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Original Article
Colorectal cancer
 Upfront surgery versus preoperative chemoradiotherapy: a comparative survival analysis for stage II/III resectable rectal cancer
Nattapanee Sukphol1,2orcid, Thitithep Limvorapitak1orcid
Annals of Coloproctology 2026;42(1):115-126.
DOI: https://doi.org/10.3393/ac.2025.00724.0103
Published online: February 26, 2026

1Division of Colorectal Surgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

2Department of Surgery, Chulabhorn Hospital, Princess Srisavangavadhana College of Medicine, Chulabhorn Royal Academy, Bangkok, Thailand

Correspondence to: Thitithep Limvorapitak, MD Division of Colorectal Surgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathumwan, Bangkok 10330, Thailand Email: thitithep.l@chulahospital.org
• Received: June 3, 2025   • Revised: August 9, 2025   • Accepted: September 29, 2025

© 2026 The Korean Society of Coloproctology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    Current international guidelines recommend neoadjuvant chemoradiotherapy (nCRT) followed by total mesorectal excision (TME) for locally advanced rectal cancer (LARC). Although nCRT reduces the risk of local recurrence, it has not demonstrated a survival advantage and increases the likelihood of preoperative overtreatment. This study investigated whether upfront TME could be offered without compromising oncologic outcomes.
  • Methods
    From January 2015 to December 2020, patients with stage II/III LARC who underwent either upfront TME or nCRT followed by TME were analyzed using propensity score matching. Long-term survival outcomes were compared between the 2 groups. The primary endpoint was 5-year disease-free survival. Secondary endpoints included 5-year local recurrence-free survival, distant metastasis-free survival, and overall survival.
  • Results
    A total of 348 patients were included, of whom 138 (39.7%) underwent upfront TME. The upfront TME group showed significantly higher 5-year disease-free survival (63.3% vs. 43.9%) and distant metastasis-free survival (88.1% vs. 70.3%). However, after excluding patients with preoperative mesorectal fascia (MRF) involvement, no significant differences were observed in long-term oncologic outcomes. Following 1:1 propensity score matching, 47 patients from each group were compared. Kaplan-Meier survival analysis revealed no significant differences in any endpoints. Cox regression analysis of the matched cohort indicated that preoperative MRF involvement, positive extramural vascular invasion, and tumor deposits were not independent prognostic factors.
  • Conclusion
    Upfront TME may represent a viable treatment option for selected patients with LARC, particularly those without MRF involvement, providing comparable oncologic outcomes to the standard nCRT approach.
  • Keywords: Rectal neoplasms; Colorectal surgery; Neoadjuvant chemoradiotherapy
Colorectal cancer (CRC) ranks as the third most common malignancy and the second leading cause of cancer-related mortality worldwide [1]. Rectal cancer specifically accounts for approximately 30% of all CRC cases. Early-stage rectal tumors can often be effectively treated with surgery alone; however, locally advanced disease is associated with high rates of locoregional recurrence and distant metastasis, necessitating a multimodal therapeutic strategy.
Over the past several decades, the management of locally advanced rectal cancer (LARC) has evolved from surgery alone to combined chemoradiotherapy. The 5-year relative survival rate for LARC ranges from 74% to 90%. Since the introduction of total mesorectal excision (TME), local recurrence rates have declined to 3.7%–13%, regardless of preoperative radiation or chemoradiation use. Nevertheless, the incidence of distant metastasis remains approximately 20% to 30%.
For clinical stage II–III LARC (cT3–T4 with or without nodal involvement), treatment guidelines diverge: the European Society for Medical Oncology (ESMO) recommends TME alone [2], while the National Comprehensive Cancer Network (NCCN) advises neoadjuvant chemoradiotherapy (nCRT) followed by TME [3, 4].
The primary aims of nCRT prior to TME are to improve survival outcomes and reduce local recurrence. Although strong evidence supports nCRT for tumor downstaging and local control [5, 6], it has not demonstrated a survival benefit and may lead to overtreatment. Moreover, nCRT can cause pelvic fibrosis, radiation-induced enteritis, and other toxicities that increase postoperative morbidity, including anastomotic leakage and delayed wound healing [7–10].
Emerging data suggest that high-quality upfront TME alone can achieve comparably low local recurrence rates (2%–4.4%) and similar 5-year disease-free survival (87% for TME alone vs. 88% for nCRT followed by TME) [11, 12]. These findings raise the question of whether nCRT is necessary for all resectable stage II–III rectal cancers.
In this study, we retrospectively evaluated whether upfront TME without preceding nCRT could provide equivalent long-term oncologic outcomes in patients with LARC.
Ethics statement
This study was approved by the Institutional Review Board of the Faculty of Medicine, Chulalongkorn University (No. 0735/66). The requirement for informed consent was waived due to the use of deidentified data and the retrospective nature of the study. All study procedures were conducted in accordance with the international guidelines for human research protection, including the Declaration of Helsinki, the Belmont Report, the Council for International Organizations of Medical Sciences (CIOMS) guidelines, and the International Conference on Harmonization in Good Clinical Practice.
Study design and patient population
A retrospective study was conducted at King Chulalongkorn Memorial Hospital. Between January 2015 and December 2020, the medical records of patients with resectable, locally advanced stage II–III rectal cancer who underwent either upfront surgery with TME (upfront TME group) or nCRT followed by TME (nCRT group) were retrospectively reviewed.
Eligible patients were aged 18 years or older with histologically confirmed adenocarcinoma of the rectum, cT3–T4 with or without nodal metastasis, and who had undergone either upfront TME surgery or nCRT followed by TME. A total of 527 patients were diagnosed with rectal cancer at King Chulalongkorn Memorial Hospital during the study period. After excluding patients with stage I or IV cancer at initial staging, those diagnosed with synchronous or metachronous cancers, and those with incomplete data due to loss to follow-up, 348 patients who met the eligibility criteria were included.
Patient characteristics were collected, including preoperative factors (age, sex, American Society of Anesthesiologists [ASA] physical status, serum carcinoembryonic antigen [CEA], tumor distance from the anal verge, clinical stage, and mesorectal fascia [MRF] involvement); operative factors (type of surgery, protective ostomy, multivisceral organ resection, surgical approach, dissection plane, and quality of mesorectal excision); pathological factors (pathologic stage, number of regional lymph nodes examined, circumferential resection margin (CRM), completeness of resection, tumor histology, and tumor regression grade); and postoperative factors (adjuvant chemotherapy and 30-day morbidity).
