Rectal cancer is a highly prevalent disease. Evidence presented in the 2025 phase-III OPERA randomised trial suggests that Contact X-ray Brachytherapy (CXB), with external beam chemoradiotherapy, is a viable organ-preserving alternative to radical surgery. We conducted a systematic review and meta-analysis to assess the clinical effectiveness of CXB in the treatment of rectal cancer. This systematic review was prospectively registered (CRD42021284969) and reported following PRISMA guidelines. Multiple electronic databases were interrogated using the search terms "Rectal cancer", "Contact Brachytherapy", and synonym terms. Clinical complete response (cCR) was the primary outcome. Proportional meta-analyses were conducted and presented as forest plots with summary proportions and 95 % confidence intervals. The literature search identified 973 studies, of which 52 studies encompassing 5447 patients met the inclusion and exclusion criteria and were included in the meta-analysis. Pooled estimates of outcomes were as follows: cCR rate = 82 % (95 % CI 76-88 %), Local Regrowth rate = 20 % (95 % CI 15-25 %), regional metastasis rate = 3 % (95 % CI 2-4 %), salvage surgery rate = 14 % (95 % CI 11-18 %), long-term disease control post-salvage surgery rate = 88 % (95 % CI 78-96 %) and organ preservation = 81 % (95 % CI 74-88 %). CXB in the appropriately selected patient population can achieve long-term disease control and organ preservation whilst avoiding major surgery. Salvage surgery remains a viable option for patients who experience disease regrowth with excellent long-term disease control. Clinicians should discuss CXB with rectal cancer patients, presenting it as a viable and safe alternative to radical surgery. This is particularly pertinent for patients who are stoma-averse or older patients in frail health.

External Beam Radiotherapy (EBRT) followed by Contact X-ray Brachytherapy (CXB) and vice versa are viable alternatives to surgery for selected rectal cancer patients who have small tumours (≤3 cm). However, the optimal sequence of treatment needs to be established. We compared two approaches using Propensity Score (PS) matching and inverse probability treatment weighting (IPTW) analyses to investigate whether the sequence of treatment affected patient outcomes. This retrospective analysis (2008-2019) included patients with rectal adenocarcinoma (cT1-3,N0-1,M0, grade 1-2, size ≤ 3 cm) who received both EBRT and CXB, irrespective of treatment sequence. PS matching and IPTW were conducted to balance covariate standardised mean differences between groups. Oncological outcomes and rate of post-treatment rectal bleeding were assessed. Following PS matching and IPTW analyses from 251 eligible patients; 103 starting with EBRT (median follow-up: 37 [IQR:18-56] months) and 148 with CXB (median follow-up: 32 [IQR:16-54] months, a significant improvement in 3-year overall survival (77% vs 85%, p = 0.02, [HR:0.58 (95% CI:0.37-0.91)]) and a higher risk of post-treatment rectal bleeding (grade 1 (26%) and grade 2 (6%)) were found in patients who started with CXB (p = 0.08). No significant differences were observed in local regrowth (18% vs 12%, p = 0.47), distant relapse (10% vs 6%, p = 0.53), 3-year organ preservation rates (70% vs 75%, p = 0.20, [HR:0.66 (95% CI: 0.35-1.26)]), or disease-free survival (78% vs 82%, p = 0.17, [HR: 0.47 (95% CI: 0.16-1.38)]) CONCLUSION: In patients with rectal cancer (≤3 cm), commencing with CXB rather than EBRT, was associated with improved overall survival, but had a higher risk of G1/2 rectal bleeding. No statistically significant differences were observed in other oncological outcomes.

Radical surgery is the standard of care for early rectal cancer. However, alternative organ-preserving approaches are attractive, especially in frail or elderly patients as these avoid surgical complications. We have assessed the efficacy of sole Contact X-ray Brachytherapy (CXB) treatment in stage-1 rectal cancer patients who were unsuitable for or declined surgery. This retrospective multi-centre study (2009–2021) evaluated 76 patients with T1/2-N0-M0 rectal adenocarcinomas who were treated with CXB alone. Outcomes were assessed for the entire cohort and sub-groups based on the T-stage and the criteria for receiving CXB alone; Group A: patients who were fit enough for surgery but declined, Group B: patients who were high-risk for surgery and Group C: patients who had received prior pelvic radiation for a different cancer. With a median follow-up of 26(IQR:12–49) months, initial clinical Complete Response (cCR) was 82(70–93)% with rates of local regrowth 18(8–29)%, 3-year actuarial local control (LC) 84(75–95)%, distant relapse 3 %, and no nodal relapse. 5-year disease-free survival (DFS) and overall survival (OS) were 66(48–78)% and 58(44–75)%. Lower OS was observed in Groups B [HR:2.54(95 %CI:1.17, 5.59), p = 0.02] and C [HR:2.75(95 %CI:1.15, 6.58), p = 0.03]. Previous pelvic radiation predicted lower cCR and OS. The main toxicity was G1-2 rectal bleeding (26 %) and symptoms of impaired anal sphincter function were not reported in any patients. CXB treatment alone achieved a high cCR rate with satisfactory LC and DFS. Inferior oncological outcomes were observed in patients who had received prior pelvic radiotherapy. CXB alone, with its favourable toxicity profile and avoidance of general anaesthesia and surgery risks, therefore, can be considered for patients who are unsuitable for or refuse surgery.

