Abstract:

The treatment paradigm for locally advanced rectal cancer is undergoing a fundamental transformation from the traditional fixed triad of "radiotherapy-surgery-chemotherapy" to a holistic eco-system centered on precision stratification and multidisciplinary collaboration. This review synthesizes the current landscape and future perspectives of this evolution across four key dimensions. First, in surgical innovation, robotic-assisted surgery has demonstrated superiority over conventional laparoscopy in the narrow pelvis. High-quality evidence indicates that robot-assisted surgery (RAS) not only ensures better oncological outcomes, such as lower circumferential resection margin positivity, but also significantly improves functional recovery, including urinary and sexual functions. The field is further advancing towards the integration of intraoperative navigation, fluorescence imaging, and 5G remote collaboration. Second, molecular-guided immunotherapy is reshaping neoadjuvant strategies. While patients with deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) status achieve high rates of clinical complete response with immune checkpoint inhibitors, creating opportunities for organ preservation strategies like "Watch and Wait", research in the proficient mismatch repair/microsatellite stable (pMMR/MSS) population is pivoting towards synergistic radio-immunotherapy combinations to overcome immune-cold microenvironments. Third, artificial intelligence and radiomics are enabling non-invasive quantitative risk stratification and treatment response prediction. Beyond preoperative assessment, computer vision is entering the operating room to identify critical anatomical structures (e.g., nerves, ureters) in real-time and objectively assess surgical quality. Finally, liquid biopsy, particularly circulating tumor DNA, has emerged as a critical biomarker for minimal residual disease. Dynamic monitoring complements morphological imaging to guide decisions on treatment intensification or de-escalation. Collectively, these advances are driving locally advanced rectal cancer management towards a "biologically-driven" and "function-preserving" model. Future efforts must focus on establishing standardized protocols for these technologies and validating their long-term benefits in survival and quality of life through high-quality, multi-center clinical trials.

Key words: Rectal neoplasms, Precision medicine, Neoadjuvant therapy, Artificial intelligence, Robotic surgical procedures