Staging was performed in accordance with the 8th edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual. High-resolution magnetic resonance imaging (MRI) of the pelvis was the primary modality for locoregional assessment. Due to incomplete data, the cT3 subcategory was not analyzed. MRF involvement was defined as a margin of less than 1 mm between the MRF and any of the following: the primary tumor, metastatic mesorectal lymph nodes, or sites of extramural venous invasion (EMVI). In cases where MRI was unavailable, contrast-enhanced computed tomography (CT) findings were used as substitutes for staging assessment.
Treatment details
Patients diagnosed with stage II–III rectal cancer were treated with either upfront surgery with TME (upfront TME group) or nCRT followed by TME (nCRT group).
The nCRT protocol consisted of radiation therapy (4,500–5,000 cGy in 25 fractions) administered concurrently with chemotherapy—either 5-fluorouracil (FU) plus leucovorin (Mayo regimen), capecitabine, or XELOX (capecitabine and oxaliplatin) regimen. Surgery with curative intent was performed 8 to 12 weeks after completion of nCRT. In Thailand, nCRT is a routine treatment strategy for LARC. However, at our institution, upfront TME was preferred for patients with early-stage T3 cancer, while selective nCRT was administered to those with more advanced or lower rectal cancer exhibiting lymph node positivity.
TME was performed as the standard surgical procedure. All patients underwent curative surgery: either low anterior resection or abdominoperineal resection. All operations were performed or supervised by colorectal surgeons at King Chulalongkorn Memorial Hospital. Histopathological evaluation was conducted by pathologists, and tumor regression grading was completed for most specimens using the modified Ryan grading system [13].
Since 2010, a multidisciplinary team approach has been implemented at our institution. The decision to administer adjuvant chemotherapy was made at the discretion of the treating physicians.
Outcomes
Long-term survival outcomes were compared between the 2 groups. The primary endpoint was 5-year disease-free survival (DFS). Secondary endpoints included 5-year local recurrence–free survival (LRFS), distant metastasis–free survival (DMFS), and overall survival (OS). DFS was defined as the time interval between surgery and tumor recurrence or the last follow-up. LRFS was defined as the time between surgery and the first local recurrence. DMFS was defined as the time between surgery and the occurrence of distant metastasis or the date of censoring at the latest follow-up. OS was defined as the time between surgery and the date of death or last follow-up.
Statistical analysis
All statistical analyses were performed using Stata ver. 19.5 (StataCorp). Continuous variables are presented as mean±standard deviation. To compare categorical variables between the 2 groups (upfront TME alone vs. nCRT followed by TME) the chi-square test or the Fisher exact test was applied as appropriate. For continuous variables, the independent t-test or Mann-Whitney U-test was used. The Kaplan-Meier method with log-rank testing was employed to analyze survival differences between groups. The prognostic model for 5-year DFS was constructed using univariable and multivariable Cox regression analyses. Multivariable models included covariates with P<0.1 from univariable analyses, and stepwise backward elimination was used to identify the final model. Propensity score matching was performed to reduce confounding effects between treatment groups (upfront TME alone vs. nCRT followed by TME). Covariates used for adjustment included pathological T stage, tumor distance from the anal verge, preoperative MRF involvement, lymphovascular invasion (LVI), pathological CRM (pCRM), perineural invasion (PNI), EMVI, and tumor deposits. The number of neighbors was used to calculate matched outcomes. All P-values were two-sided, and statistical significance was defined as P<0.05.
Clinical characteristics in the original cohort
Between 2015 and 2020, 348 patients with resectable LARC who met the inclusion criteria were analyzed. The median follow-up duration was 39 months (interquartile range, 25–60 months). Baseline patient characteristics are summarized in Table 1. Of these, 138 patients (39.7%) underwent upfront surgery with TME (upfront TME group), while the remaining 210 patients (60.3%) received nCRT followed by TME (nCRT group).
In both groups, most patients were male, had a mean age of 68 years or older, were diagnosed with clinical stage III rectal cancer, underwent sphincter-preserving surgery, had pathological T3 disease, and achieved complete surgical resection with an adequate number of harvested lymph nodes.
In the upfront TME group, the majority of patients had rectal tumors located 6–10 cm from the anal verge (40.6%) and no preoperative MRF involvement (83.3%). Compared with the nCRT group, upfront TME group showed higher proportions of patients with LVI (96.4% vs. 65.2%), PNI (60.9% vs. 36.7%), EMVI (50.7% vs. 27.6%), and tumor deposits (44.2% vs. 10.5%).
In contrast, the majority of patients in the nCRT group had lower rectal cancer located ≤5 cm from the anal verge (63.8%) and preoperative MRF involvement (65.2%). This group also had higher rates of multivisceral organ resection (35.7% vs 13.8%) and a greater proportion of patients with no pathological lymph node involvement (66.2% vs. 9.4%) than the upfront TME group.
In the nCRT group, pathological complete response was achieved in 10 patients (4.8%), while most cases demonstrated tumor regression grade 2 (64.7%). Significant tumor downstaging was observed, with the proportion of clinical stage III disease decreasing from 67.6% to 33.9% at the pathological stage.
Adjuvant chemotherapy, consisting of 5-FU, 5-FU plus oxaliplatin, or 5-FU plus irinotecan, was planned for 261 of the 348 patients (75.0%). However, 56 of 261 (21.5%) failed to complete treatment due to chemotherapy intolerance or serious adverse events.
No significant differences were observed between the 2 groups in terms of positive pCRM, R0 resection rate, adjuvant chemotherapy administration, or 30-day postoperative morbidity.
Survival analysis in the original cohort
Compared to the nCRT group, the upfront TME group demonstrated significantly better 5-year DFS (63.3% vs. 43.9%, P=0.001) (Fig. 1A, Table 2). The 5-year LRFS was comparable between groups, with no statistically significant difference (92.3% vs. 92.3%, P=0.676). The 5-year OS for the upfront TME group was 68.3% compared to 72.9% for the nCRT group, with no statistically significant difference (P=0.748). However, the upfront TME group showed a significantly higher 5-year DMFS (88.1% vs. 70.3%, P=0.009) (Fig. 1B–D, Table 2).
A sensitivity analysis excluding cases with preoperative MRF involvement revealed no significant differences between the upfront TME and nCRT groups in terms of 5-year DFS, LRFS, DMFS, or OS (all P>0.05) (Table 3).
Risk factors associated with DFS in the original cohort
Univariable and multivariable Cox regression analyses were conducted to identify factors influencing DFS. In the overall cohort, Cox regression analysis revealed that (y)pT4 (adjusted hazard ratio [aHR], 6.18; P=0.003), (y)pN1 (aHR, 1.92; P=0.012), (y)pN2 (aHR, 2.79; P=0.001), pCRM (aHR, 1.71; P=0.029), and positive EMVI (aHR, 1.58; P=0.017) were significant negative prognostic factors for DFS (Table 4).
Clinical characteristics after propensity score matching
