Yi Xiao

PURPOSE: High-risk locally advanced rectal cancer (LARC) carries a substantial risk of distant recurrence, which limits disease-free survival (DFS). We compared total neoadjuvant therapy (TNT) integrating long-course radiotherapy (LCRT) with uninterrupted doublet chemotherapy (doublet-LC TNT) versus conventional neoadjuvant chemoradiotherapy (nCRT). METHODS: In this multicenter, randomized, phase III trial, patients with stage II/III LARC and at least 1 high-risk feature (cT4a-b, cN2, mesorectal fascia involvement, or cT3c-d with extramural vascular invasion) were enrolled. Patients were assigned to doublet-LC TNT (induction, concurrent, and consolidation capecitabine plus oxaliplatin with LCRT) before surgery or nCRT (capecitabine with LCRT) followed by surgery and adjuvant chemotherapy. The primary end point was DFS (ClinicalTrials.gov identifier: NCT03177382 ). RESULTS: Between June 6, 2017, and December 27, 2023, 458 patients were randomly assigned to doublet-LC TNT (n = 232) or nCRT (n = 226). At a median follow-up of 51 months, doublet-LC TNT improved 3-year DFS (74.8% v 66.0%; hazard ratio [HR], 0.674 [95% CI, 0.489 to 0.929]; P = .016). Metastasis-free survival (MFS; 77.7% v 67.6%; HR, 0.655 [95% CI, 0.469 to 0.915]) and pathologic complete response rates (pCR; 26.37% v 9.80%; P < .001) were higher with doublet-LC TNT, whereas locoregional failure remained low and comparable (6.03% v 6.19%; P = .943). Although grade ≥3 adverse events during the neoadjuvant phase were more frequent with doublet-LC TNT (27.59% v 8.56%; P < .001), severe toxicities during the entire treatment course (28.02% v 24.32%; P = .371) and major postoperative complications (3.98% v 2.94%; P = .567) were comparable. CONCLUSION: Compared with conventional nCRT, doublet-LC TNT improved DFS, MFS, and pCR rates with manageable toxicity. These findings support this intensified, doublet-based regimen as a standard option within the modern TNT paradigm. Further comparative studies are warranted to evaluate these results against other short-course radiotherapy‑based or nondoublet-concurrent TNT regimens.

Objectives This study aimed to evaluate the diagnostic accuracy of MRI-based Node Reporting and Data System (Node-RADS) in diagnosing lymph node metastasis (LNM) and to investigate its prognostic significance in rectal cancer (RC) patients. Materials and methods Patients with RC who underwent radical rectal resection (including LN dissection) without any prior anti-tumour therapy between May 2019 and April 2023 were retrospectively included. Two radiologists independently scored lymph nodes using the MRI-based Node-RADS. The diagnostic performance of Node-RADS was estimated using the area under receiver operating characteristic (ROC) curves (AUC) and compared with size criteria and MRI reports conducted by experienced radiologists. Intra- and inter-observer agreement were both assessed. Disease-free survival (DFS), which served as a key postoperative prognostic indicator, was evaluated and compared between patients with low (1–3) and high (4–5) scores. Results Overall, 163 patients with RC were enrolled, including 53 with LNM. There were 98 men and 65 women with a mean age of 62.6 ± 10.1 years. Node-RADS showed a larger AUC (0.912) with higher sensitivity (81%) and specificity (97.3%) compared to size criteria (75.5% and 71.8%) and MRI reports (91.0% and 41.8%). Node-RADS scores were also evaluated and correlated with the prognosis in patients who had undergone radical rectal resection. A multivariable Cox model combining Node-RADS and extramural venous invasion (EMVI) showed good predictive performance for DFS (C-index: 0.718). Conclusion The Node-RADS scoring system, based on MRI, enhanced both sensitivity and specificity in detecting LNM in RC patients who directly received radical rectal resection and showed potential prognostic significance for RCs. Key Points Question What is the clinical utility of the MRI-based Node-RADS for treatment-naive RC? Findings The MRI-based Node-RADS demonstrated better diagnostic accuracy (AUC 0.912) for LNM and provided significant prognostic value for DFS in treatment-naive RC patients. Clinical relevance The MRI-based Node-RADS is a reliable diagnostic method for lymph node assessment in treatment-naive RC with higher sensitivity and specificity. It is also useful in predicting postoperative outcomes. Graphical Abstract

