Distal intramural spread of rectal cancer after preoperative radiotherapy: The results of a multicenter randomized clinical study

Chmielik, Ewa; Bujko, Krzysztof; Nasierowska‐Guttmejer, Anna; Nowacki, Marek P.; Kępka, Lucyna; Sopyło, Rafał; Wojnar, Andrzej; Majewski, Przemysław; Sygut, Jacek; Karmolinski, Andrzej; Huzarski, Tomasz; Wandzel, Piotr

doi:10.1016/j.ijrobp.2005.11.039

Cited by 38 publications

(40 citation statements)

References 18 publications

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“…We acknowledged this potentially important selection bias and separately analyzed clinical material of 192 patients previously published by our group. 5 Distal intramural spread of C5 mm was more frequently observed in patients undergoing APR (23.4%, 18 of 77) than in those undergoing AR (12.2%, 14 of 115), P = 0.049 (two-sided chi-square test, Chmielik, unpublished data). These findings are consistent with existing pathologic data demonstrating the risk for distal intramural spread within 1 cm from visible tumor also in patients after chemoradiation and show the selection explaining why patients with \ 5 mm bowel clearance have had low risk of local recurrence.…”

Section: Discussionmentioning

confidence: 92%

“…These findings are consistent with existing pathologic data demonstrating the risk for distal intramural spread within 1 cm from visible tumor also in patients after chemoradiation and show the selection explaining why patients with \ 5 mm bowel clearance have had low risk of local recurrence. [1][2][3]5,16 Thus, the results of the present study should be considered with caution in light of this potential bias, and the short margins may be considered to be applicable to patients with lowrisk tumors or good response to neoadjuvant therapy. Of note, it is not possible to adjust results for this bias.…”

Section: Discussionmentioning

confidence: 94%

“…On the other hand, on rare occasions, distal intramural spread up to 5 mm was reported below a residual ulceration in patients with a clinical complete response after chemoradiation. 5 All of the above indicate that at surgery, the clinical evaluation of tumor response to preoperative radiation may not adequately represent what is happening at the microscopic level and the risk of distal intramural spread after radiation is difficult to predict. This may lead to a need for conversion to APR as a result of positive distal bowel margin.…”

Section: Discussionmentioning

confidence: 99%

“…In case of a lack of relevant information in the reports published by our group, information was extracted from the original databases. 5,9,20,23 In cases requiring additional clarification, the authors of the reports were contacted.…”

Section: Methodsmentioning

confidence: 99%

“…[1][2][3][4][5] For these reasons, for patients with low-lying cancer who are undergoing anterior resection (AR), C1 cm of distal bowel clearance is recommended as minimally acceptable. 6 The 1-cm rule is occasionally violated, particularly after preoperative radiation.…”

Section: Introductionmentioning

confidence: 99%

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Is the 1-cm Rule of Distal Bowel Resection Margin in Rectal Cancer Based on Clinical Evidence? A Systematic Review

Bujko

Rutkowski

Chang

et al. 2012

Indian J Surg Oncol

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Background. Distal intramural spread is present within 1 cm from visible tumor in a substantial proportion of patients. Therefore, C1 cm of distal bowel clearance is recommended as minimally acceptable. However, clinical results are contradictory in answering the question of whether this rule is valid. The aim of this review was to evaluate whether in patients undergoing anterior resection, a distal bowel gross margin of \1 cm jeopardizes oncologic safety. Methods. A systematic review of the literature identified 17 studies showing results in relation to margins of approximately \1 cm (948 patients) versus [1 cm (4626 patients); five studies in relation to a margin of B5 mm (173 patients) versus [5 mm (1277 patients), and five studies showing results in a margin of B2 mm (73 patients). In most studies, pre-or postoperative radiation was provided. Results. A multifactorial process was identified resulting in selection of favorable tumors for anterior resection with the short bowel margin and unfavorable tumors for abdominoperineal resection or for anterior resection with the long margin. In total, the local recurrence rate was 1.0% higher in the \1-cm margin group compared to the [1-cm margin group (95% confidence interval [CI] -0.6 to 2.7; P = 0.175). The corresponding figures for B5 mm cutoff point were 1.7% (95% CI -1.9 to 5.3; P = 0.375). The pooled local recurrence rate in patients having B2 mm margin was 2.7% (95% CI 0 to 6.4). Conclusions. In the selected group of patients, \1 cm margin did not jeopardize oncologic safety.

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Section: Discussionmentioning

confidence: 92%