pT4 colon tumors are associated with worse oncologic prognosis. Although minimally invasive surgery (MIS) improves postoperative recovery, concerns remain regarding its long‑term oncologic safety. This is a secondary analysis of a retrospective, multicenter national cohort including patients with pT4 colon cancer treated with curative intent in 50 hospitals. We compared oncologic outcomes (local, peritoneal and systemic recurrence, disease‑free survival [DFS] and overall survival [OS]) between open surgery and MIS. Variables associated with surgical approach were incorporated into a propensity score (PS) to adjust outcomes. A total of 1850 patients were analyzed: 725 (39.2

ABSTRACT Background The pT3 category of colon cancer staging is heterogeneous and has significant prognostic value. However, this is not reflected in the current TNM staging system. The objective of this work is to determine whether the extent of infiltration beyond the muscularis propria of pT3 colon carcinoma is an independent risk factor for worse oncologic outcomes after curative surgery. Methods Retrospective analysis of 536 patients from a tertiary University Hospital with pT3M0 colon cancer (1995–2015) was collected and re‐evaluated to assess tumor infiltration extent beyond the muscularis propria layer. The main outcome measures studied were local recurrence, systemic recurrence, disease‐free survival, and cancer‐specific survival. Results An infiltration extent of 5 mm was the best cutoff for predicting oncological results in this group of patients. Multivariable analysis showed that tumor infiltration depth into the pericolic fat was an independent risk factor for a higher local recurrence rate (p = 0.02, HR 1.11 per mm, 95% CI 1.04–1.23), a higher risk of systemic recurrence (p = 0.02, HR 1.08 per mm, 95% CI 1.01–1.16), worse disease‐free survival (p = 0.008, HR 1.08 per mm, 95% CI 1.02–1.14), and cancer‐specific survival (p = 0.009, HR 1.09 per mm, 95% CI 1.02–1.16). In a sub‐analysis, these results were confirmed in patients with positive lymph nodes but not in the group of patients with negative lymph nodes. Conclusions The extramural spread of pT3 colon cancer is a significant prognostic factor for worse oncological outcomes after curative surgery. Therefore, this parameter should be considered in selecting adjuvant therapy and possibly included in the TNM staging system.

To assess the relevance of peritoneal reflection involvement in long-term oncological outcomes in patients with rectal cancer. Prospective observational study from a specialized colorectal unit that included a consecutive series of patients undergoing mesorectal excision for rectal cancer. Peritoneal reflection (PR) involvement was evaluated on pathological examination using Shepherd’s classification. Overall survival (OS), disease-free survival (DFS), and local recurrence (LR) were assessed. One hundred sixty patients were included in the present analysis. Peritoneal involvement was present in 28.2

La exenteración pélvica (EP) representa una opción terapéutica potencialmente curativa para pacientes con cáncer de recto localmente avanzado (LARC) o recurrencia local (LRRC) con afectación multivisceral. Inicialmente concebida como un procedimiento paliativo, los avances técnicos y el enfoque multidisciplinar han ampliado sus indicaciones, permitiendo resecciones R0 en más del 60% de los casos. La correcta selección de pacientes, basada en estudios de imagen avanzados y una valoración funcional integral, es esencial para maximizar los beneficios oncológicos. En la actualidad, el límite de la indicación quirúrgica se establece en la posibilidad razonable de lograr una resección oncológica completa (R0) con una morbilidad aceptable en el paciente adecuado, lo que puede traducirse en tasas elevadas de supervivencia.La cirugía debe abordarse de forma compartimental y con la colaboración de múltiples especialidades. La reconstrucción urinaria, ginecológica, vascular, ósea y de tejidos blandos se adapta a la extensión tumoral y las necesidades del paciente. En casos seleccionados, la EP puede utilizarse con intención paliativa. La radioterapia intraoperatoria (IORT) y la cirugía mínimamente invasiva han demostrado ser estrategias complementarias prometedoras.Los resultados oncológicos y funcionales dependen en gran medida de la obtención de márgenes negativos. Aunque la morbilidad puede ser elevada, las tasas de mortalidad han disminuido en centros especializados. La calidad de vida postoperatoria se ha convertido en un parámetro clave, destacando el papel de las medidas reportadas por los pacientes (PROM) en la toma de decisiones. La EP continúa desafiando los límites tradicionales de la resecabilidad, ofreciendo esperanza a pacientes seleccionados.