Background: The optimal level of ligation of the inferior mesenteric vein (IMV) during rectal cancer surgery remains unclear. Lymph nodes are distributed at the root of the IMV, but whether root ligation and lymphadenectomy significantly increase the number of lymph nodes harvested or improve patient prognosis remains unclear. This multicenter randomized–controlled trial was designed to compare long-term survival and short-term outcomes (surgical complications, lymph node yield, postoperative recovery) between high and low IMV ligation during laparoscopic radical rectal cancer resection. Methods: This multicenter randomized–controlled trial will enroll 1,516 patients undergoing laparoscopic-assisted radical resection for rectal cancer. Participants will be recruited and randomized (1:1) by using a dynamic minimization algorithm to balance covariates, including age, sex, American Society of Anesthesiologists classification, tumor location, body mass index, preoperative clinical stage, and neoadjuvant therapy. Patients will be allocated to either high ligation or low ligation of the IMV. The primary endpoint is 3-year disease-free survival. Discussion: The IMV ligation level is a critical yet controversial step in radical rectal cancer resection. High-level evidence is lacking regarding whether high IMV ligation improves rectal cancer prognosis, necessitating robust evidence to determine the optimal ligation level. Trial registration: ChiCTR, ChiCTR2300069149. Registered 8 March 2023, https://www.chictr.org.cn/showproj.html? proj=187562.

Purpose: Although robotic surgery has advanced minimally invasive techniques, its ergonomic limitations pose significant musculoskeletal risks to surgeons. This study evaluated whether the Kangduo SR-01 (KD) open console system mitigates intraoperative ergonomic strain while preserving technical performance during robotic colorectal resection. Methods: This study utilized data from a multicenter randomized controlled non-inferiority trial comparing the efficacy and safety of KD versus Da Vinci (DV) robotic systems in assisting colorectal cancer resection. The assessment framework included ergonomic strain (Borg CR-10 Scale), team coordination (Oxford NOTECHS II), and blinded video-based technical performance analysis [Objective Structured Assessment of Technical Skills (OSATS)]. Results: A total of 100 patients were included in the modified intention-to-treat analysis: 50 in the KD group and 50 in the DV group. Body mass index (BMI) and resection types were comparable between groups. Postural demands were significantly higher for neck and back during DV procedures. Discomfort increased significantly more over time (up to 3 h) in the DV group for both neck [MD (95% c.i.) −0.889 (−1.077, −0.701), P < 0.001] and back [MD (95% c.i.) −0.606 (−0.847, −0.364), P < 0.001]. Notably, both systems achieved equivalent technical proficiency (OSATS total: 29.0 vs. 29.0, P = 0.259) and team coordination (NOTECHS II: 74.0 vs. 73.0, P = 0.120) with comparable short-term outcomes. Conclusions: The Kangduo SR-01 open console system significantly alleviated musculoskeletal strain, particularly in the neck and back, during robotic colorectal surgery while maintaining equivalent technical performance. These findings position open console platforms as a viable solution to ergonomic challenges in robotic surgery without compromising team dynamics or procedural efficiency.

Background: Rectal endometriosis is a complex condition requiring multidisciplinary treatment. Accurate preoperative assessment is critical for selecting the appropriate surgical technique, with transvaginal ultrasound (TVS) and endorectal ultrasound (ERUS) being key diagnostic tools. While TVS is effective in detecting ovarian endometriosis and pelvic deep infiltrating endometriosis, it has limitations in assessing bowel involvement. ERUS, however, provides detailed imaging of the rectal wall and depth of invasion. Materials and methods: A single-center prospective cohort study included 23 patients suspected of rectal endometriosis between August 2023 and September 2024. Perioperative findings and questionnaires, including Endometriosis Health Profile-30 and Gastrointestinal Quality of Life Index (GIQLI), were assessed. Results: Preoperative ERUS revealed that 82.6% of patients had a single rectal nodule, with a mean size of 2.1 ± 0.7 cm in length and 1.1 ± 0.6 cm in width. Luminal stenosis was found in two patients, and 100.0% of nodules extended into the muscular layer. TVS detected ovarian endometriosis and adenomyosis in 47.8% of patients and identified single rectal nodules in 60.9%, with a mean nodule length of 2.7 cm. Surgical approaches included rectal shaving (12 patients), disc excision (8 patients), and segmental resection (3 patients). Luminal stenosis was absent in the shaving and disc excision groups but present in 66.7% of segmental resection cases. The segmental resection group had significantly larger nodules (3.4 ± 0.5 cm length, 2.1 ± 0.8 cm width, 56.8 ± 0.4 cm ² area). Postoperative complications were generally mild, with only one patient experiencing Grade II rectal bleeding. Significant improvements were observed in pain ( P = 0.004), control and powerlessness ( P = 0.004), emotional well-being ( P = 0.035), work-related issues ( P = 0.030), and sexual relationship quality ( P = 0.044). Conclusion: Our study highlights that combining preoperative ERUS with TVS improves the accuracy of assessments, enabling a more tailored surgical approach that enhances surgical outcomes and optimizes the management of rectal endometriosis.

