Recent advancements in molecular characterization, targeted therapies, and immunotherapy highlight a significant evolution towards personalized medicine. The effective integration of these innovations requires enhanced interdisciplinary collaboration to improve patient prognosis and quality of life. Full article

Background/Objectives: This retrospective study evaluates the predictive role of magnetic resonance imaging (MRI) in complications and recurrence in rectal cancer patients undergoing surgery and neoadjuvant therapy, highlighting the impact of structured reporting templates on MRI quality. Compared to traditional free-text reports, structured radiology reports offer a point-by-point evaluation, improving clarity and completeness by thoroughly addressing all relevant findings. MRI is critical in rectal cancer staging, guiding treatment based on tumor characteristics like T stage, sphincter involvement, vascular invasion, and lymph node status. Methods: A retrospective analysis of MRI and reports from 67 rectal cancer patients at the time of diagnosis, who were subsequently treated with neoadjuvant radiochemotherapy and surgery, was conducted. MRI report features, including tumor location, morphology, T stage, sphincter infiltration, mesorectal fascia involvement, lymph nodes, and extramural vascular invasion, were evaluated against European Society of Gastrointestinal and Abdominal Radiology (ESGAR) recommendations. Multivariate and univariate analyses were performed to correlate MRI findings with postoperative outcomes such as complications, local recurrence, bleeding, and 30-day anastomotic leaks. Results: Sphincter involvement showed a strong association with increased complications (multivariate β = 0.410, univariate r = 0.270). Extramural vascular invasion was linked to higher rates of local recurrence (multivariate β = 0.199, univariate r = 0.127). Lymph node involvement correlated with an elevated risk of postoperative bleeding (multivariate β = 0.133, univariate r = 0.293). Additionally, advanced T staging predicted a higher incidence of 30-day anastomotic leaks (multivariate β = 0.210, univariate r = 0.261). These findings may provide clinically relevant insights to support personalized surgical planning and improve preoperative risk stratification. Conclusions: Detailed MRI reporting, aligned with structured templates, significantly guides surgical and therapeutic strategies in rectal cancer management. However, the retrospective nature of the study and the limited sample size may affect the generalizability of the results. Full article

Background and Objectives: This study aimed to investigate the predictive and prognostic value of pre-treatment systemic inflammatory markers in patients with locally advanced rectal cancer (RC) undergoing neoadjuvant chemoradiotherapy (CRT) or radiotherapy (RT) alone. Materials and Methods: A total of 79 patients with biopsy-confirmed locally advanced RC treated at a single tertiary center between 2011 and 2017 were retrospectively analyzed. Pre-treatment blood-based inflammatory indices, including neutrophil-to-lymphocyte ratio (NLR), derived NLR, platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and hemoglobin levels, were recorded. Tumor response was assessed using the Ryan tumor regression grade (TRG), and associations between laboratory parameters, treatment response, and recurrence-free survival (RFS) were evaluated. Results: Among 79 patients (mean age: 55.9 ± 11.98 years; 67.1% male), 57 received neoadjuvant CRT and 22 underwent short-course RT. Complete pathological response (pCR) was observed in 10 patients (12.7%). No statistically significant associations were found between baseline inflammatory markers and TRG, tumor differentiation, or pCR. ROC analysis revealed that none of the markers demonstrated significant discriminatory power for predicting tumor response or recurrence. However, a weak but statistically significant inverse correlation was identified between poor TRG response and higher baseline values of NLR, derived NLR, and PLR (p < 0.05). Conclusions: Inflammatory biomarkers such as NLR, PLR, and LMR, while easily accessible and cost-effective, did not demonstrate strong predictive or prognostic value in this cohort of RC patients receiving neoadjuvant therapy. These findings suggest that reliance solely on systemic inflammatory indices may be insufficient for predicting treatment outcomes, emphasizing the need for integrative models incorporating molecular and pathological markers. Full article

Background: Total mesorectal excision (TME) remains the gold standard for the resection of rectal cancer regardless of the modality: open, laparoscopic, or robotic. The transanal TME (TaTME) approach has been utilized to overcome the difficulties encountered with the dissection of tumors in the distal pelvis. Recently, a single-port robotic approach (rSPa) was introduced, where three arms and a camera emanate from a 2.5 cm diameter port. This report presents the first experience in the United States combining those two approaches (rSPa TaTME) in rectal cancer, evaluating its safety and oncologic outcomes. Methods: This is a retrospective review of our prospectively maintained rectal cancer database. Patient demographics, tumor characteristics, neoadjuvant treatment, and oncologic and surgical outcomes were recorded. Results: Between May 2022 and August 2024, ten patients (six females, four males) with a median age at surgery of 53 years (range: 38–85) and a mean BMI of 26 (±5) kg/m² were included for analysis. The median distance of tumors from the anorectal junction was 3.2 cm (range: 2–5.3 cm). All patients had negative margins, with eight complete TME specimens, one near complete, and one incomplete. The mean number of lymph nodes harvested was 24 (±11). The average operative time was 351 (243–411) min. The average length of stay was four days. The ileostomy was reversed in nine out of ten patients. Six patients experienced complications within 30 days of surgery. There were no local or distal recurrences, with a mean follow-up of 20 months (range: 4–30). Conclusions: rSPa TaTME is a unique and innovative method of combining two minimally advanced approaches for the resection of distal rectal cancers, with acceptable surgical and oncologic outcomes. Full article