In our previous survey of experts, surgeon’s decision-making process (DMP) about protective ileostomy (PI) creation after anterior resection was investigated. Based on our previous data, a multiple choice questionnaire has been developed. The aim is to perform a quantitative analysis of the results obtained from an international survey and to describe the clinical practice worldwide. Ten questions were related to participants’ demographics and, 20 questions (of which 17 Likert scale questions) investigated the DMP regarding PI creation. To evaluate the tendency of the answers in the Likert-type questions, the mean of the answers obtained was compared with the mean point of the Likert scale. The survey was completed by 1019 physicians. Neoadjuvant chemoradiotherapy and distance of the anastomosis from the anal verge ≤ 10 cm were each considered alone sufficient to justify creation of a PI, with statistically significant differences in comparison to the mean point of the scales in (p = < 0.0001 in both cases). Total Mesorectal Excision alone was not considered a factor sufficient to create a PI (p = 0.416). Most of the participants agree to define their approach to create a PI “tailored” to patients’ risk factors (p = < 0.0001) and “influenced by my experience” in case of patients with low/moderate risk of anastomotic leakage (p = < 0.0001). This study provides useful insights on the worldwide clinical practice regarding creation of PI following anterior resection. Given the lack of standardization and evidence-based guidelines, this analysis may be helpful to assist surgeons’ practice.

Pelvic exenteration (PE) is a potentially curative surgical option for patients with locally advanced rectal cancer (LARC) or locally recurrent rectal cancer (LRRC) involving multivisceral structures. Originally conceived as a palliative procedure, advancements in surgical techniques and multidisciplinary management have broadened its indications, enabling R0 resections in over 60% of cases. Appropriate patient selection, based on advanced imaging and comprehensive functional assessment, is essential to optimize oncologic outcomes. Currently, the surgical indication is primarily determined by the reasonable possibility of achieving an R0 resection with acceptable morbidity in a suitable candidate, which may translate into high survival rates. Surgical planning should follow a compartmental approach and require close collaboration among colorectal, urologic, gynecologic, vascular, orthopedic, plastic, and reconstructive surgeons. Urinary, gynecologic, vascular, osseous, and soft tissue reconstructions are tailored to the tumor's extent and the patient's individual needs. In selected cases, PE may be performed with palliative intent. Intraoperative radiotherapy (IORT) and minimally invasive approaches have emerged as valuable adjuncts. Long-term oncologic and functional outcomes are closely linked to the achievement of negative margins. While postoperative morbidity remains significant, mortality rates have declined in high-volume centers. Postoperative quality of life has become a key outcome, with increasing emphasis on patient-reported outcome measures (PROMs) to guide clinical decision-making. PE continues to challenge traditional limits of resectability, offering renewed hope to carefully selected patients.

Pelvic exenteration (PE) is a potentially curative surgical option for patients with locally advanced rectal cancer (LARC) orlocallyrecurrent rectal cancer (LRRC) involvingmultivisceralstructures. Originally conceived as a palliative procedure, advancements in surgical techniques and multidisciplinary management have broadened its indications, enabling R0 resections in over 60% of cases. Appropriate patient selection, based on advanced imaging and comprehensive functional assessment, is essential to optimize oncologic outcomes. Currently, the surgical indication is primarily determined by the reasonable possibility of achieving an R0 resection with acceptable morbidity in a suitable candidate, which may translate into high survival rates. Surgical planning should follow a compartmental approach and require close collaboration among colorectal, urologic, gynecologic, vascular, orthopedic, plastic, and reconstructive surgeons. Urinary, gynecologic, vascular, osseous, and soft tissue reconstructions are tailored to the tumour's extent and the patient's individual needs. In selected cases, PE may be performed with palliative intent. Intraoperative radiotherapy (IORT) and minimally invasive approaches have emerged as valuable adjuncts. Long-term oncologic and functional outcomes are closely linked to the achievement of negative margins. While postoperative morbidity remains significant, mortality rates have declined in high-volume centres. Postoperative quality of life has become a key outcome, with increasing emphasis on patient-reported outcome measures (PROMs) to guide clinical decision-making. PE continues to challenge traditional limits of resectability, offering renewed hope to carefully selected patients.