Background/Objectives: With recent advancements in rectal cancer management leading to longer patient survival, the impact of various treatment approaches on patients’ quality of life (QOL) becomes an important focus of attention. While QOL studies exist for watch-and-wait after (chemo)radiation with/without local excision, data on health-related QOL (HRQOL) outcomes after contact X-ray brachytherapy (CXB) remain limited. This study evaluated functional and HRQOL outcomes in rectal cancer patients undergoing CXB and (chemo)radiation over one year. Methods: This prospective observational study (enrolment January–October 2023) with one-year follow-up assessed functional and HRQOL outcomes after CXB and (chemo)radiation using EORTC-QLQ-CR29, HADS, and EQ-5D-3L questionnaires. Longitudinal analyses were conducted using linear mixed-effects models, incorporating both fixed and random effects, following data processing based on relevant scoring manuals. Results: QOL was assessed in 53 patients who attended our centre for CXB for various clinical indications, with 51, 47, and 42 remaining at the end of treatment, 6-month, and 12-month follow-ups, respectively. Overall, symptom and functional scores from EORTC-QLQ-CR29 remained stable throughout the follow-up period. Significant improvements were observed in abdominal pain, flatulence, urinary frequency, and body weight at 12 months. HADS and EQ-5D-3L scores remained stable, while EQ-VAS scores showed improvement, indicating a good overall quality of life following CXB treatment. Conclusions: CXB treatment combined with (chemo)radiation maintained stable HRQOL, with some improvements in symptoms and QOL noted during the subsequent year. These findings will help rectal cancer patients understand the benefits and limitations of CXB as a treatment option.

Local excision can be a definitive treatment for T1 SM1 N0 rectal adenocarcinomas, but post-excision histology may reveal adverse features or more advanced tumour stage, requiring adjuvant treatment. For patients who are unfit or unwilling to undergo invasive surgery, Contact X-ray Brachytherapy (CXB) boost and external beam (chemo)radiotherapy [EB(C)RT] can be used as an alternative option to reduce recurrence risk. This study reports on patients who received post excision CXB with EB(C)RT between 2003 and 2020. It reports on lesion characteristics, excision techniques, and adjuvant treatment characteristics. Survival outcomes were compared across local excision techniques and radiotherapy schedules. Regression analysis was conducted to identify factors predictive of (local and distant) recurrence. In this cohort of 323 patients 5-year overall survival (OS) was 84.2 %, 3-year recurrence free survival (RFS) was 91.6 %, with 94.7 % disease-free and 95 % stoma-free. No significant differences were observed for 5-year OS and 3-year RFS between excision types (p = 0.10, p = 0.56) or radiotherapy schedules (p = 0.90, p = 0.13) respectively. Resection margin involvement tripled recurrence risk compared to R0 resections (OR = 3.67, 95 % CI: 1.13-16.42, p = 0.048). For high-risk pT1 tumours, post-excision treatment with EB(C)RT and CXB boost resulted in survival outcomes comparable to those reported with conversion to radical surgery. There were no significant differences in survival outcomes between radiotherapy schedules and local excision techniques. Involved resection margins were associated with a significantly increased recurrence risk. The clinical benefit of CXB should be formally evaluated in large, prospective studies.

Background: Minimally invasive techniques are the standard of care in colorectal surgery. However, high body mass index (BMI) presents technical and anaesthetic challenges. Robotic-assisted surgery offers potential advantages in this population; however, given its relatively recent adoption, outcome data remain limited. This article presents a single-centre case series evaluating the short-term surgical and anaesthetic outcomes of obese patients undergoing robotic colorectal resections. Methods: A retrospective review was performed of patients with BMI > 30 kg/m ² who underwent robotic colorectal cancer resection at Liverpool University Hospital NHS Trust between July 2019 and April 2024. Demographic, surgical, anaesthetic, and clinical outcome data were collected from a prospectively maintained database. Key measures included operative time, Trendelenburg positioning, critical care admissions, complications, and mortality. Results: Seventy-five patients [mean BMI 35.8 (range 30.0–66.1) kg/m ² ] underwent robotic resection. Conversion to open surgery occurred in one case (1.3%). Mean operative time was 380 min for rectal and 289 min for colonic resections. The average Trendelenburg tilt was 20 ^o (range 15–22), with an average lateral tilt of 15 ^o (range 10–20), and mean head down duration was 225 (range 120–320) min. Fifty-six (74.7%) patients had primary anastomosis; the anastomotic leak rate was 9.3%. Thirty-two per cent of patients were electively admitted to the critical care as part of our institutional pathway for high BMI-cases. Of these, three patients (4.0%) required overnight mechanical ventilation and were both extubated the following morning without further organ support. One case of postoperative visual disturbance, attributed to positioning, resolved fully. The 30- and 90-day mortality rate was 1.3%. Conclusion: Robotic colorectal surgery is a feasible and safe option in elevated BMI patients, with low conversion rates and acceptable morbidity. Importantly, prolonged Trendelenburg position did not appear to increase anaesthetic risk, with only one reversible positioning-related complication observed.