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Colorectal cancer
Effects of clinical information on the treatment decisions for good responders to neoadjuvant chemoradiotherapy among rectal cancer patients
Eon Bin Kim, In Ja Park, Hwa Jung Kim, Jong Keon Jang, Seong Ho Park, Young Il Kim, Min Hyun Kim, Jong Lyul Lee, Chan Wook Kim, Yong Sik Yoon, Seok-Byung Lim, Chang Sik Yu
Ann Coloproctol. 2025;41(5):473-482.   Published online July 10, 2025
DOI: https://doi.org/10.3393/ac.2024.00276.0039
  • 1,628 View
  • 35 Download
  • 1 Web of Science
  • 1 Citations
AbstractAbstract PDFSupplementary Material
Purpose
The decision for treatment after neoadjuvant chemoradiotherapy (nCRT) in rectal cancer is intricately linked to tumor response and clinical parameters. This study was designed to elucidate determinants influencing treatment decisions for good responders to nCRT, while concurrently evaluating the ramifications of modifications in magnetic resonance imaging (MRI) tumor response evaluation protocols.
Methods
A survey was constructed with 5 cases of good responder after nCRT based on the magnetic resonance–based tumor regression grade (mrTRG) criteria. A total of 35 colorectal surgeons in Korea participated in the survey via email, and they were introduced to 2 discrete MRI-based tumor response evaluation methodologies: the conventional mrTRG and an emergent complete response (CR)/non-CR classification system. Surgeons were directed to select between total mesorectal excision, local excision, or a watch and wait strategy.
Results
Treatment decisions varied significantly (P<0.01), as gradually more clinical information was provided with mrTRG. The paradigm shift from mrTRG to CR/non-CR evaluation criterion instigated the highest alteration in decision (P<0.01). Even comparing with other sets of information, decision change with different tumor response assessment (i.e., mrTRG vs. CR/non-CR) was statistically significant (P<0.01). Three particular cases consistently displayed a declining predilection for total mesorectal excision, favoring a more pronounced inclination towards watch and wait strategy or local excision. Nonetheless, the magnitude of these decisional shifts oscillated depending on the specific endoscopic imagery present.
Conclusion
Our current findings underscore the significant role of tumor response assessment methods in shaping treatment decisions for rectal cancer patients who respond well to nCRT. This highlights the need for clear and accurate tools to interpret MRI results.

Citations

Citations to this article as recorded by  
  • Clinical implications of radiologic criteria and prognostic factors for lateral lymph node metastasis in low rectal cancer
    Gyung Mo Son
    Annals of Coloproctology.2025; 41(6): 489.     CrossRef
Colorectal cancer
Is clinical complete response as accurate as pathological complete response in patients with mid-low locally advanced rectal cancer?
Niyaz Shadmanov, Vusal Aliyev, Guglielmo Niccolò Piozzi, Barıs Bakır, Suha Goksel, Oktar Asoglu
Ann Coloproctol. 2025;41(1):57-67.   Published online February 28, 2025
DOI: https://doi.org/10.3393/ac.2024.00339.0048
  • 10,246 View
  • 313 Download
  • 5 Web of Science
  • 6 Citations
Graphical AbstractGraphical Abstract AbstractAbstract PDF
Purpose
The standard treatment for locally advanced rectal cancer involves neoadjuvant chemoradiation followed by total mesorectal excision surgery. A subset of patients achieves pathologic complete response (pCR), representing the optimal treatment outcome. This study compares the long-term oncological outcomes of patients who achieved pCR with those who attained clinical complete response (cCR) after total neoadjuvant therapy, managed using a watch-and-wait approach.
Methods
This study retrospectively evaluated patients with mid-low locally advanced rectal cancer who underwent neoadjuvant treatment from January 1, 2005, to May 1, 2023. The pCR and cCR groups were compared based on demographic, clinical, histopathological, and long-term survival outcomes.
Results
The median follow-up times were 54 months (range, 7–83 months) for the cCR group (n=73), 96 months (range, 7–215 months) for the pCR group (n=63), and 72 months (range, 4–212 months) for the pathological incomplete clinical response (pICR) group (n=627). In the cCR group, 15 patients (20.5%) experienced local regrowth, and 5 (6.8%) developed distant metastasis (DM). The pCR group had no cases of local recurrence, but 3 patients (4.8%) developed DM. Among the pICR patients, 58 (9.2%) experienced local recurrence, and 92 (14.6%) had DM. Five-year disease-free survival rates were 90.0% for cCR, 92.0% for pCR, and 69.5% for pICR (P=0.022). Five-year overall survival rates were 93.1% for cCR, 92.0% for pCR, and 78.1% for pICR. There were no significant differences in outcomes between the cCR and pCR groups (P=0.810); however, the pICR group exhibited poorer outcomes (P=0.002).
Conclusion
This study shows no significant long-term oncological differences between patients who exhibited cCR and those who experienced pCR.

