Purpose of Review Rectal cancers are treated with chemotherapy, radiotherapy, and surgery. While trials have illustrated the benefits of radiotherapy for locoregional control, recent investigations have questioned the need in select cases. This review seeks to understand why, how, and when radiation can be omitted from rectal cancer management. Recent Findings Absolute contraindications of radiation include pregnancy, and relative contraindications include fertility concerns, sexual outcomes, autoimmune conditions, and prior radiation. Low-risk features of rectal cancer might warrant the omission of neoadjuvant radiation. MRI-directed therapy, chemotherapy alone, and immunotherapy may offer future ways to omit radiation. Summary While radiation continues to be an essential component for rectal cancer treatment, there may be circumstances that it can be omitted. It is important to educate patients that not receiving radiation is a deviation from standard of care. In the future, we may see developments and changes in the treatment paradigm for rectal cancer.
The surgical management of metastatic colorectal cancer (CRC) has evolved over time. Most often, the management of asymptomatic primary CRC with simultaneous liver metastases (LM) proceeds with neoadjuvant chemotherapy followed by surgical resection. Although the timing of surgical resection has remained controversial, the ability to achieve R0 resection and the importance of patient selection remain widely accepted. Preoperative novel modalities such as portal vein ligation (PVL) or portal vein embolization (PVE) have allowed for improved surgical outcomes and decreased post-surgical morbidity. Combination or hybrid management has also seen increased utility by associating ablation therapies with surgical resection. Finally, patients with significant comorbidities and surgically unresectable disease have benefited greatly from locoregional salvage therapies such as percutaneous ablation and radioembolization. Here we will review pertinent literature associated with surgical management for resectable disease and explore newly developed locoregional salvage therapies for unresectable disease.
Purpose of Review Laparoscopic hemicolectomy (LHC) is widely used to treat benign and malignant colorectal disease. However, the optimal method to restore intestinal continuity is still controversial; hence, this study aims to compare the safety and efficacy of intracorporeal anastomosis (IA) with extracorporeal anastomosis (EA). Recent Findings Current literature comprises largely of retrospective cohort studies and three significant randomized controlled trials examining the differences between IA and EA in mostly right-sided colectomies. The evidence points to superior intraoperative and postoperative outcomes such as reduced incision length, incidence of wound infection and length of stay for IA, but with incongruous findings on outcomes such as anastomotic leakage and lymph node yield. Likewise, existing meta-analyses have reached differing conclusions about some of these key outcomes. Summary This paper provides a timely update to existing reviews and shows that IA is associated with superior intraoperative, postoperative and long-term recovery outcomes. We provide more conclusive evidence that lymph node yield for cancer patients is improved in IA. Furthermore, lymph node yield and lowered readmission rate appeared to be more pronounced in patients with higher BMI through regression analysis. Our key recommendation is for surgeons to acquire a high level of proficiency in performing IA to improve patient outcomes.
The non-operative management of rectal cancer is an area of active research. Dose-escalated radiotherapy may improve sustained local control but toxicity is a concern. Brachytherapy is emerging as a promising boost technique that may confer dosimetric advantages over external beam radiotherapy (EBRT)–based boosts. Preliminary findings from two multicenter prospective randomized phase II/III trials suggest high rates of sustained 2-year local control with a combination of EBRT and either contact X-ray brachytherapy or high dose rate endorectal brachytherapy compared with an EBRT boost. Brachytherapy is a promising technique in the non-operative management of patients with rectal cancer. Further research will be needed to characterize long-term oncologic and toxicity outcomes.
Treatment paradigms for locally advanced rectal cancer have evolved over the last several decades. Patients now have several different “standard” options with different radiation courses, sequencing of treatment modality and in some scenarios potentially avoidance of surgery. In this context, an updated understanding of treatment toxicity is needed to help patients make informed decision regarding their treatment. The RAPIDO study showed no difference in cumulative rate or grade of toxicity between short and long course radiation. Based upon our experience, patients with short course radiation tend to present with acute symptoms 1–2 weeks after completion of radiation, while those receiving long course chemoradiation have symptoms towards the end of treatment. Treatments that may be helpful particularly for short course radiation toxicity include Bentyl (dicycloverine) and steroids. The most common toxicities from radiation are due to bowel and rectal inflammation leading to diarrhea, cramping, and urgency. The combination of surgery and radiation can exacerbate these symptoms. The most common late toxicity in patients receiving doublet chemotherapy is neurotoxicity. Rates of infertility differ in men versus women; all efforts for fertility preservation should be completed prior to initiation of any therapy.
