Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer

Wibe, Arne; Rendedal, P R; Svensson, Elisabeth; Norstein, Jarle; Eide, T. J.; Myrvold, H. E.; Søreide, Odd

doi:10.1046/j.0007-1323.2001.02024.x

Cited by 605 publications

(402 citation statements)

References 12 publications

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“…This is consistent with most studies on the prognostic prediction of CRM 6, 7, 8, 12, 13, 14, 15, 16…”

Section: Discussionsupporting

confidence: 92%

“…Many studies considered CRM as positive when it was ≤1 mm (R1) and associated with obviously poor prognosis as compared to CRM >1 mm (R0), which was in accordance with the ESMO guidelines 6, 8, 12, 13, 14, 15, 16, 17. The criterion to define a positive CRM remains unclear.…”

Section: Introductionmentioning

confidence: 74%

“…While several studies showed that CRM should not be used as a prognostic factor in rectal cancer,4, 5 other studies demonstrated the importance of CRM as an independent prognostic factor of local recurrence and long‐term survival,6, 7, 8, 9 including the first report by Quirke et al10 suggesting that CRM might be a strong predictor of long‐term oncologic outcomes. According to the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for rectal cancer, CRM is defined as involved if it is ≤1 mm from the tumor‐free margin, leading to an increased risk of local recurrence, distant metastases, and poorer survival 11…”

Section: Introductionmentioning

confidence: 99%

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Circumferential resection margin as a prognostic factor after rectal cancer surgery: A large population‐based retrospective study

et al. 2018

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AimThis study aimed to investigate circumferential resection margin (CRM) as a prognostic factor for long‐term oncologic survival after rectal cancer surgery.MethodsPatients diagnosed with malignant rectal cancer between 1 January 2010 and 31 December 2014, from the Surveillance, Epidemiology, and End Results (SEER) program were identified for this study. The patients were divided into five CRM groups to compare the baseline characteristics and assess cancer‐specific survival (CSS): 0‐1 mm, 1.1‐2.0 mm, 2.1‐5.0 mm, 5.1‐10.0 mm, and >10 mm. The main endpoint was CSS.ResultsCircumferential resection margin ≤1 mm was independently associated with 99% increased risk of cancer‐specific mortality in rectal cancer [hazard ratio (HR) = 1.990, 95% confidence interval (CI) = 1.613‐2.454, P < 0.001, using CRM (1.1‐2.0 mm) as a reference]. CRM (5.1‐10.0 mm) was independently associated with 29.2% decreased risk of cancer‐specific mortality [HR = 0.708, 95% CI = 0.525‐0.954, P = 0.152, using group (2.1‐5.0 mm) as reference]. CRM ≤2 mm or ≤0.4 mm was not obviously associated with CSS.Conclusionscircumferential resection margin is an independent prognostic factor in rectal cancer. Surgeons should try to maximize the CRM. Rectal cancer patients with CRM ≤1 mm should receive more postoperative attention depending on individual situation. Also, CRM should be accurately measured in millimeters in a preoperative magnetic resonance imaging or pathological report, rather than simply described as “involved” or “clear.”

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“…This is consistent with most studies on the prognostic prediction of CRM 6, 7, 8, 12, 13, 14, 15, 16…”

Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 74%

Section: Introductionmentioning

confidence: 99%

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Circumferential resection margin as a prognostic factor after rectal cancer surgery: A large population‐based retrospective study

et al. 2018

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“…Circumferential resection margin status predicts for local recurrence and overall survival (Birbeck et al, 2002;Wibe et al, 2002). However, CRM status is rarely reported.…”

Section: Discussionmentioning

confidence: 99%

Preoperative radiotherapy combined with 5 days per week capecitabine chemotherapy in locally advanced rectal cancer