Citations

Citations to this article as recorded by  
  • Total neoadjuvant therapy in rectal cancer: The FOREST protocol, a patient‐centered approach that clusters two cohorts with different outcomes
    Hector Guadalajara, Jose Luis Domínguez‐Tristancho, Raquel Fuentes Mateo, Miguel Leon‐Arellano, Raquel Sanz‐Baro, Eleonora Geraldi, Ana Isabel Hormigo‐Sanchez, Víctor Manuel Castellano Megías, Marta Pérez Cobos, Patricia Mellado Miras, Begoña Lopez‐Botet
    International Journal of Cancer.2026; 158(3): 697.     CrossRef
  • Organ preservation in rectal cancer: Clinical basis of the watch-and-wait strategy
    Rosa M. Jimenez-Rodriguez, Fátima Aguilar-del-Castillo, Felipe Quezada-Diaz, Julio García-Aguilar
    Cirugía Española (English Edition).2026; 104(1): 800248.     CrossRef
  • Preservación del órgano en cáncer de recto: fundamentos clínicos de la estrategia watch-and-wait
    Rosa M. Jimenez-Rodriguez, Fátima Aguilar-del-Castillo, Felipe Quezada-Diaz, Julio García-Aguilar
    Cirugía Española.2026; 104(1): 800248.     CrossRef
  • Pathological Complete Response in Rectal Cancer Patients: A Correlation Between Pathological and Clinical Stage and Oncological Outcome
    Ana Grigoraș, Dragoș-Viorel Scripcariu, Ionuț Huțanu, Bogdan Filip, Mihaela-Mădălina Gavrilescu, Maria-Gabriela Aniței, Gheorghe Bălan, Viorel Scripcariu
    Cancers.2026; 18(2): 223.     CrossRef
  • The Shifting and Evolving Neoadjuvant Treatments and Surgical Platforms on Oncological Outcomes and Sphincter Preservation in Distal Rectal Cancer: A 23-Year Retrospective Experience
    Niyaz Shadmanov, Vusal Aliyev, Barıs Bakır, Suha Goksel, Oktar Asoglu
    Journal of Gastrointestinal Cancer.2025;[Epub]     CrossRef
  • Clinical implications of radiologic criteria and prognostic factors for lateral lymph node metastasis in low rectal cancer
    Gyung Mo Son
    Annals of Coloproctology.2025; 41(6): 489.     CrossRef
Efficacy and Feasibility of Adding Induction Chemotherapy to Neoadjuvant Chemoradiation in Locally Advanced Rectal Cancer: A Phase II Clinical Trial
Hamid Nasrolahi, Sepideh Mirzaei, Mohammad Mohammadianpanah, Ali Mohammad Bananzadeh, Maral Mokhtari, Mohammad Reza Sasani, Ahmad Mosalaei, Shapour Omidvari, Mansour Ansari, Niloofar Ahmadloo, Seyed Hasan Hamedi, Nezhat Khanjani
Ann Coloproctol. 2019;35(5):242-248.   Published online October 31, 2019
DOI: https://doi.org/10.3393/ac.2018.09.06
  • 6,664 View
  • 93 Download
  • 5 Web of Science
  • 5 Citations
AbstractAbstract PDF
Purpose
Currently, neoadjuvant chemoradiation (CRT) followed by total mesorectal resection is considered the standard of care for treating locally advanced rectal cancer. This study aimed to investigate the efficacy and feasibility of adding induction chemotherapy to neoadjuvant CRT in locally advanced rectal cancer.
Methods
This phase-II clinical trial included 54 patients with newly diagnosed, locally advanced (clinical T3–4 and/or N1–2, M0) rectal cancer. All patients were treated with 3 cycles of preoperative chemotherapy using the XELOX (capecitabine + oxaliplatin) regimen before and after a concurrent standard long course of CRT (45–50.4 Gy) followed by standard radical surgery. Pathologic complete response (PCR) rate and toxicity were the primary and secondary endpoints, respectively.
Results
The study participants included 37 males and 17 females, with a median age of 59 years (range, 20–80 years). Twenty-nine patients (54%) had clinical stage-II disease, and 25 patients (46%) had clinical stage-III disease. Larger tumor size (P = 0.006) and distal rectal location (P = 0.009) showed lower PCR compared to smaller tumor size and upper rectal location. Pathologic examinations showed significant tumor regression (6.1 ± 2.7 cm vs. 1.9 ± 1.8 cm, P < 0.001) with 10 PCRs (18.5%) compared to before the intervention. The surgical margin was free of cancer in 52 patients (96.3%). Treatment-related toxicities were easily tolerated, and all patients completed their planned treatment without interruption. Grade III and IV toxicities were infrequent.
Conclusion
The addition of induction chemotherapy to neoadjuvant CRT is an effective and well-tolerated treatment approach in patients with rectal cancer.