Given the substantial imbalance in key prognostic factors between the 2 treatment groups, propensity score matching was performed as described in the statistical methods. Propensity scores were calculated using multivariate logistic regression and included the following variables: tumor distance from the anal verge, preoperative MRF involvement, pathological T category, pCRM, LVI, PNI, EMVI, and tumor deposits. After 1:1 matching, 47 patients from each group were included in the propensity score–matched analysis. The baseline characteristics of the matched groups were well balanced, as shown in Table 1.
Survival analysis in the propensity score–matched cohort
After propensity score matching, Kaplan-Meier analysis showed no significant differences in DFS, LRFS, DMFS, or OS between patients who underwent upfront TME and those who received nCRT followed by TME (Fig. 2, Table 2).
Risk factors associated with DFS in the propensity score–matched cohort
In the propensity score–matched cohort, univariable analyses indicated that preoperative MRF involvement (HR, 2.23; P=0.032), positive EMVI (HR, 2.56; P=0.015), and tumor deposits (HR, 2.27; P=0.028) were independent prognostic factors for DFS. However, these variables did not remain significant in the multivariable Cox regression analysis (Table 4).
In our single-center retrospective study, we evaluated the 5-year oncologic outcomes of upfront TME versus nCRT followed by TME in resectable, locally advanced stage II and III rectal cancer. In the original cohort, pathological features such as LVI, PNI, EMVI, tumor deposits, and tumor stage were lower in the nCRT group than in the upfront TME group, likely reflecting the therapeutic effects of nCRT. The 30-day morbidity rate was comparable between the 2 groups. Long-term oncologic outcomes, however, demonstrated significantly poorer 5-year DFS (43.9% vs. 63.3%, P=0.001) and DMFS (70.3% vs. 88.1%, P=0.009) in the nCRT group. This difference may be explained by the substantially higher proportion of patients with preoperative MRF involvement in the nCRT group (65.2% vs. 16.7%), a factor well known to be strongly associated with adverse oncologic outcomes. Multivariable analysis identified (y)pT4, (y)pN1–2, positive pCRM, and positive EMVI as significant negative prognostic factors for DFS.
Sensitivity analysis matched for tumor distance from the anal verge, preoperative MRF involvement, pathological T category, pCRM, LVI, PNI, EMVI, and tumor deposits was performed to minimize confounding and selection bias. After propensity score matching, clinical characteristics were well balanced between the 2 groups. No significant differences were observed in 5-year DFS, LRFS, DMFS, or OS between the nCRT and upfront TME groups. Cox regression analysis in the matched cohort indicated that preoperative MRF involvement, positive EMVI, and tumor deposits were not independent prognostic factors, though they exhibited trends toward poorer outcomes.
The role of nCRT in the management of LARC remains controversial, with inconsistent evidence regarding its effect on oncologic outcomes. In our study, 5-year OS (75.7% for the upfront TME group vs. 81.2% for the nCRT group, P=0.445) did not differ significantly between treatment arms, consistent with findings from prior studies [14, 15]. The Dutch TME trial examined whether short-course preoperative radiotherapy (25 Gy in 5 fractions over 1 week) could further improve outcomes in patients undergoing high-quality TME. This multicenter randomized controlled trial demonstrated that short-course preoperative radiotherapy significantly reduced local recurrence risk but did not improve OS [16]. Similarly, the German Rectal Cancer Study Group and MRC-07 trials showed that although short-course preoperative radiotherapy improved local control compared with surgery followed by elective postoperative chemoradiotherapy, it did not affect OS [17]. The German CAO/ARO/AIO-94 trial compared long-course preoperative versus postoperative chemoradiotherapy in patients with LARC. Despite improved local control, no significant difference in 10-year OS was found between the preoperative and postoperative groups (59.6% vs. 59.9%) [14]. Other studies have also suggested that nCRT may be unnecessary and potentially lead to overtreatment in certain stage II rectal cancer cases [18, 19].
Our study did not demonstrate an improvement in LRFS with nCRT in the propensity score–matched cohort (95.3% vs. 90.5% for the upfront TME group, P=0.451). This likely reflects the high standard of TME performed by experienced colorectal surgeons, as evidenced by the low incidence of positive pCRM (14.9% in the upfront TME group vs. 8.5% in the nCRT group). A meticulously executed TME can achieve excellent local control, even without nCRT, particularly in patients with favorable tumor characteristics. Consequently, it may be difficult for nCRT to yield a statistically significant reduction in local recurrence rates within this subset of patients [20].
Previous studies have identified preoperative MRF involvement as a high-risk feature for local recurrence [21–23]. In our propensity score–matched cohort, positive pCRM rates were 14.9% in the upfront TME group and 8.5% in the nCRT group, consistent with published literature. To address our primary research question, subgroup analyses stratified by MRF status were conducted. In sensitivity analyses excluding patients with preoperative MRF involvement, no significant differences were observed between the upfront TME and nCRT groups in 5-year DFS, LRFS, DMFS, or OS. These findings suggest that patients without MRF involvement may safely omit nCRT without compromising long-term oncologic outcomes, thereby avoiding unnecessary overtreatment [24, 25].
In this study, MRF status was primarily assessed using magnetic resonance imaging, with CT employed as an alternative when MRI data were unavailable. Previous research has underscored the critical importance of MRF assessment in identifying candidates for preoperative therapy and reducing local recurrence risk [26–28]. High-resolution rectal MRI has been shown to optimize the selection of MRF-negative patients. Favorable-prognosis tumors treated with upfront surgery alone have demonstrated positive CRM rates of only 2% to 5%, with 5-year local recurrence rates as low as 4.4%. In contrast, reliance on CT rather than MRI may introduce inaccuracies not only in assessing MRF involvement but also in subclassifying cT3 tumors, detecting EMVI, and evaluating nodal status. These parameters are essential for accurate prognostication and for tailoring appropriate therapeutic strategies.
Emerging evidence suggests that patients without threatened CRM on high-resolution MRI may safely omit nCRT and proceed directly to TME, with or without postoperative chemotherapy. A retrospective propensity-matched analysis comparing upfront TME with nCRT followed by TME reported no significant difference in 3-year DFS (88% vs. 83%, P=0.326). Locoregional recurrence rates at 3 years were likewise low (2% vs. 3%, P=0.667) [29]. The Quicksilver trial further confirmed a low (4.9%) positive CRM rate with a surgery-alone approach in rectal cancers with favorable prognostic features (T2–T3b, N0–2, predicted CRM-negative) [30]. The current evidence supporting upfront TME is derived largely from retrospective series and smaller, nonrandomized trials. To establish this approach as a noninferior alternative to the standard of care, several large-scale, prospective, randomized controlled trials are currently underway [31].
