MRI plays a critical role in assessing clinical complete response for patient selection and monitoring with the watch and wait strategy, otherwise known as nonoperative management, in rectal cancer... The diagnosis and treatment of rectal cancer have evolved dramatically over the past several decades. At the same time, its incidence has increased in younger populations. This review will inform t...

BACKGROUND: The watch-and-wait strategy provides an opportunity to pursue nonoperative management in rectal cancer patients with clinical complete response after neoadjuvant therapy. The management of those with near-complete response remains controversial. OBJECTIVE: We assessed the oncologic outcomes of patients managed by watch-and-wait versus total mesorectal excision according to clinical response to neoadjuvant therapy. DESIGN: Retrospective cohort study. SETTINGS: Comprehensive cancer center in New York. PATIENTS: Patients with rectal adenocarcinoma diagnosed between January 2006 and December 2020. INTERVENTIONS: A watch-and-wait strategy of active surveillance was offered to patients if they achieved clinical complete response. Salvage surgery was used for watch-and-wait patients with local regrowth. Patients with an incomplete response underwent total mesorectal excision. MAIN OUTCOME MEASURES: Local regrowth rate, organ preservation rate, disease-free survival, and overall survival. RESULTS: Patients with rectal adenocarcinoma (n = 1230) were divided into 3 response cohorts—incomplete (n = 646), near-complete (n = 189), and complete (n = 395). Eighty-one patients (43%) in the near-complete group and 351 patients (89%) in the complete group entered watch-and-wait. Three-year local regrowth rates were 40% and 24% in the near-complete and complete response cohorts, respectively. The 5-year organ preservation rate was 53% in near-complete responders and 73% in complete responders. Five-year disease-free survival increased with greater clinical response to neoadjuvant therapy, with intermediate outcomes noted for patients with a near-complete (73%) compared to complete (82%) or incomplete (68%) response. Overall survival at 5 years was similar between the 3 cohorts (complete 90%, near-complete 86%, and incomplete 85%). LIMITATIONS: Retrospective nature. CONCLUSIONS: Greater clinical response to neoadjuvant therapy is associated with improved oncologic outcomes. Near-complete responders may avoid surgery and still achieve high organ preservation rates yet experience greater local regrowth rates than clinical complete response patients. Ongoing prospective trials integrating watch-and-wait after complete response as determined by uniform criteria will bolster the work to help treating physicians better select patients who qualify for active surveillance. See Video Abstract. CORRELACIÓN ENTRE EL GRADO DE RESPUESTA CLÍNICA A LA TERAPIA NEOADYUVANTE CONTRA EL CÁNCER DEL RECTO Y LOS RESULTADOS ONCOLÓGICOS EN LA ERA DE OBSERVAR Y ESPERAR: ANTECEDENTES: La estrategia de observar y esperar brinda la oportunidad de buscar un tratamiento no quirúrgico en pacientes con cáncer del recto con respuesta clínica completa después de la terapia neoadyuvante. El tratamiento de aquellos con respuesta casi completa sigue siendo controversial. OBJETIVO: Evaluamos los resultados oncológicos de los pacientes tratados con observar y esperar versus escisión mesorrectal total según la respuesta clínica a la terapia neoadyuvante. DISEÑO: Estudio de cohorte retrospectivo. CONFIGURACIÓN: Centro oncológico integral en Nueva York. PACIENTES: Pacientes con adenocarcinoma rectal diagnosticado entre enero de 2006 y diciembre de 2020. INTERVENCIONES: Se ofreció una estrategia de observar y esperar de vigilancia activa a los pacientes si lograban una respuesta clínica completa. Se utilizó cirugía de rescate para pacientes en observar y esperar con recrecimiento local. Los pacientes con una respuesta incompleta se sometieron a escisión mesorrectal total. PRINCIPALES MEDIDAS DE RESULTADO: Tasa de recrecimiento local, tasa de preservación de órganos, supervivencia libre de enfermedad y supervivencia general. RESULTADOS: Los pacientes con adenocarcinoma rectal (n = 1230) se dividieron en 3 cohortes de respuesta: incompleta (n = 646), casi completa (n = 189) y completa (n = 395). Ochenta y un (43%) pacientes en el grupo casi completo y 351 (89%) pacientes en el grupo completo ingresaron en observar y esperar. Las tasas de recrecimiento local a tres años fueron del 40% y 24% en las cohortes de respuesta casi completa y completa, respectivamente. La tasa de preservación de órganos a 5 años fue del 53% en los respondedores casi completos y del 73% en los respondedores completos. La supervivencia libre de enfermedad a cinco años aumentó con una mayor respuesta clínica a la terapia neoadyuvante con resultados intermedios observados para pacientes con una respuesta casi completa (73%) en comparación con la completa (82%) o incompleta (68%). La supervivencia global a los 5 años fue similar entre las tres cohortes (completa 90%, casi completa 86% e incompleta 85%). LIMITACIONES: Naturaleza retrospectiva. CONCLUSIÓN: Una mayor respuesta clínica a la terapia neoadyuvante se asocia con mejores resultados oncológicos. Los pacientes con respuesta casi completa pueden evitar la cirugía y aun así lograr altas tasas de preservación de órganos, pero experimentar mayores tasas de recrecimiento local que los pacientes con respuesta clínica completa. Los ensayos prospectivos en curso que integran observar y esperar después de la respuesta completa según lo determinado por criterios uniformes reforzarán el trabajo para ayudar a los médicos tratantes a seleccionar mejor a los pacientes que califican para la vigilancia activa. (Traducción—Dr. Aurian Garcia Gonzalez)