Citations

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    An Lu, Yuhao Guo, Yi Yan, Lin Zhai, Xiangyu Wang, Weiran Cao, Zijie Li, Zhixia Zhao, Yujie Shi, Yuanjun Zhu, Xiaoyan Liu, Huining He, Zhiyu Wang, Jian-Cheng Wang
    Chinese Chemical Letters.2024; 35(6): 108928.     CrossRef
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    In Ja Park
    Precision and Future Medicine.2022; 6(2): 91.     CrossRef
  • Intensified Total Neoadjuvant Therapy in Patients With Locally Advanced Rectal Cancer: A Phase II Trial
    F. De Felice, G. D'Ambrosio, F. Iafrate, A. Gelibter, F.M. Magliocca, D. Musio, S. Caponetto, G. Casella, I. Clementi, A. Picchetto, G. Sirgiovani, M. Parisi, C. Orciuoli, G. Torrese, G. De Toma, V. Tombolini, E. Cortesi
    Clinical Oncology.2021; 33(12): 788.     CrossRef
  • Efficacy and safety of sequential neoadjuvant chemotherapy and short-course radiation therapy followed by delayed surgery in locally advanced rectal cancer: a single-arm phase II clinical trial with subgroup analysis between the older and young patients
    Alimohammad Bananzadeh, Ali Akbar Hafezi, NamPhong Nguyen, Shapour Omidvari, Ahmad Mosalaei, Niloofar Ahmadloo, Mansour Ansari, Mohammad Mohammadianpanah
    Radiation Oncology Journal.2021; 39(4): 270.     CrossRef
  • Induction Chemotherapy in Patients With Anal Canal Cancer: A Pilot Study
    Francesca De Felice, Daniela Musio, Vincenzo Tombolini
    Clinical Colorectal Cancer.2020; 19(3): e137.     CrossRef
Combination Assessment of Clinical Complete Response of Patients With Rectal Cancer Following Chemoradiotherapy With Endoscopy and Magnetic Resonance Imaging
Hye Mi Ko, Yo Han Choi, Jeong Eun Lee, Kyung Ha Lee, Ji Yeon Kim, Jin Soo Kim
Ann Coloproctol. 2019;35(4):202-208.   Published online August 31, 2019
DOI: https://doi.org/10.3393/ac.2018.10.15
  • 7,525 View
  • 176 Download
  • 19 Web of Science
  • 19 Citations
AbstractAbstract PDF
Purpose
The response to neoadjuvant chemoradiotherapy (CRT) for rectal cancer can be assessed using digital rectal examination, endoscopy and magnetic resonance imaging (MRI). Precise assessment of clinical complete response (CR) after CRT is essential when deciding between optimizing surgery or organ-preserving treatment. The objectives of this study were to correlate the CR finding in endoscopy and MRI with pathologic CR and to determine the appropriate approach for combining endoscopy and MRI to predict the pathologic CR in patients with rectal cancer after neoadjuvant CRT.
Methods
This retrospective cohort study included 102 patients with rectal cancer who underwent endoscopy and MRI at 2–4 weeks after CRT. We assigned a confidence level (1–4) for the endoscopic and MRI assessments. Accuracy, sensitivity, and specificity were analyzed based on the endoscopy, MRI, and combination method findings. Diagnostic modalities were compared using the likelihood ratios.
Results
Of 102 patients, 17 (16.7%) had a CR. The accuracy, sensitivity, and specificity for the prediction CR of endoscopy with biopsy were 85.3%, 52.9%, and 91.8%, while those of MRI were 91.2%, 70.6%, and 95.3%, and those of combined endoscopy and MRI were 89.2%, 52.9%, and 96.5%, respectively. No significant differences were noted in the sensitivity and specificity of any each modality. The prediction rate for CR of the combination method was 92.6% after the posttest probability test.
Conclusion
Our study demonstrated that combining the interpretation of endoscopy with biopsy and MRI could provide a good prediction rate for CR in patients with rectal cancer after CRT.

