Purpose: Trials comparing minimally invasive rectal surgery have uniformly excluded T4 tumors. The present study aimed to determine the safety of minimally invasive surgery (MIS) for locally-advanced rectal cancers requiring pelvic exenterations based on benchmarked outcomes from the international PelvEx database. Methods: Consecutive patients of T4 rectal cancers with urogenital organ invasion that underwent MIS exenterations between November 2015 and June 2022 were analyzed from a single center. A safety threshold was set at 20% for R1 resections and 40% for major complications (≥grade IIIA) for the upper limit of the 95% confidence interval (CI). Results: The study included 124 MIS exenterations. A majority had a total pelvic exenteration (74 patients, 59.7%). Laparoscopic surgery was performed in 95 (76.6%) and 29 (23.4%) had the robotic operation. Major complications were observed in 35 patients (28.2%; 95% CI, 20.5%–37.0%). R1 resections were found pathologically in nine patients (7.3%; 95% CI, 3.4%–13.4%). The set safety thresholds were not crossed. At a median follow-up of 15 months, 44 patients (35.5%) recurred with 8.1% local recurrence rate. The 2-year overall and disease-free survivals were 85.2% and 53.7%, respectively. Conclusion MIS exenterations for locally-advanced rectal cancers demonstrated acceptable morbidity and safety in term of R0 resections at experienced centers. Longer follow-up is required to demonstrate cancer survival outcomes.

Purpose: The current study was conducted to examine the role of consolidation chemotherapy after neoadjuvant radiation therapy (NART) in decreasing the involvement of the mesorectal fascia (MRF) in high-risk locally advanced rectal cancers (LARCs). Methods: In total, 46 patients who received consolidation chemotherapy after NART due to persistent MRF involvement were identified from a database. A team of 2 radiologists, blinded to the clinical data, studied sequential magnetic resonance imaging (MRI) scans to assess the tumor response and then predict a surgical plan. This prediction was then correlated with the actual procedure conducted as well as histopathological details to assess the impact of consolidation chemotherapy. Results: The comparison of MRI-based parameters of sequential images showed significant downstaging of T2 signal intensity, tumor height, MRF involvement, diffusion restriction, and N category between sequential MRIs (P < 0.05). However, clinically relevant downstaging (standardized mean difference, > 0.3) was observed for only T2 signal intensity and diffusion restriction on diffusion-weighted imaging. No clinically relevant changes occurred in the remaining parameters; thus, no change was noted in the extent of surgery predicted by MRI. Weak agreement (Cohen κ coefficient, 0.375) and correlation (Spearman rank coefficient, 0.231) were found between MRI-predicted surgery and the actual procedure performed. The comparison of MRI-based and pathological tumor response grading also showed a poor correlation. Conclusion Evidence is lacking regarding the use of consolidation chemotherapy in reducing MRF involvement in LARCs. The benefit of additional chemotherapy after NART in decreasing the extent of planned surgery by reducing margin involvement requires prospective research.

PURPOSE: Perioperative chemotherapy improves survival outcomes in locally advanced (LA) gastric cancer. MATERIALS AND METHODS: We retrospectively analyzed patients with LA gastric cancer who were offered perioperative chemotherapy consisting of epirubicin, oxaliplatin, and capecitabine (EOX) from May 2013 to December 2015 at Tata Memorial Hospital in Mumbai. RESULTS: Among the 268 consecutive patients in our study, 260 patients (97.0%) completed neoadjuvant chemotherapy, 200 patients (74.6%) underwent D2 lymphadenectomy, and 178 patients (66.4%) completed adjuvant chemotherapy. The median follow-up period was 17 months. For the entire cohort, the median overall survival (OS), 3-year OS rate, median progression-free survival (PFS), and 3-year PFS rate were 37 months, 64.4%, 31 months, and 40%, respectively. PFS and OS were significantly inferior in patients who presented with features of obstruction than in those who did not (P=0.0001). There was no difference in survival with respect to tumor histology (well to moderately differentiated vs. poorly differentiated, signet ring vs. non-signet ring histology) or location (proximal vs. distal). Survival was prolonged in patients with an early pathological T stage and a pathological node-negative status. In a multivariate analysis, postoperative pathological nodal status and gastric outlet obstruction on presentation significantly correlated with survival. CONCLUSIONS: EOX chemotherapy with curative resection and D2 lymphadenectomy is a suggested alternative to the existing perioperative regimens. The acceptable postoperative complication rate and relatively high resection, chemotherapy completion, and survival rates obtained in this study require further evaluation and validation in a clinical trial.
Capecitabine* ; Chemotherapy, Adjuvant ; Cohort Studies ; Disease-Free Survival ; Drug Therapy* ; Epirubicin* ; Follow-Up Studies ; Gastrectomy ; Gastric Outlet Obstruction ; Humans ; Lymph Node Excision ; Lymph Nodes ; Multivariate Analysis ; Postoperative Complications ; Retrospective Studies ; Stomach Neoplasms* ; Survival Analysis* ; Survival Rate