Objective: To compare the overall survival (OS) and cancer-specific survival (CSS) of right-sided colon cancer patients undergoing CME versus D2 surgery after 5 years of follow-up, and to assess the heterogeneity of treatment effectiveness of CME between different subgroups. Summary Background Data: The 3-year result of the Radical Extent of lymphadenectomy of Laparoscopic Right Colectomy for colon cancer (RELARC) trial showed that standard D2 dissection should be performed in right-sided colon cancer patients. In patients with lymph node metastasis, complete mesocolic excision (CME) showed potentially favorable results. Methods: The parallel, open label, randomized controlled trial was conducted between January, 2016 to December, 2019 in 17 hospitals in China. Of a total of 1072 eligible patients enrolled, 995 patients were included in the modified intention-to-treat analysis. In the present study, the primary outcome was 5-year OS and the secondary outcome was 5-year CSS. The trial is registered with ClinicalTrials.gov (Identifier: NCT02619942). Results: 995 patients were included in the final analysis. There was no significant difference between the 5-year OS (HR: 0.74, 95%CI: 0.51–1.07, P=0.105) or CSS (HR: 0.72, 95%CI: 0.49–1.06, P=0.091) in the CME and D2 groups. CME appears to improve 5-year outcomes in patients with stage III disease (OS: HR: 0.58, 95% CI: 0.37–0.93, P=0.023; CSS: HR: 0.59, 95% CI: 0.37–0.94, P=0.028), particularly in those with pN2 (OS: HR: 0.25, 95% CI: 0.11–0.57, P=0.001; CSS: HR: 0.25, 95% CI: 0.11–0.57, P=0.001), where a statistically significant interaction was identified. Patients with lymphovascular invasion also demonstrated favorable outcomes with CME with significant interaction effect (OS: HR: 0.34, 95% CI: 0.17–0.70; interaction P=0.009; CSS: HR: 0.32, 95% CI: 0.15–0.67, interaction P=0.008). Conclusion: The standard D2 dissection provides oncologic outcomes comparable to CME on the 5-year follow-up. However, CME seems to improve 5-year outcomes in patients with stage III, particularly those with pN2 status, and may confer benefit in patients with LVI.

Background/Objectives: The metastatic patterns of apical lymph node (ALN) in rectal and sigmoid colon cancer are currently unclear, and there is no consensus on the indications for dissection of ALN. This study aimed to analyze the impact of ALN metastasis on prognosis, determine the metastatic patterns of ALN and provide evidence for indications of ALN dissection in rectal and sigmoid colon cancer. Methods: In this multicenter, retrospective cohort study, patients from five centers with stage I-III rectal or sigmoid colon cancer who underwent laparoscopic radical surgery with ALN dissection without neoadjuvant treatment from January 2015 to December 2019 were enrolled. Results: Among 2809 patients, the positive rate of ALN was 1.9%. The 5-year overall survival and cancer-specific survival rate for patients with metastatic ALN were 37.5% and 41.0%, respectively. ALN metastasis was the independent risk factor for poor prognosis. Tumor size ≥5 cm (OR = 2.32, 95% CI: 1.30–4.13, p = 0.004), signet ring cell cancer/mucinous adenocarcinoma (vs. poor differentiated adenocarcinoma, OR = 0.19, 95% CI: 0.08–0.45, p < 0.001; vs. moderate to well differentiated adenocarcinoma, OR = 0.22, 95% CI: 0.11–0.42, p < 0.001), T4 stage (OR = 1.93, 95% CI: 1.05–3.55, p = 0.034), N2 stage (OR = 8.86, 95% CI: 4.45–17.65, p < 0.001) and radiologic evidence of extramural venous invasion (OR = 1.88, 95% CI: 1.03–3.42, p = 0.040) were independent risk factors for ALN metastasis. The nomogram model developed by these factors achieved a good predictive performance. Conclusions: This research offered insights into the incidence, risk factors, and prognostic significance of apical lymph node metastasis in cases of rectal and sigmoid colon cancer. Additionally, the study furnished empirical support for the criteria guiding ALN dissection. Furthermore, a pragmatic risk assessment model was developed to predict ALN metastasis.