Citations

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  • Implementation of Organ Preservation for Locally Advanced Rectal Cancer in Canada: A National Survey of Clinical Practice
    Megan Delisle, Victoria Ivankovic, Doris Goubran, Eliane Yvonne Paglicauan, Mariam Alsobaei, Nicole Alcasid, Mary Farnand, Kristopher Dennis
    Current Oncology.2025; 32(6): 341.     CrossRef
  • Validierung künstlicher Intelligenz für die Klassifizierung von Mastdarmkrebs während endoskopischer Chirurgie
    Felix Aigner, David Duller, Christoph Skias, Gabriele Moitzi, Martin Mitteregger
    coloproctology.2025; 47(5): 340.     CrossRef
  • Endoscopic assessment of rectal cancer response after neoadjuvant chemoradiotherapy: A narrative literature review
    Fotios Seretis, Antonia Panagaki, Paraskevas Gkolfakis, Georgios Tziatzios, Konstantina Paraskeva
    World Journal of Clinical Oncology.2025;[Epub]     CrossRef
  • Assessing Endoscopic Response in Locally Advanced Rectal Cancer Treated with Total Neoadjuvant Therapy: Development and Validation of a Highly Accurate Convolutional Neural Network
    Hannah Williams, Hannah M. Thompson, Christina Lee, Aneesh Rangnekar, Jorge T. Gomez, Maria Widmar, Iris H. Wei, Emmanouil P. Pappou, Garrett M. Nash, Martin R. Weiser, Philip B. Paty, J. Joshua Smith, Harini Veeraraghavan, Julio Garcia-Aguilar
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  • Transanal endoscopic microsurgery after radiation or chemoradiation therapy for rectal cancer — peculiarities and results
    A А. Nevolskikh, A. R. Brodskiy, V. A. Avdeenko, T. P. Pochuev, Yu. Yu. Mihaleva, T. P. Berezovskaya, R. F. Zibirov, S. A. Myalina, I. A. Orehov, L. O. Petrov, S. A. Ivanov, A. D. Kaprin
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    Hannah Williams, Christina Lee, Julio Garcia-Aguilar
    Frontiers in Oncology.2024;[Epub]     CrossRef
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    Nicolai Egholt Munk, Peter Bondeven, Bodil Ginnerup Pedersen
    Acta Radiologica.2023; 64(1): 20.     CrossRef
  • Correlation of Tumor Response Between Flexible Sigmoidoscopy and Magnetic Resonance Imaging in Patients Undergoing Neoadjuvant Therapy for Locally Advanced Rectal Cancer: A Retrospective Review
    Maria A. Rojas, Jose Cataneo, Marianne Gagnon-Konamna, Daniel J. Borsuk, Angela J. Jarzabek, Slawomir J. Marecik, John J. Park, Kunal Kochar
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  • Endoscopy and MRI for restaging early rectal cancer after neoadjuvant treatment
    Rutger C. H. Stijns, Jeroen Leijtens, Eelco de Graaf, Simon P. Bach, Geerard Beets, Andre J. A. Bremers, Regina G. H. Beets‐Tan, Johannes H. W. de Wilt
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    Anqi Wang, Jieli Zhou, Gang Wang, Beibei Zhang, Hongyi Xin, Haiyang Zhou
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  • MRI Evaluation of Complete and Near-Complete Response after Neoadjuvant Therapy in Patients with Locally Advanced Rectal Cancer
    Anca-Raluca Popita, Cosmin Lisencu, Adriana Rusu, Cristian Popita, Calin Cainap, Alexandru Irimie, Liliana Resiga, Alina Munteanu, Zsolt Fekete, Radu Badea
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    In Ja Park
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    Inês Santiago, Maria-João Barata, Nuno Figueiredo, Oriol Parés, Celso Matos
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    Kirsten L Gormly
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    Cancers.2021; 13(19): 4823.     CrossRef
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    Filippo Crimì, Giulia Capelli, Gaya Spolverato, Quoc Riccardo Bao, Anna Florio, Sebastiano Milite Rossi, Diego Cecchin, Laura Albertoni, Cristina Campi, Salvatore Pucciarelli, Roberto Stramare
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    Seong Ho Park, Seung Hyun Cho, Sang Hyun Choi, Jong Keon Jang, Min Ju Kim, Seung Ho Kim, Joon Seok Lim, Sung Kyoung Moon, Ji Hoon Park, Nieun Seo