et al. 2007

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There is increasing evidence supporting the use of preoperative chemoradiotherapy in patients with locally advanced rectal cancer in an attempt to facilitate complete surgical resection with clear margins. We describe our experience of using a 5-day per week regime of preoperative capecitabine chemoradiotherapy. Between November 2004 and September 2006, 70 patients with MRI-defined locally advanced rectal cancer were selected for treatment. Capecitabine was given at a dose of 900 mg m À2 for 5 days per week combined with 45 Gy of radiotherapy in 25 doses. This regime was well tolerated with 89% of our patients receiving the full dose of chemotherapy and 96% receiving the full dose of radiotherapy. Ninety-three per cent proceeded to macroscopically complete surgical resection. The pathological complete response rate was 9.2% with a node-negative rate of 66%. A negative circumferential margin was achieved by 79% of the patients who underwent resection. Compared to studies using a 7-day per week capecitabine schedule, our results show increased compliance and less dose reductions with comparable pathological outcome. There is clear evidence from two systematic reviews that adjuvant radiotherapy reduces the risk of local recurrence in patients with resectable rectal cancer (Camma et al, 2000; Colorectal Cancer Collaborative, 2001). The greatest benefit is seen when preoperative radiotherapy is used with a biologically equivalent dose of 430 Gy. Further clinical trials were required to assess the benefit of adding concurrent chemotherapy to preoperative radiotherapy.The recent publication of two phase III trials confirms that preoperative concurrent chemoradiation (CRT) is superior to long-course radiotherapy alone in patients with T3/4 or nodepositive resectable rectal cancer. The EORTC 22921 (Bosset et al, 2005) and FFCD 9203 (Gerard et al, 2006) trials compared intravenous 5-fluorouracil (5FU) and leucovorin (LV) given during the first and fifth weeks of radiotherapy with radiotherapy alone (dose of RT was 45 Gy in 25 fractions in both arms of the studies). Both trials demonstrated a reduction in the rates of local recurrence at 5 years from 17% with radiotherapy alone to 8 -9% with preoperative CRT, but neither trial showed any difference in overall survival. A further recent phase III trial has demonstrated that preoperative 5FU CRT is superior to post-operative CRT with a significant reduction in local recurrence from 12 to 6% as well as a significant reduction in both acute and long-term toxicity (Sauer et al, 2004). This evidence will clearly result in an increasing use of fluoropyrimidine-based CRT.Intravenous 5FU-based chemoradiation presents many logistical challenges. Continuous infusion of 5FU requires the insertion of a central venous line with its attendant risks of thrombosis and infection as well as the inconvenience of a portable infusion pump. The use of the bolus 5FU/LV regimen used in the EORTC and FFCD trials requires 10 daily visits to the chemotherapy day unit, with associated waiting time, t...

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“…The other important prognostic factor is the quality of surgery offered to the patient in the sense that how clear was the margin and adopting non-touch technique in handling the tumor as well as harvesting enough number of lymph nodes (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20).…”

Section: Introductionmentioning

confidence: 99%

Surgeons’ Evaluation of Colorectal Cancer Resections Against Standard HPE Protocol—Auditing the Surgeons

et al. 2011

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The survival of Colorectal Cancer patients is very much dependent on complete tumor resection and multimodality adjuvant treatment. However, the main determinants for management plan of these patients rely heavily on accurate staging through histopathological examination (HPE). A reliable standard HPE protocol will be a significant impact in determining best surgical outcome. We evaluate surgeons' intra-operative judgment and the quality of resected specimens in the treatment of colorectal cancers. To quantify the quality of surgery by applying standard HPE protocol in colorectal cancer specimens and to assess the use of new format for pathological reporting in Colorectal Cancer using a formulated standard proforma. We perform a prospective observation of all colorectal cancer patients who underwent surgical resection over 8 month duration. Surgeons are required to make selfassessment about completion of tumor excision and possible lymph nodes or adjacent organ involvement while all pathologists followed standard reporting protocol for examination of the specimens. We evaluate the accuracy of surgeons judgment against HPE. The study involved 44 colorectal cancers comprising of 23 male and 21 female patients. The majority of these patients were Malay (50%) followed by Chinese (43%) and Indian (7%). The main presenting symptoms were bleeding (32%), intestinal obstruction (29%) and perforation (7%). Sixteen (36%) patients underwent emergency surgery.Rectal tumor was the commonest (53%) followed by sigmoid colon (22.7%). Neoadjuvant Chemoradiation were given to 8 patients and complete pathological response was observed in 1 (12.5%) of these. The final TNM classification for staging were; stage I (22.7%), stage IIa (18.2%), stage IIb (11.4%), stage IIIa (2.3%), stage IIIb (25%), stage IIIc (13.6%) and stage IV (6.8%).The commonest surgery performed was anterior resection with mesorectal excision (43.2%). Ten patients (22.7%) had laparoscopic surgery with 3 (30%) patients converted to open surgery. The surgeons claimed to have performed a curative resection with complete excision and clear margin in 40 (90%) patients. Of these, only 1 (2.5%) patient had a positive resection margin. Meanwhile, the surgeons reported involvement of resection margins in 4 cases but this was disputed by the HPE in all 4 cases. Lymph nodes involvement was detected intra-operatively in 13 (29.5%) of the cases and all were proven positive for metastases through HPE. On the other hand, of the remaining 31 patients who were reported as no obvious lymphadenopathy by the surgeons, lymph nodes positvity was found in 7 (22.5%) cases. Using standard HPE reporting protocol brings suitable evaluation of surgery in colorectal cancer treatment. Although surgeons' judgment is fairly accurate in predicting margin clearance and complete specimen excision, complete mesocolic and mesorectal excision is of utmost importance since lymph nodes metastatic involvement may not be obvious at surgery.

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Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer

Abstract: The circumferential margin has a significant and major prognostic impact on the rates of local recurrence, distant metastasis and survival. Information on circumferential margin is important in the selection of patients for postoperative adjuvant therapy.

Cited by 605 publications

References 12 publications

Circumferential resection margin as a prognostic factor after rectal cancer surgery: A large population‐based retrospective study

Circumferential resection margin as a prognostic factor after rectal cancer surgery: A large population‐based retrospective study

Preoperative radiotherapy combined with 5 days per week capecitabine chemotherapy in locally advanced rectal cancer

Surgeons’ Evaluation of Colorectal Cancer Resections Against Standard HPE Protocol—Auditing the Surgeons

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