Kim NK, et al. Yonsei Med J. 2021 Mar;62(3):187-199. https://doi.org/10.3349/ymj.2021.62.3.187

The current standard treatment for locally advanced rectal cancer (LARC) in Korea and Western countries is a multimodal approach incorporating preoperative long‐course chemoradiotherapy (LCRT) followed by total mesorectal excision (TME) and adjuvant chemotherapy. This approach has significantly improved local control and reduced recurrence rates; however, the overall survival benefit has not been established. Although LCRT is a good option, there remain challenging unresolved problems for colorectal surgeons. We focused on four challenging issues in this review article. The first is LARC with resectable liver metastases, for which there has been no consensus regarding optimal management and practice thus far. The second is cancer progression at the time of restaging after completion of preoperative LCRT. To date, there have been few reports on this issue. The third is early recurrence after TME following preoperative LCRT, the reason for which is thought to be the delayed systemic chemotherapy in the preoperative LCRT protocol. The fourth is cost‐effectiveness. The preoperative LCRT protocol takes 5 weeks. After a 6‐8‐week waiting period, surgery is performed. Therefore, it is more time‐consuming than short‐course chemoradiotherapy. To overcome these issues, total neoadjuvant treatment (TNT) modalities, performed using various protocols, have been conducted globally based on cumulative experience. We also attempted to discuss previous TNT protocols in this article. One treatment strategy is not sufficient for patients with varying clinical characteristics. Therefore, we should revisit current treatment strategies based on recent clinical experience.

Aeris Jane D. Nacion, M.D., Youn Young Park, M.D., Ho Seung Kim, M.D., Ph.D., Seung Yoon Yang, M.D., Nam Kyu Kim, M.D., Ph.D., FACS, FASCRS. Journal of Minimally Invasive Surgery 2019;22:164-70. https://doi.org/10.7602/jmis.2019.22.4.164

Purpose: Locally advanced rectal cancer (LARC) is managed by chemoradiotherapy (CRT), followed by surgery. Herein we reported patients with metastases during or after CRT.Methods: Data of patients with LARC who received CRT from 2008 to 2017 were reviewed. Patients with metastases after CRT were included. Those with metastatic tumors at the initial diagnosis were excluded.Results: Fourteen patients (1.3%) of 1,092 who received CRT presented with metastases. Magnetic resonance circumferential resection margin (mrCRM) and mesorectal lymph nodes (LNs) were positive in 12 patients (85.7%). Meanwhile, magnetic resonance extramural vascular invasion (mrEMVI) was positive in 10 patients (71.4%). Magnetic resonance tumor regression grade (mrTRG) 4 and mrTRG5 was detected in 5 and 1 patient respectively. Ten patients (71.4%) underwent combined surgery and 3 (21.4%) received palliative chemotherapy.Conclusion: Patients with metastases after CRT showed a higher rate of positive mrCRM, mrEMVI, mesorectal LNs, and poor tumor response. Further studies with a large number of patients are necessary for better survival outcomes in LARC.