Objective: To evaluate the feasibility of a 3D image processing and reconstruction system (3D-IPR) based on pelvic magnetic resonance imaging (MRI) for surgical planning of locally advanced rectal cancer (LARC) and recurrent pelvic rectal cancer (PRCR). Background: Achieving R0 resection is critical for prognosis in LARC and PRCR, but 2D imaging often limits precise surgical planning in complex pelvic anatomy. 3D reconstruction may enhance visualization and decision-making. Methods: In this prospective feasibility multicenter study, 37 patients with LARC or PRCR and threatened circumferential resection margins on MRI underwent surgical planning using 3D-IPR. This tool provides information on tumor localization, infiltration volume, and precise spatial relationships with adjacent structures. Outcomes included surgeon satisfaction, changes in surgical approach, and perioperative results. Results: A total of 56.7% of cases were primary rectal cancer and 43.2% were recurrent cancer. Satisfaction percentage of 3D-IPR to select the best surgical route was 100%. Minimally invasive techniques were employed in 40% of the surgeries. In 37.8% of cases, it was considered that the 3D-IPR changed the decision on the surgical attitude with respect to the neighboring organ with suspicion of infiltration. R0 resection was achieved in 75.7% of cases, with no perioperative mortality and a severe complication rate of 27%. Conclusions: A surgical planner based on 3D reconstruction using mathematical algorithms from pelvic MRI is feasible for performing tailored surgery for locally advanced rectal cancers and pelvic recurrence. Further research will show if this new tool reduces the morbidity and mortality rates, increasing the probability of R0 surgery, and increasing survival.

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.

The following systematic review aimed to present the current status of immunotherapy in colorectal cancer, in the neoadjuvant, adjuvant and metastatic setting. Pubmed, Cochrane and Embase databases were searched up to April 2024 and the PICO framework, as well as the following inclusion criteria (clinical studies in English published ≥2000 per year, both retrospective and prospective, including abstracts from relevant congresses, yet excluding case reports, letters, phase I clinical trials and radioimmunotherapy) were applied. MINORS and RoB2 were used to assess quality and risk of bias. Due to heterogeneity of the studies, a descriptive analysis was performed. In total, 99 studies (including 11 226 patients) were analysed, concluding that immunotherapy application, although encouraging, still needs refinement, most importantly in terms of patient and treatment regimen selection. The review was registered on the PROSPERO platform (ID: CRD42023417537) and funded by a grant by the Spanish Association of Surgery (AEC).

IntroducciónLa resección local (RL) es una alternativa a la exéresis mesorrectal total (EMT) que permite evitar su morbilidad asociada en detrimento de la radicalidad oncológica en estadios precoces de cáncer de recto. Existen diversos condicionantes para el éxito de esta estrategia, como factores histológicos de mal pronóstico (FHMP), afección de márgenes de resección, infraestadificación clínica, o complicaciones que pueden conllevar la indicación de cirugía radical con EMT.Pacientes y métodoSe ha diseñado un estudio multicéntrico internacional observacional prospectivo en régimen abierto. Se incluirán pacientes consecutivos diagnosticados de cáncer de recto precoz (cT1N0 en RMN±ecografía endorrectal) cuyo límite inferior esté a un máximo de 2cm proximal a la unión anorrectal. El objetivo primario del estudio es determinar la prevalencia global de FHMP tras RL y que obligan a EMT o realización de radio-quimioterapia postoperatoria.DiscusiónLa prevalencia de FHMP como factor limitante de éxito de una RL en cáncer de recto distal precoz apenas ha sido objeto de estudio en la literatura, existiendo muy poca información con carácter prospectivo. Considerando el progresivo interés de la estrategia watch and wait en cáncer de recto y su posible aplicación en tumores con estadificación precoz, parece necesario conocer esta información.Los resultados del estudio ayudarán a guiar la práctica clínica en pacientes con cáncer de recto distal precoz. También se conseguirá información de calidad para el diseño de estudios comparativos futuros que permitan mejorar el éxito en preservación de órgano en estos pacientes.Número de registro: NCT05927584.