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Surgical, oncological, and functional outcomes of local and radical resection after neoadjuvant chemotherapy or chemoradiotherapy for early- and mid-stage rectal cancer: a systematic review and meta-analysis

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International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Background

Radical resection is typically the standard treatment for early- and mid-stage rectal cancer as local resection may result in a high rate of recurrence and risk of distant metastasis. A growing number of studies have shown that local excision after neoadjuvant chemotherapy or chemoradiotherapy can significantly reduce recurrence rates and is a feasible strategy to preserve the rectum as an alternative to conventional radical resection.

Objective

This study aims to compare the efficacy of local resection after neoadjuvant chemotherapy or chemoradiotherapy with radical surgery for early- and mid-stage rectal cancer and to report the evidence-based clinical advantages of both techniques.

Methods

Clinical trials comparing oncologic and perioperative outcomes of local and radical resection after neoadjuvant chemotherapy or chemoradiotherapy in patients with early- to mid-stage rectal cancer were searched in PubMed, Embase, Web Of Science, and Cochrane databases, and a total of 5 randomized controlled trials and 11 cohort study trials were included.

Results

In terms of oncology and perioperative outcomes, there were no statistically significant differences between the radical resection group and the local resection group in terms of OS [HR = 0.99, 95%CI (0.85, 1.15), p = 0.858], DFS [HR = 1.01, 95%CI (0.64, 1.58), p = 0.967], distant metastasis rate [RR = 0.76, 95%CI (0.36,1.59), p = 0.464], and local recurrence rate [RR = 1.30, 95%CI (0.69, 2.47), p = 0.420]. However, there were significant differences in the outcomes of complications [RR = 0.49, 95% CI (0.33, 0.72), p < 0.001], length of hospital stays [WMD =  − 5.13, 95%CI (− 6.22, − 4.05), p < 0.001], enterostomy [RR = 0.13, 95%CI (0.05, 0.37), p < 0.001], operative time [− 94.31, 95%CI (− 117.26, − 71.35), p < 0.001], and emotional functioning score [WMD = 2.34, 95% CI (0.94, 3.74), p < 0.001].

Conclusion

Local resection after neoadjuvant chemotherapy or chemoradiotherapy may be an effective alternative to radical surgery in patients with early and middle rectal cancer.

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Data Availability

This paper is a review article, date availability is not applicable to this article as no new data were created or analyzed in this study.

References

  1. Sung H, Ferlay J, Siegel RL et al (2021) Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 71:209–249

  2. On J, Aly EH (2018) Watch and wait in rectal cancer: summary of the current evidence. Int J Colorectal Dis 33:1159–68

  3. Heald RJ, Ryall RD (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1(8496):1479–82

  4. Glynne-Jones R,Wyrwicz L,Tiret E et al (2018) Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 29:iv263

  5. Emmertsen KJ, Chen TY-T, Laurberg S (2014) Functional results after treatment for rectal cancer. J Coloproctol 34:55–61

  6. Qin F, Zhen L, Ye XM et al (2018) Current status and influencing factors of sexual life in young and middle-aged patients with enterostomy. Guangzhou Medical College Learn 33(19):6+2960, 2951–2955

  7. Mellgren A, Sirivongs P, Rothenberger DA et al (2000) Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum 43:1064–1071

    Article  CAS  PubMed  Google Scholar 

  8. Rai V, Mishra N (2016) Transanal approach to rectal polyps and cancer. Clin Colon Rectal Surg 29:65e70

  9. Kawaguti FS, Nahas CS, Marques CF et al (2014) Endoscopic sub-mucosal dissection versus transanal endoscopic microsurgery for the treatment of early rectal cancer. Surg Endosc 28:1173–1179

    Article  PubMed  Google Scholar 

  10. van Oostendorp SE, Smits LJH, Vroom Y et al (2020) Local recurrence after local excision of early rectal cancer: a meta-analysis of completion TME, adjuvant (chemo)radiation, or no additional treatment. Br J Surg 107:1719–1730

  11. Garcia-Aguilar J, Renfro LA, Chow OS et al (2015) Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol 16:1537–1546

    Article  PubMed  PubMed Central  Google Scholar 

  12. Jones HJS, Goodbrand S, Hompes R et al (2019) Radiotherapy after local excision of rectal cancer may offer reduced local recurrence rates. Colorectal Dis 21(4):451–459

    Article  CAS  PubMed  Google Scholar 

  13. Li X-X, David Li (2020) Colorectal cancer neoadjuvant chemoradiation controversy and consensus of clinical complete remission after processing. Chin Med J 40(3):325–329. https://doi.org/10.19538/j.carolcarrollJPSissn1005-2208.2020.03.22