In the propensity score–matched cohort, univariable analyses identified preoperative MRF involvement, positive EMVI, and the presence of tumor deposits as significant predictors of DFS. However, none of these factors retained statistical significance in the multivariable Cox proportional hazards model, likely due to the limited statistical power associated with the reduced sample size after matching.
In recent years, total neoadjuvant therapy (TNT) has emerged as a modern treatment paradigm for patients with LARC, combining systemic chemotherapy and radiotherapy before surgical resection. TNT aims to improve treatment compliance, maximize tumor regression, promote organ preservation, and ultimately enhance oncologic outcomes. This strategy has now been widely adopted as the standard of care in many high-volume centers. A recent meta-analysis demonstrated that TNT significantly increases pathological downstaging compared with the traditional sequence of surgery followed by adjuvant chemoradiotherapy. Despite a 39% increase in pathological complete response rates within the TNT cohort, no statistically significant differences in DFS or OS were observed between TNT and standard approaches [32]. Because TNT had not yet been implemented during our patient accrual period, it was not included as a treatment arm in the present study.
Several limitations of this study warrant acknowledgment. First, its retrospective design may have introduced selection bias, as treatment allocation (upfront TME versus nCRT) was determined by clinician preference rather than randomization. Second, the single-center nature and modest sample size limited statistical power, precluded prospective sample size calculation, and restricted the number of covariates that could be included in propensity score matching. Third, the nCRT cohort contained a slightly higher proportion of lower rectal tumors, potentially confounding oncologic outcome comparisons. Fourth, preoperative MRI was not uniformly available, particularly among stage II patients, reducing the precision of staging parameters such as MRF involvement, cT3 subclassification, EMVI, and nodal assessment. Fifth, TNT, now widely used in contemporary practice, was not represented as a comparator arm. Finally, the absence of centralized pathology review, standardized TME quality-control assessment, and systematic evaluation of functional outcomes (e.g., sphincter preservation and health-related quality of life) limits the generalizability of our findings and underscores the need for future prospective multicenter studies.
Conclusions
Upfront TME may represent a viable treatment option for selected patients with LARC, particularly those without MRF involvement, offering oncologic outcomes comparable to the standard nCRT approach. Prospective studies with larger sample sizes are warranted to confirm these findings.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization: all authors; Data curation: all authors; Formal analysis: TL; Methodology: all authors; Project administration: all authors; Supervision: TL; Validation: TL; Writing–original draft: NS; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Fig. 1.
Kaplan-Meier analysis before propensity score matching. Patients with missing baseline or follow-up data specific to each clinical endpoint were excluded from that individual analysis. (A) Disease-free survival. (B) Local recurrence–free survival. (C) Distant metastasis–free survival. (D) Overall survival. TME, total mesorectal excision; nCRT, neoadjuvant chemoradiotherapy.
ac-2025-00724-0103f1.jpg
Fig. 2.
Kaplan-Meier analysis after propensity score matching. (A) Disease-free survival. (B) Local recurrence–free survival. (C) Distant metastasis–free survival. (D) Overall survival. TME, total mesorectal excision; nCRT, neoadjuvant chemoradiotherapy.
ac-2025-00724-0103f2.jpg
ac-2025-00724-0103f3.jpg
Table 1.
Baseline characteristics before and after propensity score matching
Characteristic Before propensity score matching After propensity score matching
Upfront TME (n=138) nCRT (n=210) P-value Upfront TME (n=47) nCRT (n=47) P-value
Preoperative factor
 Age (yr) 70.0±14.0 68.0±13.0 0.130 68.3±11.6 66.2±12.5 0.404
 Sex 0.536
  Male 78 (56.5) 132 (62.9) 0.263 21 (44.7) 24 (51.1)
  Female 60 (43.5) 78 (37.1) 26 (55.3) 23 (48.9)
 ASA physical statusa 0.170 0.686
  I 56/87 (64.4) 114/151 (75.5) 20/26 (76.9) 26/32 (81.3)
  II 26/87 (29.9) 32/151 (21.2) 6/26 (23.1) 6/32 (18.8)
  III 5/87 (5.7) 5/151 (3.3) 0/26 (0) 0/32 (0)
 Serum CEA >5 ng/mL 39 (28.3) 65 (30.9) 0.633 12 (25.5) 10 (21.3) 0.626
 Tumor distance from the anal verge (cm) <0.001 0.246
  ≤5 41 (29.7) 134 (63.8) 26 (55.3) 18 (38.3)
  6–10 56 (40.6) 65 (31.0) 16 (34.0) 23 (48.9)
  >10 41 (29.7) 11 (5.2) 5 (10.6) 6 (12.8)
 Clinical T category 0.016 0.227
  cT2 14 (10.1) 8 (3.8) 6 (12.8) 4 (8.5)
  cT3 98 (71.0) 143 (68.1) 26 (55.3) 34 (72.3)
  cT4 26 (18.9) 59 (28.1) 15 (31.9) 9 (19.2)
 Clinical N category <0.001 0.689
  cN0 12 (8.7) 68 (32.4) 8 (17.0) 7 (14.9)
  cN1 85 (61.6) 121 (57.6) 26 (55.3) 30 (63.8)
  cN2 41 (29.7) 21 (10.0) 13 (27.7) 10 (21.3)
 Clinical stage <0.001 0.778
  II 12 (8.7) 68 (32.4) 8 (17.0) 7 (14.9)
  III 126 (91.3) 142 (67.6) 39 (83.0) 40 (85.1)
 Preoperative MRF involvement <0.001 0.831
  Yes 23 (16.7) 137 (65.2) 18 (38.3) 17 (36.2)
  No 115 (83.3) 73 (34.8) 29 (61.7) 30 (63.8)
Operative factor
 Type of surgery <0.001 0.789
  Abdominoperineal resection 11 (8.0) 59 (28.1) 8 (17.0) 9 (19.2)
  Sphincter-preserving surgery 127 (92.0) 151 (71.9) 39 (83.0) 38 (80.8)
 Multivisceral organ resection 19 (13.8) 75 (35.7) <0.001 3 (6.4) 7 (14.9) 0.181
 Surgical approacha <0.001 0.017
  Open surgery 16/137 (11.6) 66 (31.4) 4/46 (8.7) 14 (29.8)
  Laparoscopic surgery 121/137 (88.3) 144 (68.6) 42/46 (91.3) 33 (70.2)
Pathological factor
 Pathological T category <0.001 0.227
  (y)pT0-2 16 (11.6) 56 (26.7) 6 (12.8) 4 (8.5)
  (y)pT3 97 (70.3) 106 (50.5) 26 (55.3) 34 (72.3)
  (y)pT4 25 (18.1) 48 (22.8) 15 (31.9) 9 (19.2)
 Pathological N category <0.001 0.689
  (y)pN0 13 (9.4) 139 (66.2) 8 (17.0) 7 (14.9)
  (y)pN1 87 (63.1) 50 (23.8) 26 (55.3) 30 (63.8)
  (y)pN2 38 (27.5) 21 (10.0) 13 (27.7) 10 (21.3)
 Pathological stage <0.001 0.001
  0, Tis 0 (0) 24 (11.4) 0 (0) 2 (4.3)
  I 0 (0) 20 (9.5) 0 (0) 5 (10.6)
  II 13 (9.4) 95 (45.2) 8 (17.0) 17 (36.2)
  III 125 (90.6) 71 (33.9) 39 (83.0) 23 (48.9)
 Adequate regional lymph nodes harvested >12 130 (94.2) 140 (66.7) <0.001 43 (91.5) 35 (74.5) 0.052
 Positive CRM 13 (9.4) 21 (10.0) >0.999 7 (14.9) 4 (8.5) 0.523
 R classification >0.999 0.355
  R0 124 (89.9) 188 (89.5) 39 (83.0) 43 (91.5)
  R1 14 (10.1) 22 (10.5) 8 (17.0) 4 (8.5)
 Histologic grade <0.001 0.362
  Well differentiated 9 (6.5) 30 (14.2) 3 (6.4) 7 (14.9)
  Moderately differentiated 119 (86.2) 136 (64.8) 39 (83.0) 34 (72.3)
  Poorly differentiated 10 (7.3) 44 (21.0) 5 (10.6) 6 (12.8)
 Positive LVI 133 (96.4) 137 (65.2) <0.001 44 (93.6) 40 (85.1) 0.181
 Positive PNI 84 (60.9) 77 (36.7) <0.001 24 (51.1) 23 (48.9) 0.837
 Positive EMVI 70 (50.7) 58 (27.6) <0.001 21 (44.7) 21 (44.7) 0.999
 Tumor deposit 61 (44.2) 22 (10.5) <0.001 14 (29.8) 16 (34.0) 0.658
Postoperative factor
 Adjuvant chemotherapy 107 (77.5) 154 (73.3) 0.448 39 (83.0) 41 (87.2) 0.562
 Adjuvant regimen 0.001 0.021
  5-FU 24/107 (22.4) 98/154 (63.6) 9/39 (23.1) 20/41 (48.8)
  5-FU+oxaliplatin 83/107 (77.6) 55/154 (35.7) 30/39 (76.9) 21/41 (51.2)
  5-FU+irinotecan 0/107 (0) 1/154 (0.7) 0/39 (0) 0/41 (0)
 Adjuvant chemotherapy completion 96/107 (89.7) 109/154 (70.8) 0.001 36/39 (92.3) 26/41 (63.4) 0.003
 30-Day morbidity 10 (7.3) 14 (6.7) 0.83 4 (8.5) 0 (0) 0.117