A small proportion of rectal adenocarcinomas develop in patients many years after the treatment of a previous cancer using pelvic radiation, and the incidence of these rectal cancers depends on the length of follow-up from the end of radiotherapy. The risk of radiation-associated rectal cancer (RARC) is higher in patients treated with prostate external beam radiotherapy than it is in patients treated with brachytherapy. The molecular features of RARC have not been fully investigated, and survival is lower compared to non-irradiated rectal cancer patients. Ultimately, it is unclear whether the worse outcomes are related to differences in patient characteristics, treatment-related factors, or tumor biology. Radiation is widely used in the management of rectal adenocarcinoma; however, pelvic re-irradiation of RARC is challenging and carries a higher risk of treatment complications. Although RARC can develop in patients treated for a variety of malignancies, it is most common in patients treated for prostate cancer. This study will review the incidence, molecular characteristics, clinical course, and treatment outcomes of rectal adenocarcinoma in patients previously treated with radiation for prostate cancer. For clarity, we will distinguish between rectal cancer not associated with prostate cancer (RCNAPC), rectal cancer in non-irradiated prostate cancer patients (RCNRPC), and rectal cancer in irradiated prostate cancer patients (RCRPC). RARC represents a unique but understudied subset of rectal cancer, and thus requires a more comprehensive investigation in order to improve its treatment and prognosis.

We examined racial disparities in guideline concordant care (GCC) and clinical outcomes of colon cancer patients treated at a single comprehensive cancer center. We analyzed data from self-reported Hispanic, non-Hispanic Black (NHB), and Non- Hispanic White (NHW) patients who underwent curative colectomy for stage I-III colon cancer between 2006 and 2021 at Memorial Sloan Kettering. GCC was defined as retrieval of ≥12 lymph nodes and appropriate receipt of adjuvant chemotherapy. Recurrence and overall survival from time of surgery were compared using the Kaplan-Meier method and the log-rank test. Multivariable analyses were performed using Cox regression. The study included 2209 patients, with 1911 NHW, 153 NHB, and 145 Hispanic patients. NHW patients were older, while NHB patients had higher percentages of Medicaid coverage, obesity, and lower socioeconomic status. NHB patients more often presented with stage III disease and underwent open surgery. Receipt of GCC was not different by race. NHB patients had the highest 5-year recurrence rate compared to NHW and Hispanic patients (27% vs. 15.7% vs. 15.1%; p=0.03). NHB race (HR 1.43, p=0.07) and low body mass index (HR 1.98, p=0.05) were associated with increased risk of recurrence with marginal significance. NHB race was associated with increased risk of recurrence in stage I disease (HR 3.52, p=0.03). NHB patients had shorter recurrence free survival, despite standardized quality of care. NHB race was independently associated with increased risk of recurrence in stage I disease.

Figure S2. Kaplan-Meier curves show overall survival from time of surgery for NHW, NHB and Hispanic patients.

Key Clinical Message: Here, we discuss a relatively uncommon presentation of a hepatocellular carcinoma and discuss its preoperative planning and surgical intervention required to reach complete resection.