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    Fernando López-Campos, Margarita Martín-Martín, Roberto Fornell-Pérez, Juan Carlos García-Pérez, Javier Die-Trill, Raquel Fuentes-Mateos, Sergio López-Durán, José Domínguez-Rullán, Reyes Ferreiro, Alejandro Riquelme-Oliveira, Asunción Hervás-Morón, Felipe
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Oncologic Outcomes in Patients Who Undergo Neoadjuvant Chemoradiotherapy and Total Mesorectal Excision for Locally Advanced Rectal Cancer: A 14-Year Experience in a Single Institution
Min Jung Kim, Seung-Yong Jeong, Ji Won Park, Seung-Bum Ryoo, Sang Sik Cho, Ki Young Lee, Kyu Joo Park
Ann Coloproctol. 2019;35(2):83-93.   Published online April 30, 2019
DOI: https://doi.org/10.3393/ac.2019.04.22.1
  • 6,546 View
  • 98 Download
  • 21 Web of Science
  • 19 Citations
AbstractAbstract PDF
Purpose
This study evaluated the oncologic outcomes of locally advanced rectal cancer patients who underwent preoperative neoadjuvant chemoradiotherapy (CRT) followed by surgery and determined the prognostic significance of pathologic complete response (pCR).
Methods
Between January 2002 and December 2015, 580 patients with rectal cancer who underwent surgery after neoadjuvant CRT were identified. Survival according to tumor response to CRT and pathologic stage was analyzed using the Kaplan-Meier method, and the Cox proportional hazard model was used to identify factors associated with survival outcomes.
Results
A total of 111 patients (23.7%) achieved pCR while the other 469 patients showed residual disease. Patients with pCR had a lower pretreatment carcinoembryonic antigen level and earlier cT classification than those with residual disease. With a median follow-up of 78 months, disease-free survival (DFS) and overall survival (OS) were significantly better in the pCR group than in the residual disease group. The 5-year DFS and 5-year OS for patients with ypStage 0, I, II, or III were 92.5%, 85.1%, 72.2%, 54.3% (P < 0.001) and 94.5%, 91.0%, 83.1%, 69.3%, respectively (P < 0.001). Pathologic AJCC stage after CRT was the most statistically significant independent predictor of OS (HR, 6.97 [95% confidence interval, 3.16–15.39] for stage III vs. stage 0) and DFS (HR, 7.30 [95% confidence interval, 3.63–14.67] for stage III vs. stage 0).
Conclusion
Rectal cancer patients who achieved pCR showed improved survival compared to those with residual disease after preoperative CRT. Moreover, pCR was an independent indicator of OS and DFS, and pathologic AJCC stage was correlated with survival after preoperative CRT.

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Review
How to Achieve a Higher Pathologic Complete Response in Patients With Locally Advanced Rectal Cancer Who Receive Preoperative Chemoradiation Therapy
Suk-Hwan Lee
Ann Coloproctol. 2019;35(1):3-8.   Published online February 28, 2019
DOI: https://doi.org/10.3393/ac.2019.02.17
  • 5,849 View
  • 111 Download
  • 3 Web of Science
  • 3 Citations
AbstractAbstract PDF
The current standard of care for treating patients with locally advanced rectal cancer includes preoperative chemoradiation therapy (PCRT) followed by a total mesorectal excision and postoperative adjuvant chemotherapy. A subset of these patients has achieved a pathologic complete response (pCR) and they have shown improved disease-free and overall survival compared to non-pCR patients. Thus, many efforts have been made to achieve a higher pCR through PCRT. In this review, results from various ongoing and recently completed clinical trials that are being or have been conducted with an aim to improve tumor response by modifying therapy will be discussed.

Citations

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  • Predictors of Pathologic Response After Total Neoadjuvant Therapy in Patients With Rectal Adenocarcinoma: A National Cancer Database Analysis
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