Values are presented as mean±standard deviation or number (%).

TME, total mesorectal excision; nCRT, neoadjuvant chemoradiotherapy; ASA, American Society of Anesthesiologists; CEA, carcinoembryonic antigen; MRF, mesorectal fascia; CRM, circumferential resection margin; LVI, lymphovascular invasion; PNI, perineural invasion; EMVI, extramural vascular invasion; 5-FU, fluorouracil.

aMissing data were excluded.

Table 2.
DFS, LRFS, DMFS, and OS for upfront TME and nCRT groups before and after propensity score matching
Follow-up Before propensity score matching After propensity score matching
DFS (%) LRFS (%) DMFS (%) OS (%) DFS (%) LRFS (%) DMFS (%) OS (%)
Upfront TME group
 1 yr 89.3 (82.6–93.5) 99.2 (94.4–99.9) 95.5 (89.5–98.1) 95.9 (90.3–98.3) 93.5 (81.1–97.9) 100 95.2 (82.3–98.8) 97.7 (84.6–99.7)
 3 yr 70.7 (61.8–77.8) 95.8 (90.2–98.2) 90.2 (82.4–94.6) 86.9 (79.2–91.9) 77.3 (61.8–87.1) 90.5 (76.6–96.3) 86.4 (70.0–94.2) 90.1 (75.6–96.2)
 5 yr 63.3 (53.5–71.7) 92.3 (83.6–96.5) 88.1 (79.0–93.5) 68.3 (56.3–77.7) 66.3 (48.0–79.4) 90.5 (76.6–96.3) 81.8 (62.9–91.7) 75.7 (53.6–88.3)
nCRT group
 1 yr 79.9 (73.7–84.8) 97.0 (93.4–98.6) 98.4 (95.0–99.5) 95.3 (91.2–97.6) 87.0 (73.4–94.0) 97.7 (84.9–99.7) 100 97.8 (85.6–99.7)
 3 yr 55.1 (47.4–62) 95.0 (90.5–97.4) 82.2 (75.5–87.2) 84.4 (78.4–88.9) 63.6 (46.4–76.6) 95.3 (82.4–98.8) 85.7 (70.8–93.3) 95.3 (82.5–98.8)
 5 yr 43.9 (34.8–52.5) 92.3 (85.6–95.9) 70.3 (61.6–77.4) 72.9 (64.9–79.4) 56.5 (36.0–72.7) 95.3 (82.4–98.8) 79.5 (62.8–89.3) 81.2 (57.5–92.5)
P-value 0.001 0.676 0.009 0.748 0.305 0.451 0.784 0.445

Values are presented with their 95% confidence intervals.