  14. Gu H, Wang Y, Li W (2014) Cochrane bias risk assessment: a meta-analysis of randomized controlled Studies. Chin Med J 29(02):147–148

  15. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M et al (2014) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses

  16. Fletcher J (2007) What is heterogeneity and is it important? BMJ 334:94–96

    Article  PubMed  PubMed Central  Google Scholar 

  17. Greenland S, Pearl J, Robins JM (1999) Causal diagrams for epidemiologic research. Epidemiology 10:37–48

    Article  CAS  PubMed  Google Scholar 

  18. Thilarajah S, Mentiplay BF, Bower KJ et al (2018) Factors associated with post-stroke physical activity: a systematic review and meta-analysis. Arch Phys Med Rehabil 99:1876–1889

  19. Lynn PB, Van der Valk MJM, Claassen YHM et al (2023) Chemoradiation and local excision versus total mesorectal excision for T2N0 rectal cancer: comparison of short- and long-term outcomes from 2 prospective studies. Ann Surg 277:e96-e102

  20. Brachet S, Meillat H, Ratone J-P et al (2022) Case-matched comparison of functional and quality of life outcomes of local excision and total mesorectal excision following chemoradiotherapy for rectal cancer. Dis Colon Rectum undefined:undefined

  21. Serra-Aracil X, Pericay C, Badia-Closa J et al (2022) Short-term outcomes of chemoradiotherapy and local excision vs total mesorectal excision in T2-T3ab,N0,M0 rectal cancer. A multicentre randomised, controlled, phase III trial (the TAUTEM study). Ann Oncol undefined:undefined

  22. Rizzo G, Pafundi DP, Sionne F et al (2022) Transanal endoscopic microsurgery versus total mesorectal excision in ypT0–1 rectal cancer after preoperative radiochemotherapy: postoperative morbidity, functional results, and long-term oncologic outcome. Dis Colon Rectum 65:1306–1315

  23. Bach SP, Gilbert Alexandra TREC, collaborators. et al (2021) Radical surgery versus organ preservation via short-course radiotherapy followed by transanal endoscopic microsurgery for early-stage rectal cancer (TREC): a randomised, open-label feasibility study. Lancet Gastroenterol Hepatol 6(2):92–105

    Article  PubMed  Google Scholar 

  24. Pacevicius J, Petrauskas V, Pilipavicius L et al (2021) Local excision ± chemoradiotherapy vs. total mesorectal excision for early rectal cancer: case-matched analysis of long-term results. Front Surg 8:746784

  25. Calmels M, Collard MK, Cazelles A et al (2020) Local excision after neoadjuvant chemoradiotherapy versus total mesorectal excision: a case-matched study in 110 selected high-risk patients with rectal cancer. Colorectal Dis 22:1999–2007

    Article  CAS  PubMed  Google Scholar 

  26. Melnitchouk N, Fields AC, Lu P et al (2020) Local versus radical excision of early distal rectal cancers: a national cancer database analysis. Ann Surg Oncol 27:2169–2176

  27. Rullier E, Vendrely V, Asselineau J, Rouanet P, Tuech JJ, Valverde A, de Chaisemartin C, Rivoire M, Trilling B, Jafari M, Portier G et al (2020) Organ preservation with chemoradiotherapy plus local excision for rectal cancer: 5-year results of the GRECCAR 2 randomised trial. Lancet Gastroenterol Hepatol 5(5)

  28. Jawitz OK, Adam MA, Turner MC, Gilmore BF, Migaly J (2019) Neoadjuvant chemoradiation followed by transanal local excision for T2 rectal cancer confers equivalent survival benefit as traditional transabdominal resection. Surgery 165(6)

  29. Lee L, Kelly J, Nassif GJ, Atallah SB, Albert MR, Shridhar R, Monson JR (2017) Chemoradiation and local excision for T2N0 rectal cancer offers equivalent overall survival compared to standard resection: a national cancer database analysis. J Gastrointest Surg 21(10)

  30. Pucciarelli S, Giandomenico F, De Paoli A, Gavaruzzi T, Lotto L, Mantello G, Barba C, Zotti P, Flora S, Del Bianco P (2017) Bowel function and quality of life after local excision or total mesorectal excision following chemoradiotherapy for rectal cancer. Br J Surg 104(1)

  31. Jung SM, Yu CS, Park IJ, Kim TW, Kim JH, Yoon YS, Lim SB, Kim JC (2016) Oncologic safety of local excision compared with total mesorectal excision for ypT0-T1 rectal cancer: a propensity score analysis. Medicine 95(20)

  32. Marks J, Nassif G, Schoonyoung H, DeNittis A, Zeger E, Mohiuddin M, Marks G (2013) Sphincter-sparing surgery for adenocarcinoma of the distal 3 cm of the true rectum: results after neoadjuvant therapy and minimally invasive radical surgery or local excision. Surg Endosc 27(12)

  33. Lezoche E, Baldarelli M, Lezoche G, Paganini AM, Gesuita R, Guerrieri M (2012) Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br J Surg 99(9)

  34. Callender GG, Das P, Rodriguez-Bigas MA, Skibber JM, Crane CH, Krishnan S, Delclos ME, Feig BW (2020) Local excision after preoperative chemoradiation results in an equivalent outcome to total mesorectal excision in selected patients with T3 rectal cancer.. Annal Surg Oncol 17(2)

  35. Lezoche G, Baldarelli M, Paganini AM, De Sanctis A, Bartolacci S, Lezoche E (2008) A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc 22(2):352–358

    Article  CAS  PubMed  Google Scholar 

  36. Nicholls RJ, Zinicola R, Haboubi N (2019) Extramural spread of rectal cancer and the AJCC Cancer Staging Manual 8th edition, 2017. Ann Oncol 30:1394–1395

  37. Xu ZS, Cheng H, Xiao Y, Cao JQ, Cheng F, Xu WJ, Ying JQ, Luo J, Xu W (2017) Comparison of transanal endoscopic microsurgery with or without neoadjuvant therapy and standard total mesorectal excision in the treatment of clinical T2 low rectal cancer: a meta-analysis. Oncotarget 8:115681–115690

  38. Gu J, Yang Y (2020) National guidelines for diagnosis and treatment of colorectal cancer 2020 in China (English version). Chin J Cancer Res 32(04):415–445

    Article  Google Scholar 

  39. Chiniah M, Ganganah O, Cheng Y et al (2016) Transanal endoscopic microsurgery is an oncologically safe alternative to total mesorectal excision for stage I rectal cancer: results of a meta-analysis of randomized controlled trials. Int J Colorectal Dis 31:1501–4

  40. Chen Y-L, Huang Y-L, Luo L, Chen M-Z, Wang Y-Q, Lin D-Y (2021) Changes in quality of life and its correlation with defecation symptoms in rectal cancer patients after permanent and temporary colostomy. Adv Exp Med 21(18):3559–3563+3519

  41. Elmessiry MM, Van Koughnett JAM, Maya A et al (2014) Local excision of T1 and T2 rectal cancer: proceed with caution. Colorectal Dis 16:703–709

    Article  CAS  PubMed  Google Scholar 

  42. D’Ambrosio G, Paganini AM, Balla A et al (2016) Quality of life in non-early rectal cancer treated by neoadjuvant radio-chemotherapy and endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM) versus laparoscopic total mesorectal excision. Surg Endosc 30:504–511

  43. Huang Y, Gong C, Pan J-H (2014) Research progress of cetuximab in the treatment of advanced colorectal cancer. Chin J Cancer Biotherapy 21(5):595–599

  44. Peeters KCMJ, van de Velde CJH, Leer JWH, Martijn H, Junggeburt JMC, Kranenbarg EK et al (2005) Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients: a Dutch colorectal cancer group study. J Clin Oncol 23:6199–6206

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Acknowledgements

We would like to thank the researchers and study participants for their contributions.

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Authors and Affiliations

  1. Shaanxi University of Chinese Medicine, Shaanxi, China

    Shufa Tan & Shuilan Huang

  2. Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Shaanxi Province, Deputy No. 2, West Weiyang Road, Xianyang City, 712000, China

    Yan Ou & Qiangqiang Gao

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Contributions

Conceptualization: Shufa Tan; methodology: Shufa Tan, Yan Ou; formal analysis and investigation: Shufa Tan, Yan Ou; writing—original draft preparation: Shufa Tan; writing—review and editing: Shufa Tan; funding acquisition: Qiangqiang Gao; resources: Shufa Tan; supervision: Qiangqiang Gao.

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Correspondence to Qiangqiang Gao.

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Tan, S., Ou, Y., Huang, S. et al. Surgical, oncological, and functional outcomes of local and radical resection after neoadjuvant chemotherapy or chemoradiotherapy for early- and mid-stage rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 38, 132 (2023). https://doi.org/10.1007/s00384-023-04433-6

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