Comparison of circumferential margin involvement between restorative and nonrestorative resections for rectal cancer

Abstract

Objective To study circumferential margin involvement (CMI) in patients undergoing restorative, compared with nonrestorative, surgery for rectal cancer.Data source Descriptive multicentre study, using routinely collected clinical data from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) Bowel Cancer Audit database. The study encompassed 1403 newly diagnosed patients with rectal cancer undergoing either restorative (anterior resection (AR)), or nonrestorative (abdominoperineal excision of rectum (APER) or Hartmann's procedure), surgery. Operations were carried out in 39 hospitals during a variable period between April 1999 to March 2002. A logistic regression analysis was used to control for variables associated with circumferential margin involvement.Results One thousand and thirty-six patients satisfied the inclusion criteria. The average CMI was 12.5% (range 0-33.3% between hospitals). CMI for anterior resection was 7.5% (n ¼ 629) compared with a CMI of 16.7% for APER (n ¼ 306) and a CMI of 31.7% for Hartmann's procedure (n ¼ 101); P £ 0.001. CMI for patients undergoing curative surgery was 7.1% (423 anterior resections, CMI 3.8% (n ¼ 16); 181 APER, CMI 13.3% (n ¼ 24); 29 Hartmann's procedure, CMI 17.2%). On multivariate analysis, having controlled for Dukes' stage and operative intent, the CMI was significantly different between APER and AR (odds ratio 3.3, 95%CI 2.0-5.4), but less so between Hartmann's procedure and AR (odds ratio 2.2, 95%CI 1.1-4.2).Conclusions APER is associated with a significantly higher CMI than anterior resection. Attention to surgical technique, with a wide perineal dissection and the use of pre-operative adjuvant therapy, may reduce CMI in patients undergoing APER.

Comparison of conventional and three-dimensional conformal CT planning techniques for preoperative chemoradiotherapy for locally advanced rectal cancer

“…The current practice of TME facilitates radical clearance not only of the primary tumour but also all mesorectal tissues enveloped in the visceral pelvic fascia. This technique has been clearly demonstrated to improve local recurrence rate and 5 year survival [22][23][24]. However, recent studies of more than 1000 patients even with optimal surgical technique have reported CRM involvement rates of between 6.7% and 7.5% after anterior resection and between 16.7% and 17.6% for low rectal cancers requiring abdominoperineal excision (APER) [8,23].…”

“…This technique has been clearly demonstrated to improve local recurrence rate and 5 year survival [22][23][24]. However, recent studies of more than 1000 patients even with optimal surgical technique have reported CRM involvement rates of between 6.7% and 7.5% after anterior resection and between 16.7% and 17.6% for low rectal cancers requiring abdominoperineal excision (APER) [8,23]. The evidence base for radiotherapy in operable rectal cancer is discussed at length by Craven and Sebag-Montefiore [25].…”

S3-Leitlinie – Kolorektales Karzinom

“…De Novo: [709,754,755] Konsens Hintergrund Bei der Rektum-Exstirpation ist klassisch die Rate an Präpara-ten mit unzureichenden lateralen Sicherheitsabständen erhöht [754]. Die onkologischen Ergebnisse sind gegenüber Sphinktererhaltenden Eingriffen bei vergleichbaren Tumorstadien schlechter [755].…”

Paradigm Shift in the Management of Rectal Cancer

“…This risk entering the tumour, which may lead to an involved circumferential resection margin (CRM) and greatly increases the risk of local recurrence [5]. Large national audits have demonstrated that the CRM involvement rates are far higher after APE than after anterior resection [6]. As a consequence of the high local failure rates in patients undergoing APE, the technique of extralevator abdominoperineal excision (ELAPE) has been promulgated by Holm.…”