DFS, disease-free survival; LRFS, local recurrence–free survival; DMFS, distant metastasis–free survival; OS, overall survival; TME, total mesorectal excision; nCRT, neoadjuvant chemoradiotherapy.

Table 3.
DFS, LRFS, DMFS, and OS for the upfront TME and nCRT groups, after excluding patients with preoperative MRF involvement
MRF clear 5-yr DFS (%) 5-yr LRFS 5-yr DMFS (%) 5-yr OS (%)
Upfront TME group 65.2 (54.0–74.3) 93.7 (82.9–97.8) 90.4 (79.6–95.6) 71.6 (58.0–81.4)
nCRT group 54.2 (36.4–69.0) 93.9 (80.8–98.2) 81.3 (67.7–89.6) 82.8 (69.4–90.7)
P-value 0.232 0.630 0.199 0.275

Values are presented with their 95% confidence intervals.

DFS, disease-free survival; LRFS, local recurrence–free survival; DMFS, distant metastasis–free survival; OS, overall survival; TME, total mesorectal excision; nCRT, neoadjuvant chemoradiotherapy; MRF, mesorectal fascia.

Table 4.
Risk factors associated with disease-free survival before and after propensity score matching
Variable Before propensity score matching After propensity score matching
Univariable analysis Multivariable analysis Univariable analysis Multivariable analysis
HR (95% CI) P-value aHR (95% CI) P-value HR (95% CI) P-value aHR (95% CI) P-value
Tumor distance from the anal verge (cm)
 ≤5 1 (Reference) 1 (Reference)
 6–10 1.61 (0.87–2.99) 0.127 1.57 (0.34–7.18) 0.559
 >10 2.09 (1.16–3.77) 0.014 2.86 (0.66–12.44) 0.159
Preoperative MRF involvement 1.93 (1.37–2.72) <0.001 2.23 (1.07–4.64) 0.032* 1.86 (0.88–3.93) 0.101
Pathological T category
 (y)pT2 1 (Reference) 1 (Reference) 1 (Reference)
 (y)pT3 2.94 (0.92–9.31) 0.067 2.70 (0.84–8.69) 0.095 3.52 (0.47–26.53) 0.22
 (y)pT4 7.01 (2.19–22.47) 0.001* 6.18 (1.89–20.23) 0.003* 5.94 (0.77–46.19) 0.088
Pathological N category
 (y)pN0 1 (Reference) 1 (Reference) 1 (Reference)
 (y)pN1 1.33 (0.85–2.08) <0.05* 1.92 (1.20–3.07) 0.012* 1.57 (0.46–5.38) 0.210
 (y)pN2 1.96 (1.16–3.32) 0.012* 2.79 (1.55–5.02) 0.001* 2.64 (0.73–9.64) 0.140
Histologic grade
 Well differentiated 1 (Reference) 1 (Reference)
 Moderately differentiated 0.69 (0.42–1.14) 0.147 0.49 (0.19–1.31) 0.156
 Poor differentiated 0.59 (0.30–1.15) 0.123 0.16 (0.02–1.34) 0.091
Positive pCRM 1.81 (1.12–2.90) 0.015* 1.71 (1.06–2.78) 0.029* 1.24 (0.43–3.59) 0.679
Positive LVI 1.32 (0.85–2.03) 0.211 4.12 (0.56–30.32) 0.164
Positive PNI 1.51 (1.07–2.11) 0.017 1.42 (0.68–2.95) 0.353
Positive EMVI 1.70 (1.21–2.38) 0.002* 1.58 (1.08–2.30) 0.017* 2.56 (1.20–5.46) 0.015* 1.92 (0.85–4.33) 0.117
Tumor deposits 1.25 (0.89–1.86) 0.185 2.27 (1.09–4.71) 0.028* 1.66 (0.76–3.61) 0.200
Adjuvant chemotherapy 0.63 (0.44–0.92) 0.017* 0.65 (0.45–0.96) 0.028* 0.49 (0.18–1.28) 0.145

HR, hazard ratio; CI, confidence interval; aHR, adjusted hazard ratio; MRF, mesorectal fascia; pCRM, pathological circumferential resection margin; LVI, lymphovascular invasion; PNI, perineural invasion; EMVI, extramural vascular invasion.

*P<0.05.

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        Upfront surgery versus preoperative chemoradiotherapy: a comparative survival analysis for stage II/III resectable rectal cancer
        Ann Coloproctol. 2026;42(1):115-126.   Published online February 26, 2026
        DOI: https://doi.org/10.3393/ac.2025.00724.0103
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      Upfront surgery versus preoperative chemoradiotherapy: a comparative survival analysis for stage II/III resectable rectal cancer
      Image Image Image
      Fig. 1. Kaplan-Meier analysis before propensity score matching. Patients with missing baseline or follow-up data specific to each clinical endpoint were excluded from that individual analysis. (A) Disease-free survival. (B) Local recurrence–free survival. (C) Distant metastasis–free survival. (D) Overall survival. TME, total mesorectal excision; nCRT, neoadjuvant chemoradiotherapy.
      Fig. 2. Kaplan-Meier analysis after propensity score matching. (A) Disease-free survival. (B) Local recurrence–free survival. (C) Distant metastasis–free survival. (D) Overall survival. TME, total mesorectal excision; nCRT, neoadjuvant chemoradiotherapy.
      Graphical abstract

      Fig. 1.

      Fig. 2.

