Li L, Kong QB, Sui X, Wang XJ. Advances and controversies in the management of T4 colon cancer. World J Gastroenterol 2026; 32(48): 125373 [DOI: 10.3748/wjg.125373]
Corresponding Author of This Article
Xin-Jian Wang, Department of Gastrointestinal Surgery, Weihai Central Hospital, No. 3 Mishandong Road Xi, Wendeng District, Weihai 264400, Shandong Province, China. wdwxj@126.com
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Oncology
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review-article
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Li L, Kong QB, Sui X, Wang XJ. Advances and controversies in the management of T4 colon cancer. World J Gastroenterol 2026; 32(48): 125373 [DOI: 10.3748/wjg.125373]
World J Gastroenterol. Dec 28, 2026; 32(48): 125373 Published online Dec 28, 2026. doi: 10.3748/wjg.125373
Advances and controversies in the management of T4 colon cancer
Long Li, Qing-Bin Kong, Xin Sui, Xin-Jian Wang
Long Li, Qing-Bin Kong, Xin Sui, Xin-Jian Wang, Department of Gastrointestinal Surgery, Weihai Central Hospital, Weihai 264400, Shandong Province, China
Co-corresponding authors: Xin Sui and Xin-Jian Wang.
Author contributions: Li L wrote the first draft of the manuscript and approved the final version; Kong QB performed the literature search; Sui X, Wang XJ reviewed the literature and revised this paper critically. Sui X and Wang XJ have made equal and critical contributions to the conceptualization and funding acquisition, and they will jointly take responsibility for the integrity of the entire data set.
AI contribution statement: AI tools, specifically (DeepSeek), were used solely for language polishing and formatting assistance. No AI tool was used to generate research data, interpret results, or formulate conclusions. All AI-assisted content was critically reviewed and revised by the authors, who take full responsibility for the accuracy, originality, and integrity of the manuscript.
Conflict-of-interest statement: All authors declare no conflicts of interest.
Corresponding author: Xin-Jian Wang, Department of Gastrointestinal Surgery, Weihai Central Hospital, No. 3 Mishandong Road Xi, Wendeng District, Weihai 264400, Shandong Province, China. wdwxj@126.com
Received: July 6, 2026 Revised: August 15, 2026 Accepted: September 18, 2026 Published online: December 28, 2026 Processing time: 121 Days and 14.9 Hours
Abstract
T4 colon cancer is associated with a poor prognosis. Pathological assessment may underdiagnose the distinction between T3 and T4 disease, potentially impacting treatment decisions for some patients with T4 colon cancer. While generally less precise than pathological staging, both imaging and intraoperative staging offer potential to address this diagnostic gap, particularly in differentiating T3 from T4 disease. Neoadjuvant therapy is safe and effective for locally advanced colon cancer, significantly reducing local recurrence rates and conferring survival benefits. Neoadjuvant chemotherapy should be avoided when possible in locally advanced colon cancers with deficient mismatch repair, as most are unresponsive to conventional chemotherapy. This patient subset is more suitable for neoadjuvant immunotherapy, which can yield significant pathological responses and improved survival outcomes. Universal upfront testing for mismatch repair status is crucial for stratifying patients and determining appropriate neoadjuvant treatment strategies. Overdiagnosis based on imaging may limit the application of neoadjuvant therapy, as approximately 25% of patients with clinical T3-4 disease on computed tomography are ultimately classified as low-risk stage II disease. Accurately identifying high-risk patients represents a major challenge in advancing comprehensive treatment strategies for locally advanced colon cancer. Prophylactic hyperthermic intraperitoneal chemotherapy may represent one of the most effective strategies to control postoperative peritoneal metastases in locally advanced colon cancer, yet its efficacy, optimal drug regimen, timing, and duration remain subjects of extensive debate.
Core Tip: The overall prognosis for stage T4 colorectal cancer is poor. Neoadjuvant therapy and neoadjuvant immunotherapy may improve outcomes in locally advanced colorectal cancer. Due to the T4 stage and frequent discrepancies between pathological and clinical staging, treatment planning before and after surgery is often complicated. Imaging and intraoperative staging have relatively low overall accuracy but offer unique perspectives in distinguishing between T3 and T4 tumors.
