Distal Margins in Radical Resections for Rectal Cancer after Chemoradiation Therapy: How Short Is Long Enough?

Abstract

Background: The purpose of our study was to assess the impact of distal margin length on outcome in patients with rectal cancer treated with neoadjuvant chemoradiation therapy (CRT) followed by radical resection. Methods: Fifty-three consecutive patients were evaluated. The selection criteria included: adenocarcinoma of the mid- or distal rectum, locally advanced stage, absence of distant metastases, and preoperative CRT followed by proctectomy with total mesorectal excision. The operations included low anterior resection in 33 patients (62%) and abdominoperineal resection in 20 (38%). The outcome measures were: tumor regression, complete pathologic response, length of distal resection margins, status of radial margins and recurrence rate. Results: Forty-eight patients (91%) had tumor regression, and 11 (21%) had a complete pathologic response. Distal resection margins were tumor-free in all patients, ranging in length from 0.1 to 7.4 cm (mean = 2.2). Follow-up (mean = 48.8 months) was current in 50 of 53 patients (94%). There was no locoregional recurrence. Conclusions: Distal resection margins shorter than 1–2 cm appear to be equivalent to longer margins in patients who undergo CRT followed by proctectomy with total mesorectal excision. These findings may lead to greater utilization of sphincter-saving procedures in rectal cancer.

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

“…The remaining 17 studies constituted the material for the current review. [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] Only one report prospectively explored the issue in question as the secondary end point. 20 The remaining reports were retrospective.…”

“…In the remaining 15 studies the difference in local recurrence rate between the short margin group and to the long margin group was not significant in univariate analysis. [7][8][9][10][11][12][13][15][16][17][19][20][21][22][23] Of the eight reports showing long-term survival, survival did not differ statistically between the two groups in seven; in one remaining study survival was lower in the short margin group compared to the long margin group ( Table 1).…”

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

“… ND no data, OS overall survival at 5 years, DFS disease-free survival OS at 5 years (4 years in Kuvshinoff et al15), RR row rate of survival, NS nonsignificant a Preoperative radiotherapy Refs 7,8,15,19,20,22,. postoperative radiotherapy Refs 16,17,.…”

Accurate Staging, Selective Preoperative Therapy and Optimal Surgery Can Deliver a Good Oncological and Functional Outcome in Low Rectal Cancer

“…Thirty-three patients (62%) underwent low anterior resection with a distal margin ranging from 1 to 74 mm (mean 18 mm) excluding the anastomotic rings. At a mean follow-up of 49 months, there was no evidence of locoregional recurrence [1] . This paper illustrates several important points: the evolution in the understanding of the biology of distal tumor spread in rectal cancer, the importance of accurate tumor staging, the value of meticulous surgical technique and the deployment of neoadjuvant therapy in appropriately selected patients to optimize outcome.…”

“…In this month's journal, Pricolo et al [1] report their experience of the impact of the length of the distal resection margin on outcome in rectal cancer. Fifty-three patients with advanced rectal cancer (T3/4 N0/N1) on endoscopic ultrasound (EUS) or MRI underwent neoadjuvant chemoradiation (5-fluorouracil and 50.4 Gy).…”