      Graphical abstract

      Upfront surgery versus preoperative chemoradiotherapy: a comparative survival analysis for stage II/III resectable rectal cancer
      Characteristic Before propensity score matching After propensity score matching
      Upfront TME (n=138) nCRT (n=210) P-value Upfront TME (n=47) nCRT (n=47) P-value
      Preoperative factor
       Age (yr) 70.0±14.0 68.0±13.0 0.130 68.3±11.6 66.2±12.5 0.404
       Sex 0.536
        Male 78 (56.5) 132 (62.9) 0.263 21 (44.7) 24 (51.1)
        Female 60 (43.5) 78 (37.1) 26 (55.3) 23 (48.9)
       ASA physical statusa 0.170 0.686
        I 56/87 (64.4) 114/151 (75.5) 20/26 (76.9) 26/32 (81.3)
        II 26/87 (29.9) 32/151 (21.2) 6/26 (23.1) 6/32 (18.8)
        III 5/87 (5.7) 5/151 (3.3) 0/26 (0) 0/32 (0)
       Serum CEA >5 ng/mL 39 (28.3) 65 (30.9) 0.633 12 (25.5) 10 (21.3) 0.626
       Tumor distance from the anal verge (cm) <0.001 0.246
        ≤5 41 (29.7) 134 (63.8) 26 (55.3) 18 (38.3)
        6–10 56 (40.6) 65 (31.0) 16 (34.0) 23 (48.9)
        >10 41 (29.7) 11 (5.2) 5 (10.6) 6 (12.8)
       Clinical T category 0.016 0.227
        cT2 14 (10.1) 8 (3.8) 6 (12.8) 4 (8.5)
        cT3 98 (71.0) 143 (68.1) 26 (55.3) 34 (72.3)
        cT4 26 (18.9) 59 (28.1) 15 (31.9) 9 (19.2)
       Clinical N category <0.001 0.689
        cN0 12 (8.7) 68 (32.4) 8 (17.0) 7 (14.9)
        cN1 85 (61.6) 121 (57.6) 26 (55.3) 30 (63.8)
        cN2 41 (29.7) 21 (10.0) 13 (27.7) 10 (21.3)
       Clinical stage <0.001 0.778
        II 12 (8.7) 68 (32.4) 8 (17.0) 7 (14.9)
        III 126 (91.3) 142 (67.6) 39 (83.0) 40 (85.1)
       Preoperative MRF involvement <0.001 0.831
        Yes 23 (16.7) 137 (65.2) 18 (38.3) 17 (36.2)
        No 115 (83.3) 73 (34.8) 29 (61.7) 30 (63.8)
      Operative factor
       Type of surgery <0.001 0.789
        Abdominoperineal resection 11 (8.0) 59 (28.1) 8 (17.0) 9 (19.2)
        Sphincter-preserving surgery 127 (92.0) 151 (71.9) 39 (83.0) 38 (80.8)
       Multivisceral organ resection 19 (13.8) 75 (35.7) <0.001 3 (6.4) 7 (14.9) 0.181
       Surgical approacha <0.001 0.017
        Open surgery 16/137 (11.6) 66 (31.4) 4/46 (8.7) 14 (29.8)
        Laparoscopic surgery 121/137 (88.3) 144 (68.6) 42/46 (91.3) 33 (70.2)
      Pathological factor
       Pathological T category <0.001 0.227
        (y)pT0-2 16 (11.6) 56 (26.7) 6 (12.8) 4 (8.5)
        (y)pT3 97 (70.3) 106 (50.5) 26 (55.3) 34 (72.3)
        (y)pT4 25 (18.1) 48 (22.8) 15 (31.9) 9 (19.2)
       Pathological N category <0.001 0.689
        (y)pN0 13 (9.4) 139 (66.2) 8 (17.0) 7 (14.9)
        (y)pN1 87 (63.1) 50 (23.8) 26 (55.3) 30 (63.8)
        (y)pN2 38 (27.5) 21 (10.0) 13 (27.7) 10 (21.3)
       Pathological stage <0.001 0.001
        0, Tis 0 (0) 24 (11.4) 0 (0) 2 (4.3)
        I 0 (0) 20 (9.5) 0 (0) 5 (10.6)
        II 13 (9.4) 95 (45.2) 8 (17.0) 17 (36.2)
        III 125 (90.6) 71 (33.9) 39 (83.0) 23 (48.9)
       Adequate regional lymph nodes harvested >12 130 (94.2) 140 (66.7) <0.001 43 (91.5) 35 (74.5) 0.052
       Positive CRM 13 (9.4) 21 (10.0) >0.999 7 (14.9) 4 (8.5) 0.523
       R classification >0.999 0.355
        R0 124 (89.9) 188 (89.5) 39 (83.0) 43 (91.5)
        R1 14 (10.1) 22 (10.5) 8 (17.0) 4 (8.5)
       Histologic grade <0.001 0.362
        Well differentiated 9 (6.5) 30 (14.2) 3 (6.4) 7 (14.9)
        Moderately differentiated 119 (86.2) 136 (64.8) 39 (83.0) 34 (72.3)
        Poorly differentiated 10 (7.3) 44 (21.0) 5 (10.6) 6 (12.8)
       Positive LVI 133 (96.4) 137 (65.2) <0.001 44 (93.6) 40 (85.1) 0.181
       Positive PNI 84 (60.9) 77 (36.7) <0.001 24 (51.1) 23 (48.9) 0.837
       Positive EMVI 70 (50.7) 58 (27.6) <0.001 21 (44.7) 21 (44.7) 0.999
       Tumor deposit 61 (44.2) 22 (10.5) <0.001 14 (29.8) 16 (34.0) 0.658
      Postoperative factor
       Adjuvant chemotherapy 107 (77.5) 154 (73.3) 0.448 39 (83.0) 41 (87.2) 0.562
       Adjuvant regimen 0.001 0.021
        5-FU 24/107 (22.4) 98/154 (63.6) 9/39 (23.1) 20/41 (48.8)
        5-FU+oxaliplatin 83/107 (77.6) 55/154 (35.7) 30/39 (76.9) 21/41 (51.2)
        5-FU+irinotecan 0/107 (0) 1/154 (0.7) 0/39 (0) 0/41 (0)
       Adjuvant chemotherapy completion 96/107 (89.7) 109/154 (70.8) 0.001 36/39 (92.3) 26/41 (63.4) 0.003
       30-Day morbidity 10 (7.3) 14 (6.7) 0.83 4 (8.5) 0 (0) 0.117
      Follow-up Before propensity score matching After propensity score matching
      DFS (%) LRFS (%) DMFS (%) OS (%) DFS (%) LRFS (%) DMFS (%) OS (%)
      Upfront TME group
       1 yr 89.3 (82.6–93.5) 99.2 (94.4–99.9) 95.5 (89.5–98.1) 95.9 (90.3–98.3) 93.5 (81.1–97.9) 100 95.2 (82.3–98.8) 97.7 (84.6–99.7)
       3 yr 70.7 (61.8–77.8) 95.8 (90.2–98.2) 90.2 (82.4–94.6) 86.9 (79.2–91.9) 77.3 (61.8–87.1) 90.5 (76.6–96.3) 86.4 (70.0–94.2) 90.1 (75.6–96.2)
       5 yr 63.3 (53.5–71.7) 92.3 (83.6–96.5) 88.1 (79.0–93.5) 68.3 (56.3–77.7) 66.3 (48.0–79.4) 90.5 (76.6–96.3) 81.8 (62.9–91.7) 75.7 (53.6–88.3)
      nCRT group
       1 yr 79.9 (73.7–84.8) 97.0 (93.4–98.6) 98.4 (95.0–99.5) 95.3 (91.2–97.6) 87.0 (73.4–94.0) 97.7 (84.9–99.7) 100 97.8 (85.6–99.7)
       3 yr 55.1 (47.4–62) 95.0 (90.5–97.4) 82.2 (75.5–87.2) 84.4 (78.4–88.9) 63.6 (46.4–76.6) 95.3 (82.4–98.8) 85.7 (70.8–93.3) 95.3 (82.5–98.8)
       5 yr 43.9 (34.8–52.5) 92.3 (85.6–95.9) 70.3 (61.6–77.4) 72.9 (64.9–79.4) 56.5 (36.0–72.7) 95.3 (82.4–98.8) 79.5 (62.8–89.3) 81.2 (57.5–92.5)
      P-value 0.001 0.676 0.009 0.748 0.305 0.451 0.784 0.445
      MRF clear 5-yr DFS (%) 5-yr LRFS 5-yr DMFS (%) 5-yr OS (%)
      Upfront TME group 65.2 (54.0–74.3) 93.7 (82.9–97.8) 90.4 (79.6–95.6) 71.6 (58.0–81.4)
      nCRT group 54.2 (36.4–69.0) 93.9 (80.8–98.2) 81.3 (67.7–89.6) 82.8 (69.4–90.7)
      P-value 0.232 0.630 0.199 0.275
      Variable Before propensity score matching After propensity score matching
      Univariable analysis Multivariable analysis Univariable analysis Multivariable analysis
      HR (95% CI) P-value aHR (95% CI) P-value HR (95% CI) P-value aHR (95% CI) P-value
      Tumor distance from the anal verge (cm)
       ≤5 1 (Reference) 1 (Reference)
       6–10 1.61 (0.87–2.99) 0.127 1.57 (0.34–7.18) 0.559
       >10 2.09 (1.16–3.77) 0.014 2.86 (0.66–12.44) 0.159
      Preoperative MRF involvement 1.93 (1.37–2.72) <0.001 2.23 (1.07–4.64) 0.032* 1.86 (0.88–3.93) 0.101
      Pathological T category
       (y)pT2 1 (Reference) 1 (Reference) 1 (Reference)
       (y)pT3 2.94 (0.92–9.31) 0.067 2.70 (0.84–8.69) 0.095 3.52 (0.47–26.53) 0.22
       (y)pT4 7.01 (2.19–22.47) 0.001* 6.18 (1.89–20.23) 0.003* 5.94 (0.77–46.19) 0.088
      Pathological N category
       (y)pN0 1 (Reference) 1 (Reference) 1 (Reference)
       (y)pN1 1.33 (0.85–2.08) <0.05* 1.92 (1.20–3.07) 0.012* 1.57 (0.46–5.38) 0.210
       (y)pN2 1.96 (1.16–3.32) 0.012* 2.79 (1.55–5.02) 0.001* 2.64 (0.73–9.64) 0.140
      Histologic grade
       Well differentiated 1 (Reference) 1 (Reference)
       Moderately differentiated 0.69 (0.42–1.14) 0.147 0.49 (0.19–1.31) 0.156
       Poor differentiated 0.59 (0.30–1.15) 0.123 0.16 (0.02–1.34) 0.091
      Positive pCRM 1.81 (1.12–2.90) 0.015* 1.71 (1.06–2.78) 0.029* 1.24 (0.43–3.59) 0.679
      Positive LVI 1.32 (0.85–2.03) 0.211 4.12 (0.56–30.32) 0.164
      Positive PNI 1.51 (1.07–2.11) 0.017 1.42 (0.68–2.95) 0.353
      Positive EMVI 1.70 (1.21–2.38) 0.002* 1.58 (1.08–2.30) 0.017* 2.56 (1.20–5.46) 0.015* 1.92 (0.85–4.33) 0.117
      Tumor deposits 1.25 (0.89–1.86) 0.185 2.27 (1.09–4.71) 0.028* 1.66 (0.76–3.61) 0.200
      Adjuvant chemotherapy 0.63 (0.44–0.92) 0.017* 0.65 (0.45–0.96) 0.028* 0.49 (0.18–1.28) 0.145
      Table 1. Baseline characteristics before and after propensity score matching

      Values are presented as mean±standard deviation or number (%).

      TME, total mesorectal excision; nCRT, neoadjuvant chemoradiotherapy; ASA, American Society of Anesthesiologists; CEA, carcinoembryonic antigen; MRF, mesorectal fascia; CRM, circumferential resection margin; LVI, lymphovascular invasion; PNI, perineural invasion; EMVI, extramural vascular invasion; 5-FU, fluorouracil.

      aMissing data were excluded.

      Table 2. DFS, LRFS, DMFS, and OS for upfront TME and nCRT groups before and after propensity score matching

      Values are presented with their 95% confidence intervals.

      DFS, disease-free survival; LRFS, local recurrence–free survival; DMFS, distant metastasis–free survival; OS, overall survival; TME, total mesorectal excision; nCRT, neoadjuvant chemoradiotherapy.

      Table 3. DFS, LRFS, DMFS, and OS for the upfront TME and nCRT groups, after excluding patients with preoperative MRF involvement

      Values are presented with their 95% confidence intervals.

      DFS, disease-free survival; LRFS, local recurrence–free survival; DMFS, distant metastasis–free survival; OS, overall survival; TME, total mesorectal excision; nCRT, neoadjuvant chemoradiotherapy; MRF, mesorectal fascia.

      Table 4. Risk factors associated with disease-free survival before and after propensity score matching

      HR, hazard ratio; CI, confidence interval; aHR, adjusted hazard ratio; MRF, mesorectal fascia; pCRM, pathological circumferential resection margin; LVI, lymphovascular invasion; PNI, perineural invasion; EMVI, extramural vascular invasion.

      *P<0.05.

      Table 1.

      Table 2.

      Table 3.